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OBJECTIVES: To discuss studies conducted in Brazil relating to PrEP, from 2012 to 2022, based on a narrative review. METHODOLOGY: The databases of the Virtual Health Library/PAHO, portals from Scielo, Scopus, and PubMed, and the descriptors in English and Portuguese 'Pre-exposure to HIV' and 'Brazil' were used, as well as a list of planned/in-progress demonstrative studies. Inclusion criteria consists of articles with fieldwork in Brazil coupled with PrEP in the Brazilian scenario; and articles in English or Portuguese. Articles in which PrEP was not the central theme and the participating Brazilian population did not reside in Brazil were excluded. RESULTS: 107 papers have been reviewed, 80 articles met the inclusion criteria. The majority participating population was men who have sex with men. 61 studies preceded the implementation of PrEP in Brazil. Studies carried out after implementation (n = 19) deal primarily with the impact of the COVID-19 pandemic. CONCLUSIONS: There was an incipient number of studies on the injectable form of PrEP. Fewer studies included segments with greater difficulties in access, use, and adherence. Despite the issues that circumscribe this prevention technology, literature is consensual on the importance of Brazilian leadership for implementing PrEP. [ABSTRACT FROM AUTHOR]

Community health workers (CHWs) are framed as the link between communities and the formal health system. CHWs must establish trusting relationships with the community and with the broader health service. How to find the optimal balance between the various strands of work for CHWs, and how to formalise this, has been the focus of different studies. We performed an extensive documentary analysis of federal legislation in Brazil to understand the institutionalisation of the CHW workforce in Brazil over the last 3 decades. The paper offers three contributions to the literature: the development and application of an analytical framework to consider the institutionalisation process of CHWs; a historical analysis of the professional institutionalisation of CHW in Brazil; and the identification of the paradoxes that such institutionalisation faces: firstly, institutionalisation focused on improving CHW remuneration created difficulties in hiring and paying these professionals; when CHW are incorporated within state bureaucracy they start to lose their autonomy as community agents; and that the effectiveness of CHW programmes depends on the improvement of clinical services in the most deprived areas. [ABSTRACT FROM AUTHOR]

This paper aims to present an ex-post analysis of industrial and science, technology and innovation (sti) policies to the Health Industrial Complex, between 2003-2017 in Brazil, from the perspective of the public health value. We concluded that the intention to meet social health needs was present in the policies' design, however, the lack of objectivity and clarity in their definitions made it difficult to articulate the three fields of policies. [ABSTRACT FROM AUTHOR]

Leptospirosis is one of the waterborne diseases that strongly concern the health in Brazil. Therefore, the objective of the present study was to identify, analyze, and describe the socioeconomic, environmental, and climatic factors that can be directly related to the increase of the leptospirosis cases. In addition, the present study carried out a temporal and spatial analysis to demonstrate the relationship between publications and cases-deaths in Brazil. By searching the databases of the CAPES and LILACS, we selected 43 papers that dealt with leptospirosis and flood in Brazil. Most of the evaluated papers related the occurrence of extreme hydrological events to the increase in the number of cases of leptospirosis. The others focused other factors such as waste accumulation, lack of urban drainage, working services, and so on. [ABSTRACT FROM AUTHOR]

In the context of the COVID-19 pandemic, masks and the act of masking have become emotive subjects for social and political debate. In Brazil, one of the countries most severely affected by the pandemic, the seemingly mundane act of mask-wearing has become part of a deep social, political and economic crisis at the centre of which is the far-right president Jair Bolsonaro. In this paper we explore the politics of (un)masking in Brazil from three vantage points in which the mask serves to dramatise the country's current moment. Firstly, we trace the connections and disjunctions between the politics of mask-wearing and the genealogies of hygienist policies associated with the modern aspirations of the Brazilian republic. Secondly, we consider how masks are incorporated into the everyday life of the city through popular economies, which reveal the potentialities and limitations of work beyond the modern ideals of waged labour. Finally, we explore the incorporation of masks in urban street-art. We approach graffiti and murals as situated performances of symbolic resistance that contest and reveal the incoherences of Bolsonaro's anti-science discourse. In tandem, these three perspectives foreground practices of (un)masking that expose long-standing tensions and new contemporary challenges that characterise the politics of a 'crisis society'. [ABSTRACT FROM AUTHOR]

