Brazilian Public Health Service Research Articles

Associations between Stigma, Depression, and Adherence to Antiretroviral Therapy in Brazilian Men Who Have Sex with Men Living with HIV.

Adherence to antiretroviral therapy (ART) is a complex and multi-determined process that is influenced by psychosocial variables. Although international studies have pointed to the adverse impact of HIV stigma, sexual stigma, and depression on ART adherence among men who have sex with men (MSM) with HIV, less is known about this association among Brazilians. We aimed to (a) evaluate indicators of depression, stigma related to HIV and homosexuality, and adherence to ART in a sample of Brazilian MSM living with HIV; (b) assess possible correlations between the variables analyzed, and (c) assess the impact of HIV and sexual stigma and depression on ART adherence. This cross-sectional study comprised 138 Brazilian MSM living with HIV as participants. Scales used included: a sociodemographic/clinical questionnaire, the questionnaire for assessment of adherence to antiretroviral therapy (CEAT-HIV), the Beck depression inventory (BDI-II), the internalized homophobia scale, and the HIV stigmatization scale. The mean adherence score was relatively high (78.83, within a range of 17-89 points). However, we observed inadequate ART adherence (CEAT-HIV < 75) in 28 (20.2%) respondents. Participants reported high scores for internalized sexual stigma, perceived sexual stigma in the community, and HIV stigma. Symptoms of depression were identified in 48.47% of participants. We found negative correlations between depression, HIV stigma, and treatment adherence, but not between sexual stigma and ART adherence. HIV-related stigma and sexual stigma were positively correlated with depression. Our regression analysis indicated that each year of age at diagnosis of HIV increased adherence by 0.22 points, on average. Each additional BDI-II score reduced adherence to ART by 0.20 points. The high prevalence of depression, HIV stigma, and sexual stigma, and their adverse effects on ART adherence and mental health, point to the need to implement evidence-based interventions to reduce sexual and serological stigma in the general population, as well as to mitigate the negative impacts of stigma on MSM living in HIV in Brazil. They also highlight the importance of periodically screening for these variables among MSM treated in Brazilian public health services, especially among those with inadequate adherence to ART.

Availability of Electroconvulsive Therapy in Public Health Services in the Last Decade in Brazil.

To identify the current treatment options for electroconvulsive therapy (ECT) therapy in public services linked to the Unified Health System in Brazil and compare them with data published in 2012 based on their availability. In this retrospective observational study, we mapped institutions that perform ECT under public health services in Brazil. A questionnaire was administered to active and inactive service centers between August 2022 and June 2023. We identified 16 institutions that performed ECT, including 12 linked to public universities and 4 with various links. In the last decade, 2 new public services that perform ECT in the country have emerged, whereas 4 services have ceased function. In 2022, the number of individuals treated with ECT per 100,000 population was 1.86, whereas the number of procedures performed per 100,000 people was 6.55. Although 2 new public ECT services have been identified, 4 have turned inactive. Most services are linked to public universities, and inactive service points to financial issues as the main factor in service interruption. Brazil has one of the lowest rates of individuals treated with ECT per 100,000 population compared with countries in North America and Europe. Thus, it is essential to raise awareness to improve ECT adoption rates and bring it out of the shadows in Brazil.

IDF23-0323 The continuous glucose monitoring on diabetic patients dependent on the Brazilian public health service

IDF23-0323 The continuous glucose monitoring on diabetic patients dependent on the Brazilian public health service

Abstract 18822: Disparities in Access and Long-Term Survival in St Elevation Myocardial Infarction Patients the Brazilian Public and Private Health Services- Victim Registry

