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

Objectives. To study utilization of HIV-related health care services and to describe the health status of HIV-infected women diagnosed through antenatal voluntary counseling and testing (VCT) for HIV infection in Barbados.
Methods. This is a descriptive study. The study population includes all HIV-infected women in Barbados diagnosed as HIV-infected through VCT for HIV infection during 1996–2004.
Results. The median duration of HIV infection from time of diagnosis to the time of this report for the 163 women diagnosed during the study period was 72 months (low range, 9 months; high range, 117 months). Of the 163 women, 102 (62.6%) had attended the centralized HIV/AIDS clinic for follow-up (care, treatment, and monitoring), whereas 61 (37.4%) had never attended the clinic. The median time lag between diagnosis of HIV infection and first presentation to the HIV/AIDS clinic was 36 months (low range, 1 month; high range, 114 months). Of the HIV-infected women who attended the HIV/AIDS clinic, more than onefourth had severe immunodeficiency at the time of their first follow-up visit. Of the 53 women undergoing highly active anti-retroviral therapy (HAART) at the time of the study, 23 (43.4%) began the therapy within three months of their first follow-up visit.
Conclusions. Early HIV diagnosis through antenatal VCT is not enough to ensure that women with HIV will get adequate and timely HIV-related health care. These women suffer significant premature mortality, largely related to inadequate follow-up.

Utilización de los servicios de atención sanitaria y estado de salud de las mujeres seropositivas al VIH diagnosticadas mediante el tamizaje prenatal para el VIH en Barbados, 1996–2004

Objetivos. Estudiar la utilización de los servicios de atención sanitaria relacionados con el VIH y describir el estado de salud de las mujeres infectadas con este virus, diagnosticadas mediante el asesoramiento y la prueba de detección del VIH de carácter voluntario (APDV) durante el período prenatal en Barbados.
Métodos. Este es un estudio descriptivo. La población de estudio abarcó a todas las mujeres infectadas por el VIH, diagnosticadas en Barbados mediante el APDV en 1996–2004.
Resultados. La mediana de la duración de la infección por el VIH —desde el diagnóstico hasta el momento de este informe— en las 163 mujeres diagnosticadas durante el período de estudio fue de 72 meses (nivel bajo: 9 meses; nivel alto: 117 meses). De las 163 mujeres, 102 (62,6%) asistieron a la clínica centralizada para el VIH/sida para su seguimiento (atención, tratamiento y monitoreo), mientras que 61 (37,4%) nunca asistieron a la clínica. La mediana del lapso entre el diagnóstico de la infección por el VIH y la primera presentación a la clínica para el VIH/sida fue de 36 meses (nivel bajo: 1 mes; nivel alto: 114 meses). Más de la cuarta parte de las mujeres infectadas que acudieron a la clínica presentaban inmunodeficiencia grave en el momento de su primera consulta de seguimiento. De las 53 mujeres que se sometieron al tratamiento antirretroviral de gran actividad (HAART) durante el estudio, 23 (43,4%) comenzaron el tratamiento en los tres meses siguientes a su primera visita de seguimiento.
Conclusiones. El diagnóstico temprano mediante el APDV no garantiza que las mujeres con VIH reciban una atención adecuada y oportuna para tratar esa infección. Estas mujeres sufren una mortalidad significativamente prematura, en gran parte debido al inadecuado seguimiento.

The evolution of the ethnicity/race concept and its impact on framing policies that promote equity

Acknowledging the differences between individuals based on their unique identity is a basic requirement for achieving equity. A review of international human rights efforts and the recommendations and declarations of global conferences and regional summits as they redirect policy to battle discrimination shows a positive evolution in the concept of ethnicity/ race. This is evident in the transition from using “invisible” differences as an equalizing measure to respecting lifestyle diversity and acknowledging that individuals have a right to be valued for their differences. This evolution in the ethnicity/race concept has been pivotal to building multiethnic, multicultural, and multilingual nations in which minority groups are involved in framing equitable health policies and programs. This study covers the time period from 1948 to the present day, identifying four stages in the concept’s evolution that coincide with milestones in the political and social relationship between government institutions and ethnic minority groups. The results of these five decades of positive progress is a heightened appreciation for differences, which underlies multiethnic societies and surpasses any one of the tangible benefits received by minority groups. The progress of democratic societies depends heavily on this concept, one that ensure a stronger foundation for future development.