In this paper, we discuss the impact of COVID-19 on Brazilian families, considering socioeconomic data from before and during the outbreak. The coronavirus threatens Brazil's entire population. Since May 2020, Brazil is considered the pandemic epicenter, presenting high rates of infections and deaths at least up to the end of August 2020. Families in which members may have lost their jobs or are living from informal work face the challenge of protecting themselves from COVID-19, but also of maintaining financial conditions despite the risk. Access to healthcare has proven to be more precarious for the poor, Indigenous, Black, street population, women, and LGBTQI+. Impacts on the mental health of family members who comply with social isolation and are overburdened with domestic duties, home office and their children's education by digital media are increased by stress, anxiety, and uncertainties about the future. Due to the great impact COVID-19 has provoked on Brazilian families, already existing socioeconomic iniquities increased during the pandemic. Unemployment, bad basic sanitation conditions and a high rate of informal work contrast with the situation of high-income families. The postpandemic period will be decisive for Brazil to prioritize the recovery of its already existing public policies. We suggest the proposed initiatives be organized around the goal of mitigating adverse effects on mental health aggravated by COVID-19. [ABSTRACT FROM AUTHOR]

This paper aims to discuss how the public budget and the model of basic attention in public health could affect the infant mortality rates in a certain territory. The research was carried out in the Southern Coastal Territory of Bahia, in the State of Bahia, Northeast Region of Brazil. It is a quantitative and descriptive investigation, based on secondary data referring to the period from 2006 to 2015, collected between 2017 and 2018 in official Brazilian public data banks. It was verified that, although the average rate of infant mortality fell gradually from 2006 in the territory, it is still higher than the national average within the investigated period. In 2006, the average rate of the territory was 35.53% and decreased to 18.56% in 2015. However, throughout the period the average rate remained higher than the Brazilian average, which is 18%. Infant mortality rates have a strong relationship with social, economic, and environmental factors. In the case investigated, they are associated with the fragmentation and fragility of public health service networks in the municipalities of the region. [ABSTRACT FROM AUTHOR]

Cannabis is the most commonly used illegal drug, and is associated with well-documented adverse health outcomes, both acute and chronic. Cannabis use prevalence in Brazil is lower than in high-use regions in the Americas (e.g., North America), but concentrated among young people. Frameworks for cannabis control are increasingly shifting towards public health-oriented principles, with some countries undertaking respective policy reforms. These frameworks require a continuum of population-level interventions (e.g., prevention and treatment) including targeted prevention of adverse health outcomes among users. In this context, and based on examples from other health fields, an international expert group developed the evidence-based Lower-Risk Cannabis Use Guidelines (LRCUG), originally for Canada, including a set of 10 recommendations based on systematic data reviews and expert consensus methods. The LRCUG form a scientific population-health prevention tool to reduce adverse public health impacts for broad application among cannabis users. In Canada, the LRCUG have been formally endorsed and are supported by leading national health organizations and government authorities within the continuum of cannabis interventions. As the LRCUG are being internationalized, this paper introduces the LRCUG's concept and content - including their original recommendations translated into Portuguese - to the Brazilian context as an evidence-based population-level intervention tool for uptake, dissemination, and discussion. Sociocultural adaptation may be required for meaningful implementation. [ABSTRACT FROM AUTHOR]

Drawing on ethnographic research conducted from 2011 to 2015 and the authors' long-term engagement in diverse aspects of HIV and human rights advocacy in Brazil, this paper explores key elements of the Brazilian sex workers' movement response to HIV and the broader political factors that profoundly influenced its trajectory. We argue that the movement has constantly challenged representations of prostitution by affirming sex workers' roles as political actors, not just peer educators, in fighting the HIV epidemic and highlight their development of a sex positive and pleasure centred response that fought stigma on multiple fronts. Moments of tension such as the censorship of an HIV prevention campaign and implementation of 'test and treat' projects are analysed, as are the complex questions that Brazil's 2016 political and economic crisis evokes in terms of how to develop and sustain responses to HIV driven by communities but with material commitment from the State. We conclude with what we see to be the unique, central components of Brazilian sex workers' approach to HIV prevention and what lessons can be learned from it for broader collective health movements in Latin America and beyond. [ABSTRACT FROM AUTHOR]

Abstract The Brazilian Unified Health System was created in the late 1980s to ensure free universal access to health care and was funded by taxes and social contributions. The persistent inequity in access to health services in favour of richer individuals in Brazil has been observed in the literature. However, to the best of our knowledge, no measurement of inequality in medicine use or private health insurance (PHI) among children has been performed with longitudinal data. This paper uses inequality indices and their decompositions to analyse the income-related inequalities/inequities in children's health care in the city of Pelotas, Brazil, using longitudinal data following children from 12 to 72 months of age. Our sample with data in all waves has between 1877 and 2638 children (varying according to outcome). We seek to answer three questions: i) How does the inequality/inequity in health care evolve as children grow up? ii) What are the main factors associated with inequality in children's health care? iii) How much of the change in inequality/inequity is explained by mobility in children's health care and income mobility? We found that inequities in health care have their beginnings in early childhood but that there was a reduction in inequity at 72 months of age. Ownership of children's PHI was associated with greater pro-rich inequity in health care. The reduction in inequality/inequity was linked to mobility in the sense that initially poorer children had greater gains in health care (a greater increase in PHI ownership and a lower reduction in medicine use). Despite this improvement among the poorest, apparently, the Brazilian public health service seems to fail to ensure equity in health care use among children, with possible long-term consequences on inequalities in health. Highlights • The inequities in health care have their beginnings even in early childhood. • Income and mother's education have a strong contribution in the inequalities. • Private health insurance has strong contribution in inequalities of medicine use. • There was reduction in inequity for children's health care in Pelotas/Brazil. • This improvement for poorest children occurred when they reached 72 months. [ABSTRACT FROM AUTHOR]

Within the context of a globalising agenda for genetic research where ‘global health’ is increasingly seen as necessarily informed by and having to account for genomics, the focus on rare genetic diseases is becoming prominent. Drawing from ethnographic research carried out separately by both authors in Brazil, this paper examines how an emerging focus on two different arenas of rare genetic disease, cancer genetics and a class of degenerative neurological diseases known as Ataxias, is subject to and a product of the dynamics of inclusion and exclusion as this concerns participation in research and access to health care. It examines how in these different cases ‘rarenesss’ has been diversely situated and differently politicised and how clinicians, patients and their families grapple with the slippery boundaries between research, rights to health and the limits of care, therapy or prevention. It illustrates how attention to rare genetic disease in Brazil emerges at the intersection of a particular history of genetic research and public health infrastructure, densely complicated feedback loops between clinical care and research, patient mobilisation around the ‘judicialisation’ of health and recent state legislation regarding rare disease in Brazil. It highlights the relevance of local configurations in the way rare genetic disease is being made relevant for and by different communities. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to test whether training correctional facility (CF) officers in the admission process would identify risk factors for inmates' unscheduled transfers to healthcare units in the first 24 hours. Design/methodology/approach Correctional officers (COs) were trained to use a questionnaire with ten closed questions, which seeks to identify occupational or nosocomial risk, applied upon the admission of inmates to a CF. Findings There were 1,288 admissions in six CFs in Ribeirão Preto and Serra Azul/Brazil from March 2010 to May 2011. Of those admissions, 21.2 percent were in penitentiaries and 78.9 percent in provisional detention centers. Of the questionnaires applied, 580 answered affirmatively (45 percent) for one or more of the questions, with nearly 60 percent related to drug use in the last 12 hours, 37.7 percent use of medications while the most frequently mentioned diseases were respiratory diseases (37 percent) and mental disorders (19 percent).The number of positive responses per evaluation presented an odds ratio of 3.6 (CI 95% - 1.6, 10.5) for unscheduled transfers for external clinical evaluation. Research limitations/implications The lack of a control group and the fact that morbidities described by prisoners could not be confirmed are study limitations. The research does, however, still contribute to the goal of achieving appropriate medical care within CFs. Originality/value The training of COs to identify risk factors that predict the need for unplanned transfers to healthcare units was feasible. These findings have important implications for CFs that do not provide ongoing medical service, a universal reality in Brazil. [ABSTRACT FROM AUTHOR]

The global health community is increasingly advocating for the local production of pharmaceuticals in developing countries as a way to promote technology transfer, capacity building and improve access to medicines. However, efforts to advance drug manufacturing in these countries revive an old dilemma of fostering technological development versus granting access to social services, such as healthcare. This paper explores the case of Brazil, a country that has developed large-scale health-inspired industrial policies, but is, yet, little understood. Brazil’s experience suggests that progressive healthcare bureaucrats can create innovative practices for technology and knowledge transfers. It also demonstrates that highly competitive pharmaceutical firms can collaborate with each other, if a government provides them the right incentives. Reforming regulatory policies is crucial for guaranteeing high-quality products in developing countries, but governments must play a crucial role in supporting local firms to adapt to these regulations. These findings send a strong message to global health policymakers and practitioners on the conditions to create a suitable environment for local production of medical products. [ABSTRACT FROM PUBLISHER]