Introduction: This study aims to evaluate the impact of disparities in access to specialized services and reperfusion therapies on the long-term survival of patients with ST-elevation myocardial infarction (STEMI) treated under the Unified Health System (SUS) and those covered by Private Healthcare Insurance (PHI). Scarce data exist for regions characterized by significant socioeconomic disparities. Methods: The VICTIM registry was utilized to compare disparities among STEMI patients treated under SUS and PHI. The registry involved all Percutaneous Coronary Intervention (PCI) hospitals in Sergipe, the smallest state in Brazil, consisting of one facility for SUS patients and three facilities for private patients. We examined the patient's opportunity to reach a PCI hospital, reperfusion data from 2014 to 2018, and long-term survival through telephone interviews between 2020 and 2021. Long-term outcomes evaluated using the Gehan-Breslow test with Dunn correction, and significance level p&lt;0.05. Results: Out of the 1.082 patients evaluated, 893 (82.53%) received treatment under SUS, while 189 (17.47%) covered by PHI. SUS patients had to travel a distance six times greater from the site of pain to the PCI hospital (58.2 km vs. 8.7 km; p&lt;0.001); had lower rates of reperfusion (49.8% vs. 67.2%; p&lt;0.001) and primary PCI (47.2% vs. 66.5%; p&lt;0.001); and often had to pass through at least one institution before reaching the PCI hospital (76.1% vs. 41%; p&lt;0.001). The time from symptom onset to seeking help was similar for both groups, but the overall time from symptom onset to arrival at the PCI hospital was longer for public service patients (10.3h vs. 5.3h; p&lt;0.001). Fibrinolytic therapy was underused (2.5% vs. 1.1%; p=0.411). Long-term survival results displayed in Figure 1. Conclusions: SUS patients exhibited higher long-term mortality rates, longer travel distances, and reduced access to reperfusion therapies compared to PHI patients, indicating disparities in care.

Responding to the mental health needs of children in a public health service in Brazil

The COVID-19 pandemic has further intensified the substantial demand for psychological treatment for children. However, in Brazil and various other nations, there is a lack of resources and evidence-based treatments focused on child mental health. Given this scenario, an evaluation of the efficacy of a pilot psychosocial group approach called "Operative Play Group" (OPG) was conducted within a public health service. This model aims not only to promote mental health but also to enhance equity through recognizing the social determinants of health. To measure behavioral problems, an analysis grounded in the principle of Intent-to-Treat was employed. However, this analysis did not demonstrate the effectiveness of the intervention. Nevertheless, through comprehensive research of cases, it was found that the program positively impacted the internalizing issues observed in children. The OPG model presents a distinctive feature as it stands out as one of the few methods incorporating dance. Dance can foster the expression of emotions and expand bodily perception. The findings of this study suggest the feasibility and relevance of utilizing body movement and dance as practical components in psychosocial interventions.

Evaluation of the availability of secondary dental care within the Brazilian public health system: a cross-sectional study

To achieve the goal of comprehensive care provided between primary and secondary care, the interface must be without barriers. This cross-sectional study evaluated the availability of secondary dental care services in public health services in Brazil. This study focused on reference Dental Specialty Centers (DSCs) with 18,114 Oral Health Teams (OHTs) that adhered to the second cycle of the “National Program for Improving Access and Quality of Primary Care” (PMAQ-AB). Questions about the availability of DSCs for patient referrals by OHTs and the type of dental specialties provided by municipalities in DSCs were analyzed descriptively and compared per Brazilian macro-region. Seventy-five percent of OHTs reported the existence of DSCs for patient referral. The most available specialties at DSCs included minor oral surgery (90.1%), endodontics (82.0%), patients with special needs (81.5%), and periodontics (80.5%). The OHTs presented a mean of 5.77 (±2.08) referable specialties. OHTs from the South and Southeast regions reported the availability of more specialized consultations. The most available specialties in all regions included minor oral surgery, endodontics, patients with special needs, and periodontics. The best results were found in the Southeast, followed by the Northeast and South regions. Brazilian public oral health shows a structure of secondary oral health care, however, a difference was observed among the OHTs, especially as regards the frequency and availability of specialties. More investments in public oral health care in Brazil are required to improve the availability of secondary dental care in regions with lower economic development.

The feasibility of sequential short-course radiation therapy and chemotherapy in the neoadjuvant treatment of rectal adenocarcinoma: Cases series treated in a Brazilian public health service

Introduction: Total Neoadjuvant Therapy (TNT) is now recognized as the preferred standard for the treatment of locally advanced rectal cancer. With recent progress in surgery, radiotherapy and chemotherapy, management strategies have become more complex but also more refined, in order to adapt to each situation

Trajectory of blood pressure levels and weight gain in pregnant women: A group-based approach