En América Latina existen notables desigualdades en relación con el estado de salud y el acceso a los servicios de salud de grupos étnicos/raciales en comparación con el resto de la población. Esta situación es frecuente en países con diferentes niveles de desarrollo, lo que indica que no es solo consecuencia del nivel económico del país, sino también de las estructuras político-sociales prevalecientes. Uno de los requisitos fundamentales para alcanzar la equidad es reconocer las diferencias que se derivan de la propia identidad de los individuos. Es por ello que este estudio pretende, desde el entendimiento de la evolución del concepto etnia/raza, contribuir a la formulación de políticas y programas de salud con un enfoque de equidad y facilitar la participación de los grupos étnicos/raciales en este proceso.

Underserved regions in the developing world are challenging areas to provide emergency medical care. As populations in these often remote or isolated districts may have minimal access to regular health care, contacts with medical providers are frequently episodic and driven by an acute condition. Health promoters—practitioners who provide basic medical care and promote public health in numerous countries across Central and South America, Asia and Africa—help to fill this void. Typically, health promoters are certified through a formal training program in their country and come from the same population as the clients they serve, which helps them form a link between their community and the dominant health care system in the region (1–2). Access to health and social services in regions served by health promoters is usually minimal, resulting in high morbidity and mortality associated with preventable diseases. Health promoters strive to improve the overall health of these communities by supplementing and improving the curative, preventive, and promotional aspects of the existing health system.

Entrenamiento médico en urgencias para promotores de salud de América Central y América del Sur

Los promotores de salud, las parteras y otros proveedores de cuidados médicos básicos trabajan en comunidades locales de todo el mundo para mejorar y facilitar la atención sanitaria. No hay suficiente información que describa los programas educacionales dirigidos a mejorar los conocimientos y las habilidades de los promotores de salud y sobre su impacto sanitario a largo plazo. Muchas iniciativas educacionales dirigidas a los promotores de salud consisten en intervenciones aisladas que permiten evaluar sus conocimientos inmediatamente después de la intervención, pero no miden los progresos a largo plazo en la base de conocimientos o la atención sanitaria. La Alianza Pediátrica Global —una organización sin ánimo de lucro basada en los EE.UU. que trabaja con personal médico y sanitario local— creó un programa educacional para promotores sanitarios y parteras en Ecuador, Guatemala, México y Nicaragua con un enfoque centrado en reducir la mortalidad materna e infantil y en mejorar la atención primaria y de urgencias. En este artículo se describen estas iniciativas educacionales diseñadas para mejorar las habilidades de los promotores de salud y las parteras mediante un entrenamiento médico avanzado y sostenible, ajustadas a las necesidades específicas de cada comunidad.

Objectives. The culture of stigma associated with mental illness is particularly intense when persons who are normally victims of that stigmatization (mentally ill persons and their family members) themselves act negatively toward others whom they associate with mental illness. We attempt to determine the extent of this internalization and assimilation of stigmatizing attitudes, cognitions, and behaviors in persons who are at risk for such stigmatization in Jamaica.
Methods. Data from a 2006 national survey on mental health were analyzed. Demographic variables, the presence or absence of mental illness in respondents and in their family members, and responses pertaining to behaviors and attitudes toward mentally ill persons were examined. Subsamples (respondents with mental illness, respondents with a family member with mental illness, respondents with neither) were compared using the chi-square test.
Results. Respondents with family members with mental illness were less likely to demonstrate a number of different manifestations of stigmatization than others (P = 0.009–0.019). Respondents with mental illness showed no difference in the demonstration of a number of different manifestations of stigmatization from other respondents (P = 0.069–0.515).
Conclusions. The small number of mentally ill respondents resulted in low statistical power for demonstrating differences between that subgroup and other respondents. The significantly more positive attitudes and behavior of respondents with family members with mental illness suggest that some benefit may be gained by creating more opportunities for the general public to interact with persons with mental illness.