Background: Aedes aegypti, vector of dengue, chikungunya and Zika viruses, is found at high densities in tropical urban areas. The dissemination of this vector is partially the consequence of failures in current vector control methods, still mainly relying upon insecticides. In the State of São Paulo (SP), Brazil, public health managers employed pyrethroids against Ae. aegypti adults from 1989 to 2000, when a robust insecticide resistance monitoring system detected resistance to pyrethroids in several Ae. aegypti populations. However, pyrethroids are also the preferred compounds engaged in household applications due to their rapid knockdown effect, lower toxicity to mammals and less irritating smell. Methodology/Principal findings: We evaluated pyrethroid resistance in Ae. aegypti populations over the course of a decade, from 2004 to 2015, after interruption of pyrethroid public applications in SP. Qualitative bioassays with papers impregnated with a deltamethrin diagnostic dose (DD) performed with insects from seven SP municipalities and evaluated yearly from 2006 to 2014, detected resistance in most of the cases. Quantitative bioassays were also carried out with four populations in 2011, suggesting a positive correlation between resistance level and survivorship in the DD bioassays. Biochemical tests conducted with seven insect populations in 2006 and 2015, detected increasing metabolic alterations of all major classes of detoxifying enzymes, mostly of mixed function oxidases. Genotyping of the voltage-gated sodium channel (AaNaV, the pyrethroid target-site) with a TaqMan real time PCR based technique was performed from 2004 to 2014 in all seven localities. The two kdr mutations, Val1016Ile and Phe1534Cys, known to be spread throughout Brazil, were always present with a severe decrease of the susceptible allele over time. Conclusions/Significance: These results are discussed in the context of public and domestic insecticide use, the necessity of implementation of a strong integrated vector control strategy and the conceptual misunderstanding between 'vector control' and 'chemical control of vectors'. [ABSTRACT FROM AUTHOR]

Engaging in collaborative networks can be an important facilitator of innovation for public sector science and technology (S&T) organizations. It is also an important component of S&T policies that require indicators that can assess the networks through which these organizations innovate. In this study, we apply network indicators to two S&T organizations that are part of the Brazilian public health sector. The indicators cover two complementary perspectives: one that considers the organizations' scientific networks and the other that considers their technological networks. The indicators allowed the analysis of the networks in which the organizations were engaged and the understanding of important aspects of their collaboration patterns that can support strategic decisions. The method employed in this paper proved to be a valuable diagnostic tool and a useful mechanism for evaluating the performance and supporting the development of S&T institutions. [ABSTRACT FROM AUTHOR]

The struggle for healthy eating is a nascent social movement that represents active resistance to the hostile food environments created by multinational food and beverage corporations. Using a political economy approach and leveraging Winson's [2013.The industrial diet: the degradation of food and the struggle for healthy eating. Vancouver: UBC Press] concepts of dietary regimes and the industrial diet, this paper will examine the strengths and limitations of Brazil's new dietary guidelines and discuss its role as a precursor to a new dietary regime that incorporates social justice and sustainability. [ABSTRACT FROM AUTHOR]