Background and objectivesMorbidities associated with increased blood pressure levels during pregnancy represent one of the main causes of maternal mortality. The objective was to identify patterns of systolic blood pressure (SPB) trajectory in pregnant women undergoing prenatal care at the Unified Health System, and associations with weight gain trajectory, demographic, obstetric, anthropometric data, and health related behaviors. Methods and resultsCohort study with pregnant women using the public health services in Brazil. Data were collected through questionnaires and medical records. Trajectory patterns of SBP and weight gain were identified by a group-based trajectory model. For trajectory analysis, 460 women had SBP information available, totaling 2839 measurements, with an average of 6.2 measurements during pregnancy. Three SBP trajectory patterns were identified and classified as “Group 1” (48.0%), with a mean of 103 mmHg (95% CI 102.5–103.7 mmHg), “Group 2” (42.7%) with a mean of 114 mmHg (95% CI 113.7–114.9 mmHg), and “Group 3” (9.1%) with the highest mean SBP value of 130 mmHg (95% CI 128.8–131.5 mmHg). It was observed that regardless of the weight gain trajectory group, women classified in the group with the highest SBP had the highest SBP levels. The probability of being classified in Group 3 was higher among women with higher education, who started pregnancy presenting obesity, and who were using antihypertensive drugs. ConclusionThe probability of belonging to groups with a greater trajectory of SBP during pregnancy was associated with obesity, education, and hypertension under treatment.

Strategies for the Management of Voices Shared in a Brazilian Hearing Voices Group.

Hearing Voices peer support groups allow people to construct understandings of their voices. The groups focus on supporting voice hearers in reducing distress associated with voices through an array of strategies. This study sought to describe the voice management strategies shared in a hearing voices peer support group within a Brazilian public mental health service. In this qualitative study we recorded 10 group meetings. Transcripts were coded and analyzed using thematic analysis. The findings indicated five themes, described as: (1) strategies used to avoid distressing experiences; (2) strategies for managing the voices; (3) strategies for seeking social support; (4) strategies for creating a sense of belonging in the community; and (5) strategies related to spirituality and religiosity. These strategies appear to be essential in helping voice hearers feel less alone, reducing the amount of distress associated with hearing voices, and developing coping strategies. These groups provide people who hear voices with the opportunity to share their stories with peers in a group setting, construct new understandings about the experience, and learn strategies for managing their voices. Accordingly, there are great possibilities for the use of these groups within mental health services throughout Latin America.

PP.12 Access to Molecular Testing and Factors to Implement Targeted Therapy in a Brazilian Public Health Service

PP.12 Access to Molecular Testing and Factors to Implement Targeted Therapy in a Brazilian Public Health Service

Availability of Genetic Tests in Public Health Services in Brazil: Data from the Brazilian Rare Diseases Network

Introduction: The Brazilian Policy for Comprehensive Care for People with Rare Diseases (BPCCPRD) was published in 2014, accrediting several reference centers and incorporating many genetic tests for the diagnosis of rare diseases (RDs). The Brazilian Network of Rare Diseases (RARAS) comprises more than 40 institutions that offer diagnosis and treatment for RDs in Brazil. This network includes Reference Services for Rare Diseases (RDRS), Reference Services for Newborn Screening (NSRS), and University Hospitals distributed in all Brazilian regions. Objective: The aim of the study was to map the availability and distribution of the BPCCPRD diagnostic procedures in the Brazilian Unified Health System through RARAS. Method: Data were collected through a questionnaire on the Research Electronic Data Capture platform, with 22 questions regarding the availability of procedures. Thirty-seven coordinators from RARAS participating centers received the questionnaire link for participation by email from August/2020 to March/2021. All participating institutions ethically approved this project. Results: Of the 37 institutions, 23 (62.16%) offered cytogenetic tests, 20 (54.05%) offered molecular procedures, and 22 (59.46%) offered inborn errors of metabolism diagnostic tests. The Southern blot analysis, enzyme assays on cultured tissue and urinary organic acid tests had the highest outsourcing rate. On the other hand, the procedures most frequently performed on-site were bone marrow karyotype and long-term cultured karyotype. It was observed that 10 of the 37 centers (27%) did not provide access to investigated procedures (on-site or outsourced). The North and Midwest regions stood out in terms of the unavailability of such techniques in at least 40% of the evaluated institutions. Discussion and Conclusion: This study reveals large discrepancies in the supