Revista Panamericana de Salud Pública/Pan American Journal of Public Health

Stress: diagnosis of military police personnel in a Brazilian city

Objectives. To diagnose the occurrence and stage of stress among military police enlisted personnel and officers in the city of Natal (the capital of the state of Rio Grande do Norte, Brazil), and to determine the prevalence of physical and mental symptoms.
Method. This cross-sectional descriptive study investigated a sample of 264 individuals from a population of 3 193 military personnel from the Natal police command. The data were collected between June 2004 and January 2005 using Lipp’s Adult Stress Symptoms Inventory (Inventário de Sintomas de Stress para Adultos de Lipp). The research assessed: (1) presence of stress, (2) the stage of stress (alert, resistance, near-burnout, and burnout), (3) the prevalence of physical and mental symptoms, and (4) the relationship between stress and police unit, rank, gender, drinking, smoking, educational level, marital status, age, years of police service, and salary.
Results. No stress symptoms were found in 52.6% of the sample; 47.4% had symptoms. Of the 47.4% of the police personnel with stress symptoms, they were distributed as: 3.4% in the alert stage, 39.8% in the resistance stage, 3.8% in the near-burnout stage, and 0.4% in the burnout stage. Psychological symptoms were recorded in 76.0% of the police personnel with stress, and physical symptoms in 24.0% of them. Of the variables investigated, only gender was related to stress (P = 0.0337), with the female police personnel being more likely to suffer from stress.
Conclusions. The levels of stress and symptoms do not indicate a critical situation of fatigue. However, it is recommended that the police take preventive actions, including implementing an effective program for the diagnosis of, training on, and control of stress.

Objetivos. Diagnosticar a ocorrência e a fase de estresse em policiais militares da Cidade de Natal, Brasil, além de determinar a prevalência de sintomatologia física e mental.
Método. Estudo descritivo, com corte transversal. Foi investigada uma amostra de 264 indivíduos extraída de uma população de 3 193 militares do Comando de Policiamento da Capital. Os dados foram coletados entre junho de 2004 e janeiro de 2005 utilizando-se o Inventário de Sintomas de Stress para Adultos de Lipp. Foi determinada a presença de estresse, a fase de estresse (alerta, resistência, quase-exaustão, exaustão), a prevalência de sintomas físicos e mentais e a relação entre estresse e unidade policial, posto policial, sexo, hábito de beber, fumo, escolaridade, estado civil, idade, tempo de serviço e faixa salarial.
Resultados. A proporção de policiais sem sintomas de estresse foi de 52,6%, enquanto que 47,4% apresentaram sintomatologia. Dos 47,4% com estresse, 3,4% encontravam-se na fase de alerta, 39,8% na fase de resistência, 3,8% na fase de quase-exaustão e 0,4% na fase de exaustão. Sintomas psicológicos foram registrados em 76,0% dos policiais com estresse, e sintomas físicos, em 24,0%. Das variáveis investigadas, a única que apresentou relação com estresse foi o sexo (P = 0,0337), sendo as mulheres as mais afetadas.
Conclusões. Os níveis de estresse e de sintomas não indicaram um quadro de fadiga crítico. É recomendável uma ação preventiva por parte da organização policial, que poderia incluir a aplicação de um programa de diagnóstico, orientação e controle do estresse.

The relationship between socioeconomic factors and maternal and infant health programs in 13 Argentine provinces

Objectives. To analyze the relationship between maternal and infant health and socioeconomic, cultural, and sanitation factors in Argentina; to evaluate how health program quality affects the primary health indicators for mothers and infants.
Methods. This is a cross-sectional study with multiple variables. The authors studied six indicators for maternal and infant health: rates for maternal, infant, neonatal, and postneonatal mortality; the percentage of newborns with low birthweight; and the percentage of premature newborns. The study was conducted in 79 administrative units in 13 provinces that represent different geographic regions of Argentina. They included (1) the provinces of Salta and Jujuy in northwest Argentina; (2) the provinces of Córdoba, Santa Fe, and Buenos Aires in central Argentina; (3) the provinces of Entre Ríos and Misiones in the Mesopotamia or northeast region; (4) the provinces of San Luis, San Juan, and Mendoza in the Cuyo or northwest, Andean region; and (5) the provinces of Neuquén, Río Negro, and Chubut in the south. The explanatory variable in the study was the quality of health programs, controlled by socioeconomic, cultural, and sanitation factors in 1999 and 2000. The definition of program quality (“poor,” “average,” “good,” and “very good”) was based on quantitative and qualitative analysis of selected variables such as policies, organization, and procedures as determined by the investigators. Documentation was obtained from secondary official sources. The investigators interviewed 117 health system managers (including supervisors of provincial and local health programs, administrators of maternal and child health programs, and hospital directors), who provided information on characteristics and indicators of the health programs.
Results. There were marked geographic differences in the levels of maternal and infant health, medical care, and socioeconomic, cultural, and sanitation factors. Only 10.0% of health programs were classified as “very good,” 35.4% as “good,” 31.6% as “average,” and 23.0% as “poor.” There was a significant correlation (P < 0.05) between rates of infant and postneonatal mortality and adverse socioeconomic circumstances. There was also a significant correlation between the percentage of low birthweight infants and the quality of health programs.
Conclusions. There are clear disparities in the level of maternal and infant health care in different administrative units in Argentina. The infant mortality rate was associated with variations in socioeconomic, cultural, and sanitation factors and with the quality of health programs. Health programs improved infant health when appropriately implemented, even in adverse socioeconomic and sanitation conditions.