The emergence of scientific disciplines, as well as the policies aimed to steer them, have geographical implications. This becomes visible in areas such as genomics and related fields. In this paper, the relation between scientific evolution, political decisions and geographical configuration is studied. The recent formation of bioinformatics in Brazil is focused on. The study involves an analysis of data collected on the website of CNPq, a funding agency attached to the Ministry of Science and Technology. Furthermore, I conducted fieldwork in four cities, interviewing 15 bioinformaticians. In the history of Brazilian bioinformatics, three periods can be identified. In the first period (1900-1996), bioinformatics was actually absent, but biology research groups were formed which would subsequently explore bioinformatics. The second period (1997-2006) was marked by the emergence of the discipline and geographical concentration of major research groups in the southern part of Brazil. A third period can be pointed to (2007-2014), in which political choices have turned geographical diffusion and institutional equality into a national target. As a consequence of the recent shifts, genomics and bioinformatics researchers have been involved in a debate, some defending the existence of few specialized research and sequencing platforms, whereas others welcoming the constitution of a scientific scenario based on decentralized platforms. I defend an intermediate solution, whereby some places would be selected to be genomics hubs. This would fit the regional diversity of this vast country, in addition to tackling the scientific weaknesses of the northern area. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity is a public health problem with high prevalence and important consequences. The aim of this paper was to verify the prevalence and distribution of multimorbidity in Brazilian older adults.Methods: A population-based survey was carried out in 2008 through face-to-face interviews with 1593 older adults (aged 60 or over) living in Bagé, a medium-sized city in Southern Brazil. Multimorbidity was evaluated by 17 morbidities and operationalized according to two cutoff points: 2 or more and 3 or more morbidities. Descriptive analysis examined the occurrence of multimorbidity by demographic, socioeconomic and health services variables. Observed and expected dyads and triads of diseases were calculated.Results: From total sample, 6 % did not have morbidities. Mean morbidity was 3.6. Morbidities showing higher prevalence were high blood pressure - HBP - (55.3 %) and spinal column disease (37.4 %). The percent of participants with multimorbidity was 81.3 % (95 % CI: 79.3; 83.3) for 2 or more morbidities and 64.0 % (95 % CI: 61.5; 66.4) for 3 or more morbidities. In both measures occurrence was higher among women, the more elderly, less socioeconomic status, the bedridden, those who did not have a health private plan, those who used health services and those living in Family Health Strategy catchment areas. We found 22 dyads of morbidities with prevalence 10 % or more and 35 triads with prevalence 5 % or more. The most prevalent observed pair and triplet of morbidities were HBP and spinal column disease (23.6 %) and HBP, rheumatism/arthritis/arthrosis and spinal column disease (10.6 %), respectively.Conclusions: Multimorbidity frequency was high in the sample studied, in keeping with percentage found in other countries. The social inequities identified increase the health system challenges for the management of multimorbidity, requiring a comprehensive and multidimensional care. The combinations of diseases can provide initial input to include multimorbidity in Brazilian clinical protocols. [ABSTRACT FROM AUTHOR]

There have been many empirical studies associating commuting time and health outcomes in the last few decades. Their general conclusion is that commuting and health are negatively related. The validity of their findings, however, is questionable, given their lack of good identification strategies to correctly account for omitted variables. In this paper, we analyze this relationship using a large and unique nationally representative sample of Brazilian individuals, coupled with the use of propensity score matching techniques, and the application of an exhaustive set of standard falsification tests and sensitivity analysis that may prevent one from claiming a causal link between the two variables. Our results indicate that individuals with more than one hour of commuting appear to have statistically higher probability, ranging from 1.9 to 4.6 percentage points, of reporting bad health status when compared to a person whose commuting time is less than one hour. [ABSTRACT FROM AUTHOR]

Background: Unhealthy lifestyle choices, such as smoking and sedentary behavior, are among the main modifiable risk factors for chronic non-communicable diseases. The workplace is regarded as an important site of potential health risks where preventive strategies can be effective. We investigated independent associations among psychosocial job strain, leisure-time physical inactivity, and smoking in public servants in the largest Brazilian adult cohort. Methods: We conducted a cross-sectional analysis of baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)-a multicenter prospective cohort study of civil servants. Our analytical samples comprised 11,779 and 11,963 current workers for, respectively, analyses of job strain and leisure-time physical activity and analyses of job strain and smoking. Job strain was assessed using the Brazilian version of the Swedish Demand-Control-Support Questionnaire; physical activity was evaluated using a short form of the International Physical Activity Questionnaire. We also examined smoking status and number of cigarettes smoked per day. The association reported in this paper was assessed by means of multinomial and logistic regression, stratified by sex. Results: Among men, compared with low-strain activities (low demand and high control), job strain showed an association with physical inactivity (odds ratio [OR] = 1.34; 95% confidence interval [CI] = 1.09-1.64) or with the practice of physical activities of less than recommended duration (OR = 1.44; 95% CI = 1.15-1.82). Among women, greater likelihood of physical inactivity was identified among job-strain and passive-job groups (OR = 1.47; 95% CI = 1.22-1.77 and OR = 1.42; 95% CI = 1.20-1.67, respectively). Greater control at work was a protective factor for physical inactivity among both men and women. Social support at work was a protective factor for physical inactivity among women, as was smoking for both genders. We observed no association between demand or control dimensions and smoking. Conclusions: Job strain, job control, and social support were associated with physical activity. Social support at work was protective of smoking. Our results are comparable to those found in more developed countries; they provide additional evidence of an association between an adverse psychosocial work environment and health-related behaviors. [ABSTRACT FROM AUTHOR]

When generic drugs were introduced into the Brazilian market, the main aim was to decrease prices and minimize public health expenditure. However, in addition to this effect, this policy brought about unintended changes to the industrial structure. In this paper, we evaluate the unplanned impacts from the introduction of generic drugs, particularly with respect to the business scale and innovation. Our main results show a large increase in market share in favor of domestic companies, but just a small increase in R&D expenditure and innovation within those companies. Such an increase in the business scale represented a window of opportunity for national firms, but the recent mergers and acquisitions by foreign firms have challenged their position. The weak competitiveness of domestic firms stems from their poor technological capabilities, which are an outcome of a successful ‘demand pull’ industrial policy without the support of a ‘technological’ industrial policy. [ABSTRACT FROM AUTHOR]

Unintended pregnancies constitute a serious public health concern in Brazil, representing up to 55% of all pregnancies, and are prevalent among women with low income and low educational backgrounds. Lack of assistance to women in their decision-making has hindered the adoption of more effective contraceptive models. Although clinical consultations constitute an important locus to assist women in decision-making and to facilitate access to subsidized methods, our current knowledge of how contraception is discussed and decisions are reached in actual consultations is limited. Just as scarce is our knowledge of how patients respond and resist contraception recommendations and how physicians counter or accommodate patients. Using a corpus of 103 audio-recorded medical visits and conversation analytic (CA) methods, this paper examines recommendation sequences in the under-investigated gynecological consultations in the Brazilian public healthcare system (SUS). The quantitative analysis reveals a strong orientation to physicians as having primary rights to govern the oversight of women's bodies: 94% of the recommendations are delivered as pronouncements (e.g. , "You'll take X″), the most authoritative action type. Patients largely assume an agreeable and passive role (66%), leading to scarce negotiation and minimal involvement in decision-making. However, in a few cases (12%), all involving contraception, patients become overtly agentive, responding with active resistance. A qualitative analysis of that subset shows that despite women's gaining some agency over their sexual bodies, that agency is still limited. Whereas physicians accommodate patient resistance on grounds of biomedically-related side-effects and incorrect assumptions about the women's lives, they overlook patient resistance based on gendered struggles over contraceptive methods in the domestic sphere. By failing to consider women's lack of agency in choosing whether to have sex or to use condoms, doctors show unawareness of significant consequences of the recommended method, which might include domestic dispute and violence and, paradoxically, ultimately misfire, leading to unwanted pregnancy. • Unintended pregnancies constitute a serious public health concern in Brazil. • Lack of assistance with decision-making hinders best-suited contraception use. • Medical consultations are valuable interactional spaces to discuss contraception. • Women gain by resisting ill-suited recommendations to their own life circumstances. • Contraception decision and access demand partnership between doctors and patients. [ABSTRACT FROM AUTHOR]

Abstract: Funds to promote access to water and sanitation in developing countries are scarce and most of the investments come from the national governments and households sources, not international resources. In many of these countries, mainly in middle income countries, households are paying direct taxes to access these services, and understanding what determines their choice and motivation is fundamental to promote access to them. It has been argued that is not enough to supply a wide range of alternatives unless the individuals can recognise their benefits and sustainability. The objective of this paper is to understand the choice of sanitation technology by residents in the city of Salvador, Brazil. We propose a unique hybrid choice model that incorporates a set of latent attitudinal variables and explains how the demographic factors within a household influence choice. The substantial difference of our hybrid choice model from descriptive frameworks is that it integrates choice and latent variables (such as attitudes and preferences) allowing us to model explicitly the cognitive process that influences sanitation adoption, draw conclusions from cognitive variables associated with individuals’ socio-economic and demographic characteristics, and establishes a causal pathway among these variables. The results show that the attributes of health protection, accessibility, privacy, and house modernisation were what households cared about when opting for flush toilet and sewerage connection, rather than the high cost and consequent household socio-economic status associated with them. The hybrid model is statistically consistent with these findings, and seems to fill the gap between behavioural theory and discrete choice models applied to sanitation. [Copyright &y& Elsevier]

This article analyses Brazilian state policy for indigenous health based on the inquiry of the recent historical, political and managerial process that resulted in the creation, in 1991, of the National Health Foundation (Funasa). I t attempts to bring together two lines of thought triggered by the examination of the Funasa Museum collection and by interviews with Funasa employees. T he threads thus woven should make possible, on the one hand, (i) to trace a genealogy of the National Health Foundation, and, on the other, (ii) to highlight its role in setting the hurdles that prevent the consolidation of a political field of respect for diversity in indigenous health policy. T he paper, therefore, consists of an approach which aims at pulling together biographic narratives with institutional memory. [ABSTRACT FROM AUTHOR]

