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

Objectives. To describe demographic and practice characteristics of male and female midwives in private practice (MIPPs) in 10 cities of Peru, and their role in the delivery of reproductive health care, specifically management of sexually transmitted infections (STIs).
Methods. As part of an intervention trial in 10 cities in the provinces of Peru designed to improve STI management, detailed information was collected regarding the number of midwives in each city working in various types of practices. A door-to-door survey of all medical offices and institutions in each city was conducted. Each MIPP encountered was asked to answer a questionnaire regarding demographics, training, practice type(s), number of STI cases seen per month, and average earnings per consultation.
Results. Of the 905 midwives surveyed, 442 reported having a private practice, either exclusively or concurrently with other clinical positions; 99.3% of these MIPPs reported managing STI cases. Andean cities had the highest density of MIPPs, followed by jungle and coastal cities, respectively. Jungle cities had the largest proportion of male MIPPs (35.5%). While both male and female MIPPs reported seeing male patients, male MIPPs saw a significantly greater number than their female counterparts.
Conclusions. In areas of Peru where physicians are scarce, MIPPs provide needed reproductive health services, including STI management. Male MIPPs in particular appear to serve as health care providers for male patients with STIs. This trend, which may exist in other developing countries with similar healthcare workforce demographics, highlights the need for new areas of training and health services research.

¿Se prefieren enfermeros obstétricos para el control de las infecciones de trasmisión sexual en hombres en los países en desarrollo?

Objetivos. Describir las características demográficas y de la práctica profesional del personal de enfermería obstétrica en consultorios privados (ECP) según el sexo en 10 ciudades de Perú y el papel que desempeñan en los cuidados de salud reproductiva, específicamente en la atención de las infecciones de transmisión sexual (ITS).
Métodos. Como parte de un ensayo de intervención en 10 ciudades de diferentes provincias de Perú, diseñado para mejorar la atención de las ITS, se recogió información detallada del personal de enfermería obstétrica ocupado en diferentes tipos de consultorios de cada ciudad. Se realizó una encuesta de puerta en puerta en todos los consultorios e instituciones médicas de cada ciudad. A cada ECP localizado se le pidió responder un cuestionario sobre datos demográficos, entrenamiento, tipo(s) de consultorio( s), número de casos de ITS atendidos mensualmente e ingresos medios por consulta.
Resultados. De los 905 enfermeros y enfermeras encuestados, 442 informaron tener una consulta privada, ya sea de forma exclusiva o concurrente con otros cargos clínicos; 99,3% de estos ECP manifestaron atender casos de ITS. Las ciudades andinas presentaron la mayor densidad de ECP, seguidas por las de la selva y la costa, en ese orden. Las ciudades de la selva presentaron la mayor proporción de ECP hombres (35,5%). Aunque tanto los ECP hombres como las ECP mujeres informaron atender pacientes masculinos con ITS, los ECP hombres atendieron un número significativamente mayor que sus contrapartes mujeres.
Conclusiones. En zonas de Perú donde no hay suficientes médicos, los ECP ofrecen los servicios necesarios de salud reproductiva, incluida la atención de las ITS. En particular, los ECP hombres parecen servir como proveedores de atención sanitaria a pacientes masculinos con ITS. Esta tendencia, que podría existir en otros países en desarrollo con personal sanitario con características demográficas similares, resalta la necesidad de establecer nuevas líneas de entrenamiento e investigación en servicios de salud.

Application of key frameworks to an indicator-based evaluation of environmental health in Latin America and the Caribbean

The establishment of environmental health indicators for assessing the adverse effects of environmental changes on the population’s health and quality of life is, as yet, a goal that has not been fully reached in Latin America and the Caribbean. As such, the United Nations Environment Program and the Pan American Health Organization (PAHO) have convened Region’s institutions and experts to develop a comprehensive method for assessing environmental health. This paper evaluates several methodologies, comprehensive or otherwise, for assessing health and the environment, and describes the frameworks that have historically undergirded the key methods that have either structured or generated the environmental health indicators being used in Latin America and the Caribbean. The recurring, methodological limitations were identified: (a) relying heavily on secondary data, which points out the need for technological infrastructure that is rarely available in Latin America and the Caribbean today; and (b) a lack of clear criteria for developing inclusive tools that would facilitate the discussion of environmental health issues at the grass-roots level. Despite the progress made by the field of environmental health with regard to understanding its interdisciplinary complexities, intersectoral operations must be improved to favor open communication and implementation of integrated policies on environmental and health.

La construcción de indicadores de salud ambiental para evaluar el efecto adverso de los cambios ambientales sobre el bienestar y la calidad de vida de la población es una meta todavía no alcanzada totalmente en América Latina y el Caribe. Por ello, el Programa de las Naciones Unidas para el Medio Ambiente y la Organización Panamericana de la Salud han convocado a instituciones y especialistas de toda la Región para desarrollar un método integral de evaluación del medio ambiente y la salud. En este trabajo se hace un análisis crítico de varias de las metodologías de evaluación ambiental y sanitaria (integrales o no) y se describen, desde una perspectiva histórica, los marcos conceptuales que fundamentan los principales métodos ordenadores o generadores de indicadores de salud ambiental utilizados en América Latina y el Caribe. Se identificaron dos limitaciones metodológicas recurrentes: a) la fuerte dependencia de datos secundarios, lo que implica la necesidad de una capacidad tecnológica instalada poco accesible en América Latina y el Caribe en la actualidad; y b) la falta de criterios claros para desarrollar instrumentos participativos que faciliten la evaluación de problemas de salud ambiental a nivel local. A pesar de los avances alcanzados en el campo de la salud ambiental en cuanto a la comprensión de su complejidad interdisciplinaria, aún se deben mejorar los mecanismos intersectoriales que favorezcan la discusión e implementación de políticas integradas de medio ambiente y salud.

Current perspectives on health care for the older adult

Standing up to the challenges of aging requires a coordinated strategy, disseminating a geriatric focus among all the specialty areas that serve the older adult. This article addresses the reasons that justify this focus and covers the objectives, goals, and methods currently being proposed to develop the approach. Preventive and curative actions, but most importantly, the overall care of seniors and improvements to their functional status, are priorities for securing a better quality of life in old age.

Enfrentar los retos de envejecer requiere una estrategia coordinada, difundiendo un foco geriátrico entre todas las áreas de la especialidad que atienden a la persona de edad. Este artículo aborda las razones que justifican este foco y abarca los objetivos, metas y métodos actualmente proponiéndose para desarrollar el enfoque. Las acciones preventivas y curativas, pero lo que es más importante la atención general de los adultos mayores y mejoras a su estado funcional, son prioridades para asegurar una mejor calidad de vida en la vejez.

Health surveys and use of maternal and child health care services in three municipalities within the São Paulo metropolitan area

Objectives. To describe the changes in the use of maternal and child health care services by residents of three municipalities—Embu, Itapecerica da Serra, and Taboão da Serra—in the São Paulo metropolitan area, 12 years after the implementation of the Unified Health System (SUS) in Brazil, and to analyze the potential of populationbased health care surveys as sources of data to evaluate these changes.
Methods. Two population-based, cross-sectional surveys were carried out in 1990 and 2002 in municipalities located within the São Paulo metropolitan area. For children under 1 year of age, the two periods were compared in terms of outpatient services utilization and hospital admission; for the mothers, the periods were compared in terms of prenatal care and deliveries. In both surveys, stratified and multiple-stage conglomerate sampling was employed, with standardization of interview questions.
Results. The most important changes observed were regarding the location of services used for prenatal care, deliveries, and hospitalization of children less than 1 year of age. There was a significant increase in the use of services in the surrounding region or hometown, and decrease in the utilization of services in the city of São Paulo (in 1990, 80% of deliveries and almost all admissions for children less than 1 year versus 32% and 46%, respectively, in 2002). The use of primary care units and 24-hour walk-in clinics also increased. All these changes reflect care provided by public resources. In the private sector, there was a decrease in direct payments and payments through company-paid health insurance and an increase in payments through selfpaid health insurance.
Conclusions. The major changes observed in the second survey occurred simultaneous to the changes that resulted from the implementation of the SUS. Populationbased health surveys are adequate for analyzing and comparing the utilization of health care services at different times.

Objetivos. Descrever as mudanças na utilização de serviços de saúde materno-infantis por residentes em três municípios da Grande São Paulo (Embu, Itapecerica da Serra e Taboão da Serra) 12 anos após a implantação do Sistema Único de Saúde (SUS) e analisar o potencial dos inquéritos de saúde de base populacional como fonte de dados para avaliar as mudanças nesses serviços.
Métodos. Em 1990 e 2002, foram realizados dois inquéritos de base populacional, de corte transversal, em municípios da região metropolitana de São Paulo. Para os menores de 1 ano, os dois períodos foram comparados quanto à utilização de serviços de saúde ambulatoriais e hospitalizações; para as mães, os períodos foram comparados quanto à realização de pré-natal e parto. Em ambos os inquéritos, utilizou-se a amostragem por conglomerados em múltiplos estágios e estratificada, com padronização de questões das entrevistas.
Resultados. As alterações de maior destaque corresponderam à localização dos serviços utilizados para pré-natal, partos e hospitalização de menores de 1 ano. Houve elevação significativa na utilização dos serviços no município de residência ou região e redução na participação do Município de São Paulo (80% dos partos e praticamente todas as internações de menores de 1 ano em 1990 contra 32% dos partos e 46% das internações de menores de 1 ano em 2002). Também aumentou a utilização de unidades básicas de saúde e prontos-socorros. Essas alterações referiram-se aos atendimentos financiados pelo setor público de saúde. No setor privado, ocorreu queda do desembolso direto e dos convênios de empresa e crescimento dos planos individuais.
Conclusões. As principais mudanças verificadas no segundo inquérito ocorreram paralelamente às alterações provenientes da implantação do SUS. Os inquéritos de saúde de base populacional mostraram-se adequados para analisar e comparar a utilização de serviços em diferentes períodos.

Health-related quality of life among people with intellectual disabilities in Spain

Objective. To measure health-related quality-of-life (HRQL) among people with intellectual disabilities in the province of Salamanca, Spain.
Methods. A population-based, cross-sectional descriptive study. The SF-36 Health Survey, adapted and validated for the Spanish population, was selected and administered to 265 people with intellectual disabilities in the province of Salamanca, Spain. Personal interviews were also conducted with the participants in the presence of their parents, tutors, or close family. Eight quality-of-life scales were explored: general health, physical functioning, role–physical, bodily pain, role–emotional, social functioning, vitality, and mental health, based on questions on sociodemographic and lifestyle variables, health services utilization, support needs, and health status and HRQL.
Results. Of the 265 people studied, 69.8% were men and 30.2% were women (median age: 35 years; minimum: 16; maximum: 72). The highest number of points pertained to role–physical and physical functioning (more than 85 points), and the lowest, to general health and vitality (less than 70 points). No significant differences were found between men and women for any of the eight components. The independent variables, age, family income, level of education, and support needs showed the greatest number of independent associations with the general health, physical functioning, and social functioning components. Of the participants, 41.5% indicated that they felt their health was good.
Conclusions. The study participants perceived their HRQL to be good, especially on the role–physical and physical functioning scales. Additional studies should be designed to evaluate HRQL in people with different degrees of intellectual disability to further contribute to intervention efforts and health and social programs designed specifically for this population group and to evaluate the interventions and program already underway.

Objetivo. Establecer la calidad de vida relacionada con la salud (CVRS) percibida por las personas con discapacidad intelectual en la provincia de Salamanca, España.
Métodos. Estudio descriptivo transversal de base poblacional. Se aplicó el cuestionario de salud SF-36, adaptado y validado para la población española, a 265 personas con discapacidad intelectual de la provincia de Salamanca, España. Se realizaron entrevistas personales a los participantes en presencia de sus padres, tutores o familiares cercanos. Se exploraron ocho dimensiones de la calidad de vida: salud general, función física, rol físico, rol emocional, función social, dolor corporal, vitalidad y salud mental a partir de variables sociodemográficas y de estilo de vida, utilización de servicios de salud, necesidades de apoyo, y estado de salud y CVRS.
Resultados. De las 265 personas estudiadas, 69,8% eran hombres y 30,2% eran mujeres (edad media: 35 años; mínima: 16; máxima: 72). Las puntuaciones máximas obtenidas correspondieron a las dimensiones rol físico y función física (por encima de 85 puntos) y las mínimas, a salud general y vitalidad (por debajo de 70 puntos). No se observaron diferencias significativas entre los hombres y las mujeres en ninguna de las ocho dimensiones. Las variables independientes edad, ingresos familiares, nivel educacional y necesidad de apoyo presentaron la mayor cantidad de asociaciones independientes con las dimensiones salud general, función física y función social. De los participantes, 41,5% manifestó que su salud percibida era buena.
Conclusiones. Los participantes en este estudio percibieron su CVRS como buena, especialmente en las dimensiones rol físico y función física. Se deben diseñar estudios para evaluar la CVRS en personas con diferentes grados de discapacidad intelectual para contribuir a elaborar intervenciones y programas sanitarios y sociales específicos para esta población y para evaluar las intervenciones y los programas en marcha.

In recent years, it has become increasingly more common to find that the declarations, resolutions, and documents of various organizations contain an appeal to improve, update, and develop valid, timely, useful, and representative information on external causes of injury (ECI). Almost all of the United Nations’ specialized agencies, including its General Assembly, have underscored its importance with the same urgency.

En los últimos años es frecuente encontrar en declaraciones, resoluciones y documentos de diversas instituciones llamados a mejorar, actualizar y hacer confiable, oportuna, útil y representativa la información sobre las lesiones de causa externa (LCE). Prácticamente todas las organizaciones especializadas de las Naciones Unidas, incluida su Asamblea General, han enfatizado la importancia de ello con singular insistencia.

In 2000, the Pan American Health Organization (PAHO), with technical assistance from the U.S. Centers for Disease Control and Prevention (CDC), initiated the project to establish injury surveillance systems in EDs with the goal of advancing injury epidemiology and prevention capacity in Latin America. Colombia, El Salvador, and Nicaragua were selected for the initial pilot surveillance systems, which were designed to enhance the ability of select hospitals to monitor injury trends and promote appropriate prevention interventions. The project also sought to increase injury awareness among health officials and personnel from other agencies.

Establecimiento de sistemas de vigilancia de lesiones en Colombia, El Salvador y Nicaragua (2000–2006)

La Organización Panamericana de la Salud (OPS), en colaboración con los Centros para el Control y la Prevención de Enfermedades (CDC) de los Estados Unidos de América, estableció en 2000 sistemas para la vigilancia de lesiones en Colombia, El Salvador y Nicaragua. Estos sistemas, basados en los servicios hospitalarios de emergencia, formaron parte de un proyecto piloto fundamentado en las guías para la vigilancia de lesiones, desarrolladas por la Organización Mundial de la Salud (OMS) y los CDC. Los objetivos de este proyecto eran evaluar la utilidad de las guías de la OMS/CDC, crear mecanismos apropiados para la vigilancia de lesiones en los tres países, promover intervenciones preventivas adecuadas e integrar la prevención y el control de lesiones en proyectos nacionales de salud pública. En este artículo se describe el proyecto piloto de la OPS/CDC y se resaltan los principios más importantes y las lecciones aprendidas durante sus seis años de funcionamiento (2000–2006). Entre las principales recomendaciones se encuentran la integración de la vigilancia de las lesiones en las unidades de epidemiología e información existentes en los ministerios de salud, la recogida de los datos importantes exclusivamente, la garantía de monitoreos y evaluaciones adecuados y la adopción de las prácticas que han demostrado ser más efectivas para el entrenamiento de personal y la diseminación de información.

Objective. This article describes the characteristics of violence-related injury (VRI) cases presenting at emergency departments (EDs) in Brazil and compares circumstances for assaultrelated and self-inflicted cases.
Methods. The study is cross-sectional. The data describe cases seen in September 2006 in 62 EDs, representing all 26 states and the Federal District. A total of 4 835 case records were analyzed. Basic statistical tabulations were complemented by logistic regression analysis to assess potential associations between type of violence (assault or self-harm) and multiple factors.
Results. Males comprised 72.8% of cases while those aged 20 to 29 comprised 35.4%. Alcohol use was reported or suspected in 42.7% of cases, more commonly among males. Assault victims comprised 91.4% of cases versus self-inflicted injuries, which accounted for 8.6%. Threefourths of the assault victims were male, while over half of the self-inflicted injury victims were female. The leading mechanism for assaults was physical force/blunt objects (46.2%), whereas poisoning was the predominant mechanism for self-inflicted injuries (71.4%). Younger females were significantly more likely to have been victims of self-inflicted injuries than younger males, while younger males were more likely to have been victims of assault; this finding is more pronounced in cases where alcohol use was reported. Self-inflicted injuries were significantly more likely to occur in residences, while assaults were more likely to occur away from home.
Conclusion. These results can improve understanding of the scope and characteristics of VRIs in Brazil (and thus contribute to national injury prevention efforts), and help identify areas for future research.

Lesiones relacionadas con la violencia en los servicios de emergencia de Brasil

Objetivos. Se describen las características de los casos de lesiones relacionadas con la violencia (LRV) que se presentan en los servicios de emergencia en Brasil y se comparan las circunstancias de los casos relacionados con asaltos y los autoinfligidos.
Métodos. En este estudio de corte transversal se describen los casos atendidos en septiembre de 2006 en 62 servicios de emergencia de 26 estados y el Distrito Federal. Se analizaron 4 835 casos por medio de tabulaciones estadísticas básicas y se evaluó mediante análisis de regresión logística la posible asociación entre los tipos de violencia (asalto o lesión autoinfligida) y diversos factores.
Resultados. De los casos, 72,8% eran hombres y 35,4% tenían entre 20 y 29 años. Se informó o sospechó del consumo de bebidas alcohólicas en 42,7% de ellos, más frecuentemente en hombres. De los casos, 91,4% eran víctimas de asaltos y 8,6% de lesiones autoinfligidas. Tres cuartas partes de las víctimas de asaltos eran hombres y la mitad de las lesiones autoinfligidas fueron en mujeres. El principal mecanismo de asalto fue la fuerza física/objetos romos (46,2%), mientras que el veneno fue el mecanismo predominante en las lesiones autoinfligidas (71,4%). Las mujeres jóvenes presentaron una probabilidad significativamente mayor de haber sufrido lesiones autoinfligidas que los hombres jóvenes, mientras que estos tuvieron una mayor probabilidad de haber sido víctimas de asaltos, especialmente cuando se informó de consumo de alcohol. Las lesiones autoinfligidas tuvieron una probabilidad significativamente mayor de ocurrir en el hogar, mientras que los asaltos fueron más probables fuera de casa.
Conclusiones. Estos resultados pueden ayudar a comprender mejor el alcance y las características de las LRV en Brasil —y así contribuir a los esfuerzos nacionales de prevención de lesiones— y a identificar nuevas áreas de investigación.

Emergency care for victims of accidents and violence in Brazil

Objective. To analyze positive results, challenges, limitations, and potential benefits associated with the Brazilian Policy for the Reduction of Morbidity and Mortality due to Accidents and Violence (PNRMAV) with regard to hospital emergency and urgent care services.
Methods. From 2004–2007, a study was carried out in four Brazilian state capitals and the Federal District. The following areas were evaluated: the availability of standard practices for managing victims of accident or violence; availability and quality of adult and pediatric intensive care beds; patient management training for health care professionals; communication among the health care areas to provide better care to victims; and structure and organization of hospital services. The study included an exploratory stage, fieldwork, analysis, and dissemination of data. Both quantitative (absolute and relative frequencies) and qualitative methods (analysis of interactions between explicit and inferred information from statements and field records) were employed in the analysis.
Results. The study revealed positive results from the implementation of PNRMAV. The following focal areas were identified: (1) the need to invest in the response capacity of primary care services, (2) the importance of strengthening and promoting the emergency and urgent care network, (3) the importance of investing in appropriate equipment and of planning maintenance so that availability is not impacted, and (4) the need to invest in continuing education for health care professionals.
Conclusions. The partial success obtained with PNRMAV shows that it is possible to include the topic of violence and accidents in the public health agenda and to implement life-promoting strategies at different levels.

Objetivo. Analisar os êxitos, lacunas, problemas e potencialidades da aplicação da Política Nacional de Redução de Morbimortalidade por Acidentes e Violências (PNRMAV) no Brasil quanto à atenção hospitalar de emergência e urgência.
Métodos. De 2004 a 2007, uma pesquisa foi realizada em quatro capitais e no Distrito Federal. Os seguintes aspectos foram investigados: existência de padronização de condutas de atendimento às vítimas de acidentes e violências; oferta e adequação de leitos de terapia intensiva (adulta e pediátrica); capacitação dos profissionais para o atendimento; existência de articulação intersetorial para melhor atendimento às vítimas; e estruturação e organização dos serviços de atendimento hospitalar. A operacionalização incluiu uma fase exploratória, trabalho de campo, análise e divulgação dos dados. Para a análise, foram utilizados métodos quantitativos (freqüências simples e relativas) e qualitativos (análise de interações entre conteúdos manifestos e inferências de conteúdos latentes nos depoimentos e anotações de campo).
Resultados. O estudo revelou resultados positivos associados à implantação da PNRMAV e permitiu identificar os seguintes pontos de atenção: 1) necessidade de investimento na resolutividade dos serviços de atenção básica, 2) importância de se fortalecer e articular a rede de urgência e emergência, 3) relevância dos investimentos em equipamentos adequados e sua manutenção no ritmo exigido pelos atendimentos e 4) necessidade de investimentos na formação permanente de profissionais.
Conclusões. Os sucessos parciais alcançados pela implantação da PNRMAV mostram que é possível incluir o tema da violência e dos acidentes na pauta da saúde pública e atuar com estratégias em diferentes níveis a favor da vida.

Control of cervical cancer in Colombia: the perspective of the health system

Objectives. To characterize the health system stakeholder’s perspective on the basics of the political, economic, and sanitary context, as well as the ways in which control activities are being realized in four of Colombia’s health departments.
Methods. This was a qualitative study of four Colombian health departments chosen for their differing cervical cancer mortality rates and their planned disease control efforts (Boyacá, Caldas, Magdalena, and Tolima). Semistructured interviews were conducted of health care managers, insurance coordinators, and public and private health institutions at the departmental and municipals levels. Focus groups comprised of professionals from health insurance companies and health care services providers were convened. Data analysis was based on the grounded theory with open codes related to the roles of health care managers, insurance companies, and heath care services provided. The technical reports were compared to the testimonies of interviewees.
Results. Thirty-eight interviews and 14 focus groups (70.9% response rate) were conducted and 12 technical reports reviewed. Cervical cancer is not perceived to be a public health priority. Interest centers on the flow of financial resources within the health system. Findings indicated unsatisfactory communication among the stakeholders and no consensus on the subject. Planning is limited to meeting the status quo. Staffing is inadequate. Cases with positive outcomes are lost to follow-up due to the fragmentation that results from affiliation with different health care systems.
Conclusions. The financial situation, normative planning, and the challenges of decentralization affect the skill-building, at-risk coverage, and the control activities needed for effective screening programs. What is needed is an integrated, more efficiently organized program in which all the health system stakeholders participate.

Objetivo. Caracterizar, desde la perspectiva de los actores del sistema de salud, los elementos del contexto político, económico y sanitario, así como la forma en que se articulan las actividades para el control del cáncer cervicouterino en cuatro departamentos de Colombia.
Métodos. Estudio cualitativo en cuatro departamentos colombianos seleccionados por sus diferentes niveles de mortalidad por cáncer cervicouterino y de organización de las actividades de control de esta enfermedad (Boyacá, Caldas, Magdalena y Tolima). Se realizaron entrevistas semiestructuradas a funcionarios, directores de aseguradoras y de instituciones de salud públicas y privadas a niveles departamental y municipal. Se conformaron grupos focales con profesionales de las empresas aseguradoras y prestadoras de servicios. El análisis de la información se basó en la teoría fundamentada con codificaciones abiertas relacionadas con las funciones de las direcciones de salud, de las empresas aseguradoras y las acciones de los servicios de salud. Los informes técnicos se contrastaron con los testimonios.
Resultados. Se realizaron 38 entrevistas y se trabajó con 14 grupos focales (70,9% de respuesta) y 12 informes técnicos. El cáncer cervicouterino no es percibido como una prioridad de la salud pública. El interés se centra en el flujo de dinero dentro del sistema. No se encontró una adecuada articulación entre los actores y no hay rectoría en el tema. La planificación se limita al cumplimiento de las normas. Los recursos humanos son inadecuados. No hay seguimiento de los casos positivos por la fragmentación de la población según su afiliación al sistema de salud.
Conclusiones. La orientación financiera, la planificación normativa y las dificultades de la descentralización afectan al desarrollo de las competencias, la cobertura de la población de alto riesgo y las actividades de control necesarias para el adecuado funcionamiento de los programas de tamizaje. Se requiere un programa integrado y mejor organizado en el que participen los diferentes actores del sistema de salud.