Objetivos. Analizar la relación entre la salud maternoinfantil y los factores determinantes socioeconómicos, culturales y sanitarios y evaluar el efecto de la calidad de los programas de salud sobre los principales indicadores de salud maternoinfantil.
Métodos. Estudio analítico de corte transversal con múltiples variables. Se estudiaron seis indicadores maternoinfantiles: las tasas de mortalidad materna, infantil, neonatal y posneonatal y los porcentajes de bajo peso al nacer y de prematuros. El estudio se realizó en 79 unidades administrativas de 13 provincias argentinas distribuidas en las cuatro principales regiones del país: Norte (Salta, Jujuy y Misiones), Centro (Córdoba, Santa Fe y Buenos Aires), Litoral (Entre Ríos), Cuyo (San Luis, San Juan y Mendoza) y Sur (Neuquén, Río Negro y Chubut). Como variable explicativa se utilizó la calidad de los programas de salud, controlada por los factores determinantes socioeconómicos, culturales y sanitarios (período 1999–2000). La calidad de los programas (mala, regular, buena y muy buena) se basó en el análisis cuantitativo y cualitativo de variables seleccionadas de políticas, organización y procesos, según el juicio consensuado de los investigadores. La información documental se obtuvo de fuentes oficiales secundarias y las características e indicadores de los programas de salud se derivaron de las entrevistas a 117 referentes clave.
Resultados. Se encontraron marcadas diferencias geográficas en el nivel de salud maternoinfantil, la atención médica y los factores condicionantes de la salud. Solo 10,0% de los programas de salud fueron calificados como muy buenos, 35,4% como buenos, 31,6% como regulares y 23,0% como malos. Se encontró una correlación significativa (P < 0,05) entre las tasas de mortalidad infantil y posneonatal y la condición socioeconómica desfavorable y entre las tasas de mortalidad infantil y neonatal y el porcentaje de bajo peso al nacer, por un lado, y la calidad de los programas por el otro.
Conclusiones. En Argentina, el nivel de salud maternoinfantil muestra marcadas diferencias entre las unidades administrativas. La tasa de mortalidad infantil estuvo asociada con las variaciones de los factores determinantes socioeconómicos, culturales y sanitarios y con la calidad de los programas de salud. Estos últimos mejoraron los niveles de salud infantil cuando se implementaron adecuadamente, incluso en condiciones socioeconómicas y sanitarias desfavorables.

Prevalence of postural changes in high school students in a city in southern Brazil

Objective. To estimate the prevalence of lateral and anteroposterior postural changes in female adolescents and to investigate whether these changes are associated with certain socioeconomic, demographic, anthropometric, or behavioral variables.
Methods. This epidemiologic survey included a representative sample of 495 high school students from regular day school programs in the city of São Leopoldo, Rio Grande do Sul, Brazil, which is in the South region of Brazil. The students, who were 14 to 18 years old, were assessed in October and November of 2004. Postural changes were defined as skews in the spinal curvature, identified through noninvasive postural assessment.
Results. The prevalence of lateral changes was 66% (95% confidence interval (CI): 61.5% to 70.0%) vs. 70% for anteroposterior changes (95% CI: 65.2% to 73.5%). Lateral changes were more prevalent in students with a normal body mass index (prevalence ratio (PR) = 1.32; 95% CI: 1.09 to 1.59) and in those who watched television for more than 10 hours weekly (PR = 1.16; 95% CI: 1.02 to 1.32). The prevalence of anteroposterior changes was higher in students whose parents/guardians had no schooling or only had elementary schooling (female guardians: PR = 1.30, 95% CI of 1.09 to 1.55; male guardians: PR = 1.20, 95% CI of 1.02 to 1.40) and in students who were overweight or obese (PR = 1.33; 95% CI of 1.19 to 1.48).
Conclusions. The high prevalence of postural changes observed is reason for concern since these changes can translate into spinal problems in the medium to long term. Health professionals, including physical education teachers, should be trained to perform postural assessments, which should be routinely done in schools.

Objetivos. Estimar a prevalência de alterações posturais laterais e ântero-posteriores em adolescentes do sexo feminino e verificar se determinados fatores socioeconômicos, demográficos, antropométricos e comportamentais estão associados a essas alterações posturais.
Métodos. Inquérito epidemiológico com amostra representativa de 495 estudantes do ensino médio regular diurno, com idade de 14 a 18 anos na Cidade de São Leopoldo, Brasil. As estudantes foram avaliadas nos meses de outubro e novembro de 2004. As alterações posturais foram definidas como alterações nas curvas fisiológicas da coluna vertebral, identificadas através de avaliação postural não-invasiva.
Resultados. Observou-se uma prevalência de 66% (IC95%: 61,5 a 70,0) para as alterações laterais e de 70% (IC95%: 65,2 a 73,5) para as alterações ântero-posteriores. As alterações laterais foram mais prevalentes nas alunas com índice de massa corporal normal (razão de prevalência, ou RP = 1,32; IC95%: 1,09 a 1,59) e nas que assistiam à televisão por mais de 10 horas semanais (RP = 1,16; IC95%: 1,02 a 1,32). A prevalência de alterações ântero-posteriores foi maior nas alunas cujos responsáveis estudaram até o nível fundamental (responsáveis femininos, RP = 1,30; IC95%: 1,09 a 1,55; e responsáveis masculinos, RP = 1,20; IC95%: 1,02 a 1,40) e nas alunas com sobrepeso ou obesidade (RP = 1,33; IC95%: 1,19 a 1,48).
Conclusões. Preocupa a alta prevalência de alterações na postura das adolescentes, uma vez que essas alterações podem gerar problemas na coluna vertebral a médio e longo prazo. É importante que profissionais da área da saúde, inclusive professores de educação física, estejam aptos a realizar avaliações posturais, e que esse procedimento seja realizado rotineiramente nas escolas.

Health in Cuba and the Millennium Development Goals

The first assessments of the Millennium Development Goals of the United Nations have been completed, and deliberations about world health are increasing. Now is an appropriate time to consider the case of Cuba, which has functioned under difficult conditions for many years, and followed its own path. Cuba’s health indicators are much better than might be expected considering its level of income; in many cases the indicators compare to those of industrialized countries. These results should be viewed as the product of a well-defined strategy and the use of essential public health principles rather than as the accumulation of better numbers. The Cuban experience demonstrates that a population’s health can improve in even the most adverse economic conditions. This is attainable when sound public health practices are implemented under the principle that health is a basic right and therefore a national priority. An understanding of the Cuban public health system can help other low-income countries adapt these practices to their own conditions and meet the Millennium Development Goals. If this were to occur, there would be substantial improvement in the world’s health.

La salud es una de las áreas clave para el progreso y ocupa un lugar destacado entre los Objetivos de Desarrollo del Milenio (ODM), adoptados en 2000 por acuerdo de 189 estados (1). Por su importancia, la Organización Panamericana de la Salud los ha incorporado a sus metas estratégicas (cuadro 1) y realiza controles periódicos sobre la marcha de su consecución (2). El debate sobre los ODM ha crecido tras las primeras evaluaciones de los objetivos relacionados con la salud, ya que las poblaciones pobres de todas las regiones del mundo continúan mostrando elevadas tasas de mortalidad infantil y materna y sufriendo enfermedades como el paludismo, la tuberculosis y el VIH/sida (3), a las que más recientemente se han incorporado las enfermedades crónicas (4). El desafío es formidable, porque se trata de países con un bajo desarrollo de su infraestructura sanitaria (5) y elevadas prevalencias de enfermedades que desde hace tiempo se pueden controlar (6–8).

A network to promote health systems based on primary health care in the Region of the Americas

Objectives. To identify the relational components of an international network of organizations that provide technical and financial assistance to promote the development of health systems based on primary health care in the countries of the Region of the Americas; to analyze the linkages that would allow the collaborating partners of the Pan American Health Organization (PAHO) to work together on health issues; and to determine the basic theoretical elements that can help to develop action strategies that support advocacy efforts by a network. Methods. This was a qualitative and quantitative cross-sectional study based on identifying key informants and on analyzing social networks. Ethnographic and relational information from 46 international organizations was collected through a self-administered semistructured questionnaire. From 46 international health cooperation organizations, 29 decisionmakers from 29 organizations participated (63.0% response rate). The structure and the strength of the network was evaluated in terms of density, closeness, clustering, and centralization. The statistical analysis was done using computer programs that included UCINET, Pajek, and Microsoft Access.
Results. We found a structurally centralized theoretical network, whose nodes were clustered into four central subgroups linked by a shared vision. The leadership, influence, and political interests reflected the formal and technical-cooperation linkages, the formal support for health systems based on primary health care, and the flow of resources being more often technical ones than financial ones.
Conclusions. The interorganizational relational components and the social-action ties that were identified could help in the development and consolidation of a thematic network for advocacy and for the management of technical and financial assistance that supports primary health care in the Americas. The linkages for joint action that were identified could advance international cooperation in developing health systems based on primary health care, once PAHO formulates clear implementation strategies and takes a leadership position in mobilizing financial resources and in creating informal and interpersonal linkages for action.

Objetivos. Identificar los componentes relacionales de una red internacional de organizaciones de cooperación técnica y financiera que promueva el desarrollo de sistemas de salud basados en la atención primaria de salud (APS) en los países de la Región; analizar los vínculos de acción social para la cooperación en salud entre los socios colaboradores de la Organización Panamericana de la Salud (OPS); y determinar los elementos teóricos básicos que pueden contribuir a desarrollar estrategias de acción que respalden la abogacía en red.
Métodos. Estudio transversal cualitativo y cuantitativo basado en la identificación de informantes clave y el análisis de redes sociales. Se colectó información etnográfica y relacional de 46 organizaciones internacionales mediante un cuestionario semiestructurado autoaplicado. Participaron 29 tomadores de decisión pertenecientes a 29 organizaciones de cooperación internacional en salud (tasa de respuesta: 63,0%). La estructura y solidez de la red se evaluó mediante la densidad, la distancia, la transitividad y la centralización de los nodos. El análisis estadístico se realizó mediante los programas informáticos UCINET, PAJEK y MS Access, entre otros.
Resultados. Se identificó una red teórica estructuralmente centralizada, cuyos nodos aglutinados en cuatro subgrupos centrales se vincularon en una visión compartida. El liderazgo, la influencia y los intereses políticos reflejaron los vínculos cooperativos de tipo formal y técnico y el apoyo formal a favor de la propuesta, con el predominio del flujo de recursos técnicos sobre los financieros.
Conclusiones. Los componentes relacionales interorganizacionales y los vínculos de acción social identificados pueden influir positivamente en la conformación y consolidación de una red temática de abogacía y gestión para la cooperación técnica y financiera en apoyo a la APS en la Región de las Américas. Los vínculos de acción identificados pueden favorecer la cooperación internacional en el desarrollo de sistemas de salud basados en la APS, una vez que la OPS formule estrategias de implementación claras y tome el liderazgo para movilizar recursos financieros y generar vínculos de acción informal e interpersonal.

Objectives. To investigate the impact of environmental tobacco smoke (ETS) exposure and mother’s place of birth (Mexico vs. United States of America) on the prevalence of asthma and dry nighttime cough among children 2–12 years old residing in the southwestern United States.
Methods. Data were collected from November 2003 through March 2004 as part of a health survey of Hispanic mothers with young children who sought emergency, nutrition, or other clinical services. Information about respiratory health was obtained for one randomly selected child per United States-born (no. = 144) or Mexico-born (no. = 125) mother. Information on maternal and household sociodemographic variables, smoking, parental asthma, and child’s exposure to room or automobile ETS during the previous seven days was also collected. Adjusted prevalence ratios were estimated with modified Poisson regression models.
Results. Most sociodemographic and ETS exposure variables differed significantly by mother’s country of birth. Modeled asthma prevalence was 1.95 [95% confidence interval (CI) = 1.03–3.68] times greater in children of United States-born mothers than children of Mexico-born mothers. This difference persisted after known asthma risk factors were controlled for, including parental asthma, socioeconomic and demographic variables, and child ETS exposure. Childrens’ recent automobile ETS exposure was associated with dry nighttime cough [adjusted prevalence ratio (PR) = 1.94, 95% CI = 1.19–3.15] and asthma (PR = 2.09; 95% CI = 0.99–4.39).
Conclusions. Exposure to ETS in automobiles is an important risk factor for asthma and dry nighttime cough among Hispanic children in the southwest United States, regardless of mother’s country of birth. Further research is needed to identify causes of the higher prevalence of asthma in Hispanic children of United States-born mothers.

Factores de riesgo de asma y tos en niños hispanos en el suroeste de los Estados Unidos de América, 2003–2004

Objetivos. Se investigó el impacto de la exposición al humo ambiental del tabaco (HAT) y del país de nacimiento de la madre (México frente a los Estados Unidos de América) en la prevalencia de asma y tos seca nocturna en niños de 2–12 años de edad que viven en el suroeste de los Estados Unidos de América.
Métodos. Los datos se colectaron de noviembre de 2003 a marzo de 2004 como parte de una encuesta de salud de madres hispanas con hijos pequeños, que solicitaron servicios de emergencia, nutrición o clínicos. Se obtuvo la información sobre el estado de salud respiratoria de un hijo seleccionado aleatoriamente por cada madre nacida en los Estados Unidos de América (n = 144) o en México (n = 125). Se colectó información sobre las variables sociodemográficas de la madre y del hogar, el hábito de fumar, los antecedentes de asma de los padres y la exposición del niño al HAT en habitaciones o automóviles en los siete días previos. Las razones de prevalencia ajustadas se estimaron mediante modelos de regresión de Poisson modificados.
Resultados. La mayoría de las variables sociodemográficas y de exposición al HAT presentaron diferencias significativas según el país de nacimiento de la madre. La prevalencia de asma según el modelo fue de 1,95 (intervalo de confianza de 95% [IC95%] = 1,03 a 3,68) veces mayor en niños de madres nacidas en Estados Unidos de América que en los de madres nacidas en México. Esta diferencia se mantuvo después de controlar por los factores de riesgo de asma conocidos, entre ellos los antecedentes de asma de los padres, las variables socioeconómicas y demográficas y la exposición del niño al HAT. La exposición reciente del niño al HAT en automóviles se asoció con la tos seca nocturna (razón de prevalencia ajustada [RP] = 1,94; IC95% = 1,19 a 3,15) y asma (RP = 2,09; IC95% = 0,99 a 4,39).
Conclusiones. La exposición al HAT en automóviles es un importante factor de riesgo de asma y de tos seca nocturna en niños hispanos en el suroeste de los Estados Unidos de América, independientemente del país de nacimiento de la madre. Se requieren más investigaciones para identificar las causas de la alta prevalencia de asma en los niños hispanos de madres nacidas en los Estados Unidos de América.

The relationship between deaths that are avoidable with adequate health care and the implementation of the Unified Health System in Brazil

Objective. To analyze the relationship between the occurrence of deaths that are avoidable with adequate health care and the reorganization of the Brazilian health care system between 1983 and 2002.
Method. This ecological study analyzed avoidable mortality in 117 municipalities of Brazil. The causes of death avoidable with adequate health care were grouped into three: (1) ones avoidable through early diagnosis and treatment, (2) ones avoidable with improvements in the quality of treatment and medical care, and (3) ischemic heart disease. To evaluate the association between avoidable mortality and reorganization of the health care system, the period under study was divided into two subperiods: from 1983 through 1992 and from 1993 through 2002 (respectively, before and after approval of the operational guideline that served as the reference for the organization of the Unified Health System (Sistema Único de Saúde)). A negative binomial regression model that controlled for sex, age, geographic region, and socioeconomic conditions was used for the analysis.
Results. During the period analyzed, 1 854 165 individuals between 0 and 74 years old died from avoidable causes in the municipalities studied. The multivariate analysis showed that, for all three groups of avoidable causes, the risk of avoidable mortality was higher in the 1983–1992 subperiod than in the 1993–2002 subperiod. For the entire 1983–2002 period, the risk was higher for males than for females, especially with respect to ischemic heart disease. Younger populations had lower risk. Higher socioeconomic level reduced the risk of death from avoidable causes, except for ischemic heart disease.
Conclusions. Our results suggest that in Brazil the decrease in avoidable mortality from the 1983-1992 subperiod to the 1993–2002 subperiod was partially due to the changes in the availability of and access to health services brought about by the reorganization of the Brazilian health care system.

Objetivos. Analisar a relação entre a ocorrência de mortes que poderiam ser evitadas por atenção à saúde e o processo de reorganização do sistema de saúde brasileiro entre 1983 e 2002.
Métodos. No presente estudo ecológico, a mortalidade por causas evitáveis foi analisada em 117 municípios. As causas de morte evitáveis por atenção à saúde foram agrupadas em: evitáveis por diagnóstico e tratamento precoce, evitáveis por melhoria no tratamento e na atenção médica e doença isquêmica do coração. Para avaliar a associação entre as causas de morte evitáveis e a reorganização do sistema de saúde, o período analisado foi dividido em dois subperíodos, 1983 a 1992 e 1993 a 2002 (antes e depois da aprovação da norma operacional que serviu como referencial para a implantação do Sistema Único de Saúde). Utilizou-se um modelo de regressão binomial negativa, com controle das variáveis sexo, idade, região geográfica e condições socioeconômicas.
Resultados. No período analisado, ocorreram 1 854 165 óbitos por causas evitáveis nas idades de 0 a 74 anos nos municípios selecionados. A análise multivariada indicou que o risco foi maior no período de 1983 a 1992 em relação ao período de 1993 a 2002 para os três grupos de causas evitáveis estudados. Observou-se que os homens apresentaram risco maior, particularmente para a doença isquêmica do coração. As populações mais jovens tiveram um risco menor. O nível socioeconômico mais elevado reduziu o risco de morte por causas evitáveis, exceto para a doença isquêmica do coração.
Conclusões. Os resultados sugerem que, no Brasil, o declínio da mortalidade por causas evitáveis entre 1983 e 2002 deveu-se, em parte, às mudanças na oferta e no acesso aos serviços de saúde, impulsionadas pela reorganização do sistema de saúde a partir da década de 1990.

Objectives. To assess the extent of gender inequalities in health status and health services utilization among adolescents and adults in Brazil.
Methods. A representative sample of 217 248 individuals from 15 to 64 years of age was obtained from the National Household Sample Survey (Pesquisa Nacional de Amostras por Domicilios, PNAD) conducted in 1998 by the Brazilian Institute of Geography and Statistics and funded by the Ministry of Health. The study focused on three outcome variables (selfassessed health status, medical visits, and hospitalizations (except childbirth)) and five exposure variables (age, gender, ethnicity, income, and education). Unconditional logistic regression and Mantel-Haenszel stratified analysis was employed. Prevalence rate ratios were calculated for each stratum. Confidence intervals were calculated using the Taylor series, with a 95% confidence interval (95% CI).
Results. Women were more likely to report fair or poor health than men (odds ratio (OR) = 1.33; 95% CI: 1.31.1.35). Gender disparities were significant for all ages, household income brackets, and education levels, and were always unfavorable to women (1.17 . OR . 1.44). Gender disparities for medical visits were higher for those in good health; tended to fall as age, income, and education increased; and were always favorable for women (1.12 . OR . 2.06). Gender disparities in hospitalization rates decreased with age, varied according to income and education level in each age group, and were always favorable for women (1.16 . OR . 1.66).
Conclusions. The difference in self-reported health status for men and women became even greater after adjusting for socioeconomic variables, suggesting that poorer women have more pronounced, relative differences than men do. The impact of structural determinants, such as education and income, is considerably smaller than the social construct of gender, although the former are more important predictors. Women use health services more often than men do, which is consistent with their health needs. However, medical visit rates show an inverse relationship to health care needs, suggesting an inequitable access to outpatient care, mainly preventive care.

Desigualdades de género y salud en adolescentes y adultos en Brasil, 1998

Objetivos. Evaluar la magnitud de las desigualdades de genero con relacion al estado de salud y la utilizacion de los servicios de salud en adolescentes y adultos en Brasil.
Metodos. Se tomo una muestra representativa compuesta por 217 248 personas de 15 a 64 anos de edad a partir de la Encuesta Nacional de Muestras de Hogares (Pesquisa Nacional de Amostras por Domicilios, PNAD), realizada por el Instituto Brasileno de Geografia y Estadisticas en 1998 con fondos del Ministerio de Salud. El estudio se concentro en tres variables de resultado (estado autoevaluado de salud, consultas medicas y hospitalizaciones (excepto para el parto)) y cinco variables de exposicion (edad, sexo, origen etnico, ingresos y educacion). Se utilizo la regresion logistica incondicional y el analisis estratificado de Mantel-Haenszel. Se calcularon las razones de las tasas de prevalencia para cada estrato. Los intervalos de confianza se calcularon mediante la serie de Taylor, con un intervalo de confianza de 95% (IC95%).
Resultados. Las mujeres tuvieron una mayor probabilidad de considerar su salud regular o mala que los hombres (razon de posibilidades [odds ratio, OR]) = 1,33; IC95%: 1,31 a 1,35). Las desigualdades segun el sexo fueron significativas para todas las edades y todos los niveles de ingresos del hogar y de educacion, siempre desfavorables para las mujeres (1,17 . OR . 1,44). Las desigualdades de genero con relacion a las consultas medicas fueron mayores en personas con buena salud; presentaron una tendencia a disminuir a medida que aumentaban la edad, los ingresos y el nivel educacional; y siempre estuvieron a favor de las mujeres (1,12 . OR . 2,06). Las desigualdades de genero en cuanto a las tasas de hospitalizacion disminuyeron con la edad, fluctuaron de acuerdo con los ingresos y el nivel educacional en cada grupo de edad y siempre estuvieron a favor de las mujeres (1,16 . OR . 1,66).
Conclusiones. Las diferencias en cuanto al estado autoinformado de salud en hombres y mujeres aumentaron despues de ajustar por las variables socioeconomicas, lo que indica que las mujeres mas pobres enfrentan mayores diferencias relativas que los hombres. El impacto de los factores determinantes estructurales, como la educacion y los ingresos, es considerablemente menor que los elementos teoricos sociales de genero, aunque los primeros son predictores mas importantes. Las mujeres utilizan los servicios de salud con mayor frecuencia que los hombres, lo que es coherente con sus mayores necesidades de atencion sanitaria. No obstante, las tasas de consultas medicas muestran una relacion inversa con respecto a las necesidades de atencion sanitaria, lo que indica que no es equitativo el acceso a la atencion ambulatoria, especialmente a la atencion preventiva.

Obstetric care and severe pregnancy complications in Latin America and the Caribbean: an analysis of information from demographic health surveys

Objective. To compile, consolidate, and analyze information obtained in surveys conducted by the MEASURE DHS [Demographic and Health Surveys] program, concerning obstetric care and pregnancy complications for women in Latin America and the Caribbean, in the five years before the survey.
Methods. This exploratory study utilized data from demographic surveys carried out in the 1990s in seven countries of Latin America: Bolivia, Brazil, Colombia, the Dominican Republic, Guatemala, Nicaragua, and Peru. The study describes the characteristics of the women who were interviewed and of the obstetric care that they received in the five years before the respective survey, and it also estimates the occurrence of prolonged labor and of hemorrhagic, hypertensive, and infectious complications in those five years.
Results. The median number of prenatal consultations ranged from 4.7 in Bolivia to 6.6 in the Dominican Republic. More than 40% of deliveries in Guatemala, Peru, and Bolivia were attended by traditional midwives, relatives, or other persons without formal training. The highest rates of deliveries performed in health care facilities (> 90%) were in the Dominican Republic and Brazil. In Guatemala, Peru, and Bolivia more than 45% of deliveries were at home. The highest rate of cesarean delivery was in Brazil (36.4%), and the lowest rates (< 12%) were in Peru and Guatemala. The rate of pregnancy complications reported by the women surveyed was 16.7% in Brazil, 17.9% in Guatemala, 42.1% in Colombia, 42.5% in Nicaragua, 43.0% in the Dominican Republic, 51.7% in Bolivia, and 51.8% in Peru.
Conclusion. The reported occurrence of severe pregnancy complications in the surveys we examined was well above the 15% rate reported in other scientific literature, suggesting that these complications may have been overestimated in the MEASURE DHS surveys. Prior validation of the questionnaires used for data collection is extremely important in the generation of high-quality data.

Objetivos. Compilar, consolidar e analisar as informações obtidas por inquéritos do projeto MEASURE DHS acerca de assistência obstétrica e complicações da gestação na América Latina e Caribe.
Métodos. O presente estudo exploratório incluiu sete inquéritos demográficos realizados na década de 1990 (Bolívia, Brasil, Colômbia, Guatemala, Nicarágua, Peru e República Dominicana). Além do levantamento das características das entrevistadas e da assistência obstétrica recebida, foi estimada a ocorrência de complicações (trabalho de parto prolongado e complicações hemorrágicas, hipertensivas e infecciosas).
Resultados. A mediana do número de visitas de pré-natal oscilou entre 4,7 (Bolívia) e 6,6 (República Dominicana). Na Bolívia, Peru e Guatemala foram observadas altas taxas (>40%) de assistência ao parto por parteiras tradicionais, parentes e outras pessoas sem treinamento formal. República Dominicana e Brasil apresentaram as maiores taxas de parto em estabelecimento de saúde (>90%). Na Guatemala, Peru e Bolívia, mais de 45% dos partos foram domiciliares. A maior taxa de cesárea foi registrada no Brasil (36,4%); as menores taxas foram registradas no Peru e Guatemala (<12%). A taxa de complicações da gestação referidas pelas mulheres foi de 16,7% no Brasil, 17,9% na Guatemala, 42,1% na Colômbia, 42,5% na Nicarágua, 43,0% na República Dominicana, 51,7% na Bolívia e 51,8% no Peru.
Conclusão. A ocorrência relatada de complicações graves da gestação nos inquéritos avaliados está muito acima da taxa de 15% citada na literatura, podendo ter sido superestimada. A validação prévia dos questionários utilizados para coleta de dados nesse tipo de estudo é extremamente importante para gerar dados mais adequados.

The validity of a presumptive diagnosis of cutaneous leishmaniasis performed by community health workers in Colombia

Objective. To validate a method for the presumptive diagnosis of cutaneous leishmaniasis based on the observation of clinical-epidemiological criteria, carried out by community health workers in three endemic municipalities in Santander, a department in northeastern Colombia.
Methods. This evaluation study of diagnostic technologies was based on a crosssectional sampling of suspected cases of cutaneous leishmaniasis in the municipalities of Rionegro, El Playon, and Landazuri. After being trained, the community health workers carried out the presumptive diagnoses of cutaneous leishmaniasis between October 2004 and November 2005. At the time of diagnosis, the health workers also collected samples for confirmatory diagnosis through Fieldfs stain method, culturing, and polymerase chain reaction. Four criteria were used to assess the validity of the presumptive diagnoses carried out by the health workers: sensitivity, specificity, positive predictive value, and negative predictive value. Replicability among the health workers was estimated through their observed level of agreement.
Results. According to the laboratory tests, of the 196 patients studied, 33 (16.8%) were negative and 163 (83.2%) were positive. For all the levels of certainty of the clinical diagnosis, the sensitivity was between 52% and 98% (ƒÈ(1, 0) = 39.0%) and the specificity between 9% and 55% (ƒÈ(0, 0) = 14.0%). The area under the receiver operating characteristic curve was 56.5% (95% confidence interval: 45.6% to 67.4%). The proportion of positive agreement and of negative agreement was 86.3% and 43.5%, respectively.
Conclusions. The sensitivity of the presumptive diagnosis carried out by the health workers surpasses that of the parasitological diagnostic methods generally used in the three endemic areas, but its specificity is much lower. Even though this approach is not useful as a diagnostic test for cutaneous leishmaniasis or as a criterion for deciding to proceed with treatment or not, the method is useful for the active identification of cases in the community.

Objetivo. Validar el método de diagnóstico presuntivo de leishmaniasis cutánea basado en la observación de criterios clínico-epidemiológicos, realizado por trabajadores comunitarios en temas de salud (TCS) en tres municipios endémicos del departamento de Santander, Colombia.
Métodos. Estudio de evaluación de tecnologías diagnósticas basado en un muestreo de corte transversal de casos sospechados de leishmaniasis cutánea en tres municipios endémicos de leishmaniasis del departamento de Santander (Rionegro, El Playón y Landázuri). Los TCS previamente capacitados realizaron el diagnóstico presuntivo de leishmaniasis cutánea entre octubre de 2004 y noviembre de 2005 y tomaron muestras para el diagnóstico confirmatorio mediante el método de tinción según Field, el de cultivo y la reacción en cadena de la polimerasa. Como criterios de validez del diagnóstico presuntivo realizado por los TCS se utilizaron la sensibilidad, la especificidad y los valores predictivos positivo y negativo. La reproducibilidad entre evaluadores se estimó mediante la concordancia observada.
Resultados. De los 196 pacientes estudiados, 33 (16,8%) fueron negativos y 163 (83,2%) fueron positivos según las pruebas de laboratorio. Para todos los grados de certeza del diagnóstico clínico, la sensibilidad estuvo entre 52% y 98% (k [1,0] = 39,0%) y la especificidad entre 9% y 55% (k [0,0] = 14,0%). El área bajo la curva ROC fue de 56,5% (IC95%: 45,6 a 67,4). La proporción de acuerdos positivos y negativos fue de 86,3% y 43,5%, respectivamente.
Conclusiones. La sensibilidad del diagnóstico presuntivo realizado por los TCS supera la de los métodos de diagnóstico parasitológicos empleados habitualmente en las zonas endémicas, sin embargo, su especificidad es mucho menor. A pesar de que este diagnóstico no es útil como prueba de diagnóstico de la leishmaniasis cutánea o como criterio para proceder o no al tratamiento, se demostró su utilidad como prueba de captación activa de casos en la comunidad.