In an earlier paper (Dressler, 2001), I suggested that medical anthropology as a research enterprise could not ignore either meaning or structure in human social life in the production of health. Rather, drawing on the early work of Bourdieu, I argued that we need to take into account both how the world is configured by the collective meanings we impose upon it, as well as the social structural (and physical) constraints on our behaviour that exist outside those meanings. Human health can be understood, in part, as the intersection of meaning and structure. Here, my aim is to extend this perspective in three ways. Firstly, I present an expanded theoretical framework within which collectivei meaning and social structure can be conceptualised. A useful theoretical framework must take into account paradoxical features of culture, including the seeming contradiction that it is a property both of social aggregates and of individuals, and that, ultimately, social structural constraints external to individuals depend on shared meaning. Secondly, I review recent research employing this perspective conducted in Brazil, the southern United States and Puerto Rico. These studies have all employed a 'structural-constructivist' theoretical orientation, using especially the concept of 'cultural consonance', or the degree to which individuals incorporate shared meaning into their own beliefs and behaviour. Where individual efforts to attain a higher cultural consonance are frustrated by structural constraints, poor health results. Thirdly, I consider some of the policy implications of this perspective. While much work in traditional public health focuses on a highly individualised notion of meaning (as in 'health beliefs'), it seems unlikely that the health of populations can be altered substantially without taking into account the structures that constrain individual action. [ABSTRACT FROM AUTHOR]

Abstract: Recent years have seen a burgeoning of intergenerational programmes aiming to improve the well being of participants. However, very few programmes have been formally evaluated. In this paper we report results from a randomised controlled trial of a school-based intergenerational intervention undertaken in Brazil. Randomly selected samples of 253 adolescents and 266 elders aged 60 and over resident in the school''s catchment area were administered a questionnaire including questions on cognitive components of social capital, family relationships, and self-rated health. Participants were then randomly allocated to control and intervention groups. The intervention comprised participation in a 4 month programme of intergenerational activities in which the elders shared their memories with the students. At the end of the intervention the questionnaire was re-administered to the samples. High proportions (85–95%) of both samples completed the questionnaires but compliance with the intervention was low in the elderly group. In the analysis of results from the elderly sample, we therefore compared the control group with the group assigned to the intervention (intention to treat analysis). Results showed that adolescents in the intervention group were nearly three times more likely to rate their health as good than those in the control group, but also more likely to judge that most people were selfish. In the elderly sample, those from the intervention group were over twice as likely as those from the control group to report positively on the helpfulness of neighbours; judge most people to be honest or consider their family relationships as good. There were no significant differences between groups on other outcome measures. These results suggest that structured intergenerational activities may have positive effects on some aspects of social capital for both adolescents and elderly people, although further research is needed to elucidate the processes involved and the extent to which the findings are context specific. This study is the first to use a controlled trial design to evaluate this type of intervention and is valuable in showing that this design can be used in interventions of this kind, and also the difficulties involved. [Copyright &y& Elsevier]

