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

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.

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.

Factors associated with functional dependence in older adults: a secondary analysis of the National Study on Health and Aging, Mexico, 2001

Objectives. To identify factors associated with dependence for basic activities of daily living (BADL) and instrumental activities of daily living (IADL) in elderly adults in Mexico.
Methods. A cross-sectional study of data from the first round of Mexico’s National Study on Health and Aging, 2001, was undertaken. The sample consisted of 7 171 participants, 60 years of age or older. Multifactorial regression analysis was used to identify associations between BADL and IADL dependence and lifestyle, sociodemographics, family background, and health history, from childhood to present.
Results. The mean age of the participants was 69.4 ± 7.6 years of age, with a range of 60–105 years; females made up 53.4% of the sample. The BADL- and IADLdependent groups had a higher mean age (P < 0.01), were predominantly female (P < 0.01), had a greater incidence of illiteracy, and reported a significantly higher number of chronic diseases and greater frequency of pain than did the independent participants. Among the 521 (7.3%) BADL-dependent, there was a higher percentage who were single or widowed (P < 0.01), and their self-assessed health was poorer, than that of the independent (P < 0.01). Among the 603 (8.4%) IADL-dependent, significant, independently associated factors were age, cerebrovascular and other chronic diseases, depression, vision issues, excessive pain, and amputation of a limb. Absence of childhood trauma and fewer years of employment were related to a lower incidence of IADL dependence.
Conclusions. Functional dependence in older adults is directly related to aging and has multiple determinants. Awareness of these determinants should help design health programs that can identify individuals who are at high risk of losing their independence, and implement interventions for slowing or reversing the process.

Objetivo. Identificar los factores asociados con la dependencia funcional de los adultos mayores para realizar actividades básicas de la vida diaria (ABVD) y actividades instrumentales de la vida diaria (AIVD).
Método. Estudio transversal de la información obtenida en la primera vuelta del Estudio Nacional sobre Salud y Envejecimiento en México (ENASEM) en 2001. La muestra estuvo compuesta por 7 171 personas de 60 años o más. Mediante el análisis de regresión logística multifactorial se analizó la asociación de la dependencia funcional para realizar ABVD y AIVD con los hábitos de vida y los antecedentes personales sociales, familiares y de salud desde la infancia de los participantes.
Resultados. La edad promedio fue de 69,4 ± 7,6 años (de 60 a 105 años); 53,4% eran mujeres. Los grupos de dependientes para realizar ABVD y AIVD tenían en promedio mayor edad (P < 0,01), en él predominaban las mujeres (P < 0,01) y había más personas analfabetas y que declararon haber tenido un número significativamente mayor de enfermedades crónicas y haber sufrido dolor con mayor frecuencia en los grupos de personas independientes (P < 0,01). Entre los 521 (7,3%) dependientes para realizar ABVD se observó una mayor proporción de personas sin pareja (P < 0,01), viudos (P < 0,01) y con una peor percepción de su salud que entre los independientes (P < 0,01). Seiscientos tres (8,4%) de los entrevistados eran dependientes para realizar AIVD. La mayor edad, padecer de enfermedad cerebrovascular, un mayor número de enfermedades crónicas, síntomas depresivos, deficiencia visual, dolores que limitan sus actividades diarias y tener algún miembro amputado resultaron ser factores significativa e independientemente asociados con la dependencia para realizar AIVD. Un menor número de problemas sociales durante la infancia y menos años de trabajo remunerado estuvieron asociados con una menor dependencia para realizar AIVD.
Conclusiones. La dependencia funcional en los adultos mayores está directamente relacionada con el envejecimiento y depende de múltiples factores determinantes. El conocimiento de estos factores debe contribuir a diseñar programas de salud que permitan identificar a los individuos en riesgo de perder su autonomía e implementar intervenciones dirigidas a detener o revertir ese proceso.