Interiorización del estigma asociado con las enfermedades mentales: resultados de una encuesta en población general en Jamaica

Objetivos. La cultura del estigma asociado con las enfermedades mentales es especialmente intensa cuando las mismas personas que normalmente son víctimas de la estigmatización (personas con enfermedades mentales y los miembros de su familia) actúan de forma negativa hacia otras personas a las que asocian con enfermedades mentales. El objetivo de este trabajo fue determinar el grado de esta interiorización y la asimilación de actitudes, juicios y comportamientos estigmatizadores en personas en riesgo de sufrir este tipo de estigmatización en Jamaica.
Métodos. Se analizaron los datos de la encuesta nacional sobre salud mental de 2006. Se examinaron las variables demográficas, la presencia o ausencia de enfermedades mentales en los encuestados y los miembros de su familia y las respuestas relacionadas con el comportamiento y las actitudes hacia las personas que sufren enfermedades mentales. Se compararon tres submuestras (encuestados con enfermedades mentales, encuestados que tenían familiares con enfermedades mentales y encuestados sin ninguna de las características anteriores) mediante la prueba de la ji al cuadrado.
Resultados. Los encuestados que tenían familiares con enfermedades mentales presentaron menos probabilidad de mostrar diversas manifestaciones de estigmatización que los otros subgrupos (P = 0,009–0,019). No se encontraron diferencias significativas entre los encuestados con alguna enfermedad mental y los otros subgrupos en cuanto a la demostración de diversas manifestaciones de estigmatización (P = 0,069–0,515).
Conclusiones. El pequeño número de encuestados con enfermedades mentales dio como resultado un bajo poder estadístico para mostrar diferencias entre ese subgrupo y los otros. Las actitudes y el comportamiento significativamente más positivos observados en los encuestados que tenían miembros de su familia con enfermedades mentales indican que se pueden obtener beneficios si se crean más oportunidades para que la población general se relacione con personas que sufren enfermedades mentales.

Objectives. To describe drug utilization by Brazilian retirees with an emphasis on inappropriate use.
Methods. Cross-sectional study with a simple random sample of 800 retirees of the Brazilian Institute of Social Security, 60 years of age and older, residing in Rio de Janeiro City, through face-to-face interviews.
Results. Medication use in the 15 days before the study was reported by 85% of the sample, with a mean of 3.7 products per person (standard deviation = 2.9). About half the sample used one to four medications and a third used five or more. The highest number of drugs used per patient was 24. More women than men used multiple medications. There is a tendency toward positive association (P < 0.001) between drug use and variables relating to disease and health care. This trend continues in the analysis by gender. Men who reported five or more diseases were five times more likely to use multiple drugs than men with up to two (zero, one, or two) diseases (prevalence ratio 5.21, 95% confidence interval = 2.48–10.90). Women who reported five or more diseases were nearly four times more likely to use multiple drugs than women with up to two diseases (prevalence ratio 3.67, 95% confidence interval = 2.24–6.02). Of the active substances used by the sample, 10% were considered inappropriate.
Conclusions. To improve drug therapy for the elderly, health practitioners can take measures to reduce unwarranted use of medication and to optimize the benefits from important drugs. Further studies should be conducted to adjust lists of medications inappropriate for the elderly to the situation in developing countries.

Uso de medicamentos y polifarmacia en adultos mayores: encuesta en la ciudad de Rio de Janeiro, Brasil

Objetivos. Describir el uso de medicamentos en los jubilados brasileños, con énfasis en su uso inapropiado.
Métodos. Estudio transversal mediante entrevistas presenciales a una muestra simple aleatoria de 800 jubilados del Instituto Brasileño de Seguridad Social, de 60 años de edad o más, que residen en la ciudad de Rio de Janeiro.
Resultados. Del total de encuestados, 85% informó el uso de medicamentos en los 15 días previos al estudio, con una media de 3,7 productos por persona (desviación estándar = 2,9). Aproximadamente la mitad de los encuestados utilizaron de uno a cuatro medicamentos y una tercera parte empleó cinco o más. El mayor número de medicamentos usado por un paciente fue de 24. Más mujeres que hombres emplearon múltiples medicamentos. Se observó una tendencia hacia una asociación positiva (P < 0,001) entre el consumo de medicamentos y las variables relacionadas con las enfermedades y la atención sanitaria. Esta tendencia se mantuvo al hacer el análisis según el sexo. Los hombres que informaron padecer cinco enfermedades o más tuvieron cinco veces más probabilidad de usar múltiples medicamentos que los hombres con dos enfermedades o menos (razón de prevalencia [RP] = 5,21; intervalo de confianza de 95% [IC95%]: 2,48 a 10,90). Las mujeres que informaron cinco enfermedades o más tuvieron casi cuatro veces más probabilidad de emplear varios medicamentos que las mujeres que padecían dos enfermedades o menos (RP = 3,67; IC95%: 2,24 a 6,02). Se consideró que 10% de las substancias activas empleadas por los encuestados eran inapropiadas.
Conclusiones. Para mejorar el tratamiento de los adultos mayores con medicamentos, los médicos pueden tomar medidas tendentes a reducir el uso injustificado de medicamentos y optimizar los beneficios de los medicamentos de interés. Se deben realizar estudios para ajustar las listas de medicamentos inapropiados para los adultos mayores a las condiciones de los países en desarrollo.

Nutritional information of meals supplied by companies participating in the Workers’ Meal Program in São Paulo, Brazi

Objective. To compare the nutritional value of meals provided by companies participating in the Workers’ Meal Program in the city of São Paulo, Brazil, to the nutritional recommendations and guidelines established by the Ministry of Health for the Brazilian population.
Methods. The 72 companies studied were grouped according to economic sector (industrial, services, or commerce), size (micro, small, medium, or large), meal preparation modality (prepared on-site by the company itself, on-site by a hired caterer, or off-site by a hired caterer), and supervision by a dietitian (yes or no). The per capita amount of food was determined based on the lunch, dinner, and supper menus for three days. The nutritional value of the meals was defined by the amount of calories, carbohydrates, protein, total fat, polyunsaturated fat, saturated fat, trans fat, sugars, cholesterol, and fruits and vegetables.
Results.Most of the menus were deficient in the number of fruits and vegetables (63.9%) and amount of polyunsaturated fat (83.3%), but high in total fat (47.2%) and cholesterol (62.5%). Group 2, composed of mostly medium and large companies, supervised by a dietician, belonging to the industrial and/or service sectors, and using a hired caterer, on averaged served meals with higher calorie content (P < 0.001), higher percentage of polyunsaturated fat (P < 0.001), more cholesterol (P = 0.015), and more fruits and vegetables (P < 0.001) than Group 1, which was composed of micro and small companies from the commercial sector, that prepare the meals themselves on-site, and are not supervised by a dietitian. Regarding the nutrition guidelines set for the Brazilian population, Group 2 meals were better in terms of fruit and vegetable servings (P < 0.001). Group 1 meals were better in terms of cholesterol content (P = 0.05).
Conclusions. More specific action is required targeting company officers and managers in charge of food and nutrition services, especially in companies without dietitian supervision.

Objetivo. Avaliar os aspectos dietéticos das refeições oferecidas por empresas inscritas no Programa de Alimentação do Trabalhador (PAT) na Cidade de São Paulo, Brasil, em relação às recomendações nutricionais do Guia Alimentar para a População Brasileira do Ministério da Saúde.
Métodos. Foram investigadas 72 empresas, caracterizadas conforme setor (indústria, serviços ou comércio), porte (micro, pequenas, médias ou grandes), modalidade do PAT (autogestão, gestão terceirizada do tipo refeição transportada ou gestão terceirizada do tipo preparo e distribuição de refeição na empresa) e supervisão de nutricionista (sim ou não). A quantidade per capita dos alimentos foi determinada nos cardápios de 3 dias de almoço, jantar e ceia. O valor nutricional das refeições foi definido com base nas variáveis energia, carboidrato, proteína, gorduras totais, gordura poliinsaturada, gordura saturada, gordura trans, açúcares livres, colesterol e frutas e hortaliças.
Resultados. A maioria dos cardápios teve baixa oferta de frutas e hortaliças (63,9%) e gordura poliinsaturada (83,3%) e excesso de gorduras totais (47,2%) e colesterol (62,5%). O agrupamento 2, composto principalmente por empresas de médio e grande porte do setor industrial e de serviços, com gestão terceirizada e supervisão de nutricionista, teve, em média, refeições com maior valor energético (P < 0,001), maior porcentagem de gorduras poliinsaturadas (P < 0,001), maior quantidade de colesterol (P = 0,015) e maior quantidade de frutas e hortaliças (P < 0,001) do que o agrupamento 1, composto por micro e pequenas empresas do setor de comércio, tendo autogestão como modalidade e sem supervisão de nutricionista. Quanto à adequação dos cardápios oferecidos às metas do Guia Alimentar para a População Brasileira, as refeições do agrupamento 2 foram mais adequadas em relação à oferta de frutas e hortaliças (P < 0,001). Em contrapartida, o agrupamento 1 apresentou maior adequação da quantidade de colesterol (P = 0,05).
Conclusões. É necessária uma ação mais direcionada aos gestores de empresas e aos responsáveis pelas unidades de alimentação e nutrição, principalmente no grupo de empresas que não tem a supervisão de nutricionista.

Prevalence of untreated caries in deciduous teeth in urban and rural areas in the state of São Paulo, Brazil

Objectives. To describe the prevalence of dental caries in children with deciduous teeth in urban and rural areas in the state of São Paulo, Brazil, and to identify associated factors.
Methods. The study included 24 744 children (5–7 years of age) examined as part of an epidemiological survey on oral health carried out in the state of São Paulo (Levantamento Epidemiológico de Saúde Bucal do Estado de São Paulo). Multilevel analysis was used to investigate whether the prevalence of untreated caries was associated with the sociodemographic characteristics of the children examined or with the socioeconomic aspects of the participating cities.
Results. Being black or brown (adjusted odds ratio (OR) = 1.27), attending school in rural areas (adjusted OR = 1.88), and attending public school (adjusted OR = 3.41) were identified as determinants for an increased probability of presenting deciduous teeth with untreated caries. Being a female (adjusted OR = 0.83) was identified as a protective factor. The negative coefficients obtained for second-level independent variables indicate that the oral health profile of the cities included in the study were positively impacted by a higher municipal human development index (β = –0.47) and fluoridated drinking water (β = –0.32).
Conclusions. The prevalence of untreated caries is influenced by individual and sociodemographic factors. The present study provides epidemiological information concerning the rural areas in the state of São Paulo. This information is useful for strategic planning and for establishing guidelines for oral health actions in local health systems, thereby contributing to oral health equity.

Objetivo. Descrever os diferenciais urbano-rurais da prevalência de cárie dentária em crianças com dentição decídua no Estado de São Paulo e identificar fatores associados.
Métodos. Participaram do estudo 24 744 crianças de 5 a 7 anos examinadas no Levantamento Epidemiológico de Saúde Bucal do Estado de São Paulo. Utilizou-se a análise multinível para verificar se havia associação entre a prevalência de cárie não tratada e as características sociodemográficas das crianças examinadas ou os aspectos socioeconômicos das cidades participantes.
Resultados. Ser negro ou pardo (razão de chances, ou OR, ajustada = 1,27), estudar na área rural (OR ajustada = 1,88) e freqüentar a escola pública (OR ajustada = 3,41) foram identificados como determinantes individuais de chance mais elevada de apresentar um ou mais dentes decíduos com cárie não tratada. Ser do sexo feminino (OR ajustada = 0,83) foi identificado como fator de proteção para essa condição. Os coeficientes negativos obtidos para as variáveis independentes de segundo nível indicaram que o perfil de saúde bucal das cidades participantes se beneficiou de valores mais elevados de índice de desenvolvimento humano municipal (b = –0,47) e da adição de flúor à rede de águas (b = –0,32).
Conclusões. A prevalência de cárie não tratada é influenciada por fatores sociodemográficos de ordem individual e contextual. O presente estudo apresenta informações epidemiológicas das áreas rurais do Estado de São Paulo, oferecendo subsídios para o planejamento estratégico e normativo das ações de saúde bucal nos sistemas locais de saúde, com o intuito de contribuir para a promoção de eqüidade em saúde bucal.

A structural equation model for predictors of mental and physical health in women

Objective. To measure the extent to which stress, social support, and self-esteem are predictors of an individual’s mental and physical health. Structural equations were integrated with previously-estimated partial models, which simplify the relationships among variables.
Methods. The study sample included 283 women with children. All of the participants resided in the municipality of General Escobedo, state of Nuevo León, Mexico. The surveys were carried out in the second semester of 2003, in the participants homes, using self-evaluation questionnaires to measure each of the variables included in the model. Each participant completed the questionnaire in one sitting. Results were analyzed with AMOS 5.0, employing the maximum likelihood method, often utilized in structural equation models.
Results. The results indicate an acceptable adjustment in the proposed model: (χ2/gl = 3.03, goodness of fit (GFI) = 0.894, adjusted goodness of fit (AGFI) = 0.848, root mean square error of approximation (RMSEA) = 0.08, incremental fit index (IFI) = 0.910). Variances were 31.9% with regard to stress, 27.4% with regard to physical health, and 72.1% with regard to mental health.
Conclusions. Social support and self-esteem are predictors of stress; age and stress are predictors of physical health; and stress, self-esteem, and physical health are predictors of mental health.

Objetivo. Valorar la capacidad predictora del estrés, el apoyo social y la autoestima respecto de la salud mental y física del individuo mediante ecuaciones estructurales, integrando modelos parciales estimados anteriormente, lo que permite simplificar los efectos entre las variables.
Métodos. La muestra estudiada abarcó 283 mujeres con hijos. Todas las participantes residían en el municipio de General Escobedo, estado de Nuevo León, México. Las encuestas se realizaron en el segundo semestre de 2003, en los domicilios, utilizando cuestionarios de autoevaluación para valorar cada una de las variables incluidas en el modelo. Cada participante respondió a los cuestionarios en una sola sesión. Los resultados se analizaron con el programa AMOS 5.0, empleando el método de máxima verosimilitud, comúnmente utilizado en los modelos de ecuaciones estructurales.
Resultados. Los resultados obtenidos indican un ajuste aceptable en el modelo propuesto (c2/gl = 3,03, GFI (índice de bondad del ajuste) = 0,894, AGFI (índice de bondad del ajuste corregido) = 0,848, RMSEA (error de aproximación cuadrático medio) = 0,08, IFI (índice de ajuste incremental) = 0,910). La varianza explicada es del 31,9% respecto del estrés, del 27,4% respecto de la salud física y del 72,1% respecto de la salud mental.
Conclusiones. El apoyo social y la autoestima son predictores del estrés; la edad y el estrés, predictores de la salud física; y el estrés, la autoestima y la salud física, predictores de la salud mental.