The story of Brazil's evolution in sexual and reproductive health and rights during the 1990s documents not only a decade of change in the population field, but the powerful role of social movements in a democracy. Between October and December 2002, 23 people were interviewed about where they believe progress has been made in Brazil and where there are still needs in relation to population trends, sexual and reproductive rights, and health policies. This paper contains excerpts from the full report and covers the economic and political background of Brazil; the role of non-governmental and women's organisations in influencing the national agenda; the intersection of national and international agendas on population and development, HIV/AIDS, human rights, racism and other issues; changes in sexual and reproductive health policies; HIV/AIDS policy progress, perhaps most importantly mandatory free treatment for people with HIV/AIDS; recent progress in women's health, especially in relation to antenatal and obstetric services, and services addressing violence against women. Finally it describes the role of policy accountability mechanisms that aim to ensure that the many excellent policies that have been passed since 1990 are implemented in a decentralised health system of national, state and local management and services. L'histoire de l'évolution du Brésil en matière de santé et de droits génésiques pendant les années 90 met en lumière des changements dans le domaine démographique et l'influence des mouvements sociaux dans une démocratie. Entre octobre et décembre 2002, on a demandé à 23 personnes d'indiquer les secteurs où le Brésil avait progressé et ceux où des lacunes demeuraient en rapport avec les tendances démographiques, les droits génésiques et les politiques de santé. Cet article, contenant des extraits du rapport, décrit l'environnement économique et politique du Brésil ; l'influence des organisations féminines et des ONG sur les politiques nationales ; l'intersection des priorités nationales et internationales en matière de population et développement, VIH/SIDA, droits de l'homme, racisme et autres questions ; les changements dans les politiques de santé génésique ; les progrès de la lutte contre le VIH/SIDA, avec le traitement gratuit obligatoire des séropositifs ; les récents progrès dans la santé des femmes, particulièrement les services prénatals et obstétriques, et les services spécialisés dans la violence à l'égard des femmes ; et enfin le rôle des mécanismes de responsabilité politique pour que les excellentes politiques adoptées depuis 1990 soient aussi appliquées dans un système de santé décentralisé avec une gestion et des services aux niveaux national, des États et local. La historia de la evolución de Brasil en salud y derechos sexuales y reproductivos durante los años noventa documenta una década de cambios en el campo de la población, y el poder de los movimientos sociales en una democracia. Entre octubre y diciembre de 2002, se entrevistaron a 23 personas respecto a los avances logrados en Brasil y las carencias aãn existentes con relación a las tendencias demográficas, los derechos sexuales y reproductivos y las políticas de salud. Este artículo contiene pasajes del informe y abarca los antecedentes económicos y políticos de Brasil; la influencia de las ONG y organizaciones de mujeres en la agenda nacional; la intersección de las agendas nacionales e internacionales respecto a la población y el desarrollo, el VIH-sida, los derechos humanos, el racismo y otros temas; los cambios en las políticas de salud sexual y reproductiva; los avances en políticas de VIH-sida, destacada la prestación obligatoria de tratamiento gratuito para las personas con VIH-sida; los recientes avances en la salud de la mujer, especialmente con relación a los servicios antenatales y obstétricos y los servicios que tratan la violencia contra las mujeres; y, por ãltimo, los mecanismos destinados a garantizar que las numerosas excelentes políticas aprobadas a partir de 1990 sean aplicadas en un sistema de salud descentralizado de administración y servicios nacionales, estatales y locales. [ABSTRACT FROM AUTHOR]

In this paper, we propose an approach to investigate the hypothesis that the residential concentration of poverty affects health status more deeply than when poverty is randomly scattered in a given geographical area. To characterize the geographic pattern of poverty in the city of Rio de Janeiro, Brazil, an index that measures the heterogeneity of poverty concentration among sub-areas was proposed. We used census data and defined poverty by means of the household head monthly income. The 153 neighborhoods that compose the city were used as the geographic units, and the census tracts as the sub-areas. The proposed index measures differences of poverty concentration across census tracts within a neighborhood. The effects of geographic poverty clustering on infant mortality related variables (early neonatal mortality rate; post-neonatal mortality rate; proportion of adolescent mothers; and fertility rate among adolescents) were estimated by partial correlation coefficients, controlling for the neighborhood poverty rate. Our study revealed that intra-city variations of the post-neonatal mortality rate are associated with geographic patterns of poverty, and that pregnancy in adolescence is strongly and contextually correlated with intra-neighborhood poverty clustering, even after adjustment for the poverty rate. The evidence of relevant health differences associated with the spatial concentration of poverty supports the hypothesis that properties of the environment of residence contextually influence health. Our findings suggest that prevention of some infant mortality related problems has to be focused directly on features of communities, considering their physical, cultural and psychosocial characteristics, being of particular concern the health of communities segregated from the society at large by extreme poverty. [Copyright &y& Elsevier]

This article explores the mobilization of power by health workers during policy implementation, showing how in a context of discretion and resource scarcity they can reproduce inequalities in access to health services. The argument innovates theoretically by supplementing the 'street-level bureaucracy' literature, which emphasizes frontline worker discretion, with a conceptualization of power as domination encompassing the shaping of behavior, the constitution of subjects and the reproduction of inequality. Empirically, the article focuses on Brazilian community health workers (agentes comunitários de saúde , CHWs). CHWs are a neglected but highly important segment of the health workforce that traditionally functions as a link between the health system and disadvantaged groups. The article examines how Brazilian CHWs act as street-level bureaucrats mobilizing power in their interactions with users. They operate within a severely under-resourced public health system, the Sistema Único de Saúde , which places constraints upon their action and forces them to make allocation decisions with little training and support. The article highlights the ways in which inequalities in access to health services are reproduced (inadvertently or not) through the practices, discursive styles and classifications of CHWs. Methodologically, the paper is based on ethnography with 24 CHWs and interviews with 77 other CHWs in Brazil. • Develops a novel framework for analysing health worker discretion and power. • Supplements the street-level bureaucracy approach with the concept of domination. • Explores the mobilization of power by Brazilian community health workers. • Shows how policy implementation can reproduce inequality in access to healthcare. [ABSTRACT FROM AUTHOR]