Objectives. To better understand how diabetes care and control are being administered by general practitioners/nonspecialists in private practice in nine countries of Latin America, and to identify the most significant patient- and physician-related barriers to care.
Methods. A multicenter, cross-sectional, epidemiological survey was conducted in nine countries in Latin America: Argentina, Brazil, Chile, Costa Rica, Ecuador, Guatemala, Mexico, Peru, and Venezuela. General practitioners in private practice were asked to provide care and control data for patients 18 to 75 years of age with type 2 diabetes mellitus (T2DM), including demographics, medical and medication history, laboratory exams, and information on the challenges of patient management.
Results. Of the 3 592 patient questionnaires returned by 377 physicians, 60% of the patients had a family history of diabetes, 58% followed a poor diet, 71% were sedentary, and 79% were obese or overweight. Poor glycemic control (fasting blood glucose . 110 mg/dL) was observed in 78% of patients. The number of patients with HbA1c < 7.0% was 43.2%. Glycemic control decreased significantly with increased duration of T2DM. Comorbid conditions associated with T2DM were observed in 86% of patients; insulin use and comorbid conditions, especially those associated with microvascular complications, increased significantly disease duration. Ensuring compliance with recommended diet and exercise plans was the most-cited patient management challenge.
Conclusions. Blood glucose levels are undercontrolled in T2DM patients in the private health care system in Latin America, particularly among those who have had the disease the longest (>15 years). Considering the differences between private and public health care in Latin America, especially regarding the quality of care and access to medication, further studies are called for in the public setting. Overall, a more efficient and intensive program of T2DM control is required, including effective patient education programs, adjusted to the realities of Latin America.

Control de la diabetes mellitus tipo 2 por médicos generales del sector privado en nueve países de América Latina

Objetivos. Comprender mejor como los medicos generales/no especialistas del sector privado atienden y controlan la diabetes en nueve paises de America Latina e identificar los principales problemas relacionados con el paciente y el medico, que obstaculizan la atencion.
Metodos. Se realizo un estudio epidemiologico, multicentrico, transversal, en nueve paises de America Latina: Argentina, Brasil, Chile, Costa Rica, Ecuador, Guatemala, Mexico, Peru y Venezuela. Se pidio a los medicos generales del sector privado la informacion sobre la atencion y el control de sus pacientes de 18 a 75 anos de edad con diabetes mellitus tipo 2 (DMT2), asi como los datos demograficos, la historia clinica y de medicacion, las pruebas de laboratorio e informacion sobre los retos relacionados con la atencion del paciente.
Resultados. De los 3 592 cuestionarios de pacientes entregados por 377 medicos, 60% de los pacientes tenian antecedentes familiares de diabetes, 58% seguian una dieta inadecuada, 71% eran sedentarios y 79% presentaban obesidad o sobrepeso. Se observo un inadecuado control glucemico (glucemia en ayunas . 110 mg/dL) en 78% de los pacientes. La proporcion de pacientes con HbA1c < 7,0% fue de 43,2%. El control glucemico se redujo significativamente al aumentar la duracion de la DMT2. En 86% de los pacientes se encontraron enfermedades concurrentes asociadas con la DMT2; el uso de insulina y las enfermedades concurrentes .especialmente las asociadas con complicaciones microvasculares. incrementaron significativamente la duracion de la diabetes. En cuanto al tratamiento de los pacientes, el reto mas frecuentemente citado fue garantizar la adhesion a la dieta y al plan de ejercicios recomendados.
Conclusiones. Los niveles de glucemia no estan suficientemente controlados en los pacientes con DMT2 que se atienden en el sistema privado de salud de America Latina, particularmente en los pacientes que han tenido la enfermedad por mas tiempo (> 15 anos). Tomado en cuenta las diferencias entre la atencion sanitaria privada y la publica en America Latina, especialmente en lo concerniente a la calidad de la atencion y el acceso a los medicamentos, se requieren estudios adicionales en el sector publico. En general, se necesita un programa mas eficiente e intensivo de control de la DMT2 y programas eficaces de educacion de los pacientes, ajustados a las realidades de America Latina.

Translation into Brazilian Portuguese and validation of the Work Limitations Questionnaire

Objectives. To translate into Brazilian Portuguese, cross-culturally adapt, and evaluate the psychometric properties, reliability, and validity of the Work Limitations Questionnaire (WLQ).
Methods. This cross-sectional observational study was performed in 2005 and 2006 at the Hospital Sao Paulo/Escola Paulista de Medicina of the Federal University of Sao Paulo, Brazil. Data from 150 individuals who were employed at the time of the study were obtained using the WLQ, the SF-36 (a generic quality of life questionnaire), and the SRQ-20 (used to screen for mental disorders). The WLQ has 25 items, which are divided into four domains: time management, physical demands, mental-interpersonal demands, and output demands. The questionnaires were administered as interviews to individuals without a university education, and were self-administered to individuals with a university degree. Descriptive statistics were used to characterize the sample. The intraclass correlation coefficient and Cronbachfs alpha were used to assess reliability (internal consistency, test-retest, interobserver, and intraobserver agreement). The Pearsonfs correlation coefficient was used to assess construct validity.
Results. The mean age of the subjects was 37.6 years (standard deviation, } 9.6 years), and 64.7% of the subjects were female. The mean number of years at the job held at the time of the interview was 8.6 (} 8.3 years); 60.7% of the subjects were satisfied with their job, and 94.0% had not missed work in the preceding two weeks. In comparison to completely healthy persons, the mean productivity loss reported by the study subjects was 4.2%. Interobserver agreement was significant and high (0.600 to 0.800) or very high (0.800 to 1.000) in all domains, except physical demands (r = 0.497, moderate agreement). Intraobserver agreement was not significant for the time management and physical demands domains. The correlations associated with intraobserver agreement were moderately significant (0.400 to 0.600). Internal consistency was very high (Cronbachfs alpha = 0.800 to 1.000). There was a significant correlation between all the SF-36 questionnaire domains and the WLQ domains of time management, mental-interpersonal demands, and output demands as well as the WLQ index score. A positive correlation was also found between the WLQ domains of time management, mental-interpersonal demands, and output demands and a positive result (score . 7) on the SRQ-20.
Conclusion. The Brazilian Portuguese version of the WLQ is a reliable and valid scale to assess the impact of health problems on the productivity of Brazilian workers.

Objetivo. Traduzir para portugues brasileiro, adaptar culturalmente e avaliar as propriedades psicometricas, a confiabilidade e a validade do questionario sobre limitacoes no trabalho (Work Limitations Questionnaire, WLQ).
Metodos. O presente estudo transversal e observacional foi realizado no Hospital Sao Paulo/Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Brasil. Os dados de 150 individuos empregados no momento do estudo foram obtidos utilizando o WLQ, o SF-36 (questionario generico de avaliacao de qualidade de vida) e o SRQ-20 (usado para triagem de transtornos mentais). O WLQ apresenta 25 itens agrupados em quatro dominios: gerencia de tempo, demanda fisica, demanda mental-interpessoal e demanda de producao. Os questionarios foram administrados por entrevista para individuos sem escolaridade superior completa e autoadministrados para individuos com escolaridade superior. A estatistica descritiva foi utilizada para caracterizar a amostra. Para avaliar a confiabilidade (consistencia interna, teste-reteste e consistencia inter e intra-observador), foram calculados o coeficiente de correlacao intraclasse e o alfa de Cronbach. O coeficiente de correlacao de Pearson foi utilizado para aferir a validade da construcao.
Resultados. A idade media dos entrevistados (64,7% do sexo feminino) foi de 37,6 } 9,6 anos. O tempo medio na funcao ocupada no momento da entrevista foi de 8,6 } 8,3 anos; 60,7% estavam satisfeitos com o emprego e 94,0% nao tinham faltado ao trabalho nas 2 semanas anteriores a coleta. A perda media de produtividade registrada foi de 4,2%. A confiabilidade interobservador foi significativa e alta (entre 0,600 e 0,800) ou muito alta (0,800 a 1,000) em todos os dominios, com excecao de demanda fisica (r = 0,497, confiabilidade moderada). A confiabilidade intra-observador nao foi significativa nos dominios gerencia de tempo e demanda fisica. As correlacoes significativas encontradas para a confiabilidade intraobservador foram moderadas (r = 0,400 a 0,600). A consistencia interna foi muito alta (alfa de Cronbach de 0,800 a 1,000). Observou-se correlacao significativa entre gerencia de tempo, demanda mental-interpessoal, demanda de producao e o indice do WLQ e todos os dominios do SF-36. Tambem houve correlacao significativa entre os dominios gerencia de tempo, demanda mental-interpessoal, demanda de producao e resultado positivo (escore . 7) no questionario SRQ-20.
Conclusão. A versão do WLQ em português brasileiro é uma medida válida e confiável e pode ser útil para medir o impacto de problemas de saúde sobre a produtividade de trabalhadores brasileiros.

Objectives. Current demographic trends point to the need for understanding the health challenges facing the elderly in Latin America today. This study assessed whether health care provider choice and household income impact utilization and health among the elderly in Brazil.
Methods. Using a sample taken in 1995 in southern Brazil, a structural model was used to estimate the parameters of a function that represents the choice of health care provider, controlled for health care services utilization and a health production function. The dependent variable for the production function was self-assessed health. These two functions were structurally linked by introducing the probability of choosing a private over a public provider in the health production function as an added explanatory variable. With this structural linkage, the production function assessed how much the selection of a public versus a private provider affects health, while controlling for the possibility that individuals with poorer health have a tendency to prefer one or other health care provider.
Results. Health care services utilization by the elderly was constrained by two factors: the number of providers at the municipality level and household income. The elderly who live in municipalities with a greater number of public, outpatient clinics and providers were more likely to use the public system. Patients who used the public health care system had lower selfassessed health status than those using the private system. This result is valid even after controlling for demographic variables and morbidity.
Conclusions. Brazil’s public health system does not adequately provide for the health needs of the elderly population. Policy recommendations include further investments in the public health care infrastructure, full implementation of the National Plan for Elderly Health, and developing new programs for effective geriatric consultations at the primary care level.

Selección y utilización del proveedor de atención sanitaria por adultos mayores de un estado de Brasil: modelo estructural

Objetivos. Las tendencias demográficas actuales subrayan la necesidad de comprender los retos de salud que enfrentan los adultos mayores de América Latina. En este estudio se examina si la selección del proveedor de atención sanitaria y los ingresos del hogar influyen en el nivel de utilización y de salud de los adultos mayores en Brasil.
Métodos. Se empleó un modelo estructural con una muestra tomada en 1995 en el sur de Brasil, para estimar los parámetros de una función que represente la selección del proveedor de atención sanitaria, controlada por la utilización de los servicios de salud y una función de producción de salud. La variable dependiente para la función de producción fue el autoinforme de salud. Estas dos funciones se relacionaron estructuralmente mediante la probabilidad de escoger un proveedor privado sobre uno público en la función de producción de salud, introducida como variable explicativa adicional. Con este vínculo estructural, la función de producción estableció en qué grado influyó en el estado de salud la selección de un proveedor privado frente a uno público, controlado por la posibilidad de que las personas con peor salud tengan la tendencia de preferir uno u otro tipo de proveedor de atención sanitaria.
Resultados. La utilización de los servicios de salud por parte de los adultos mayores se vio limitada por dos factores: el número de proveedores en el municipio y los ingresos del hogar. Los adultos mayores que viven en municipios con un mayor número de proveedores y clínicas ambulatorias públicos mostraron una mayor probabilidad de utilizar el sistema público. Los pacientes que utilizaron el sistema público de atención sanitaria consideraron peor su estado de salud que los que utilizaron el sistema privado. Este resultado no varió después de controlar por las variables demográficas y la morbilidad.
Conclusiones. El sistema público de salud de Brasil no responde adecuadamente a las necesidades de salud de los adultos mayores. Entre las recomendaciones de políticas se encuentran invertir más en la infraestructura de los servicios públicos de salud, implementar el Plan Nacional para la Salud de los Adultos Mayores en su totalidad y desarrollar nuevos programas para lograr consultas geriátricas eficacientes en el nivel primario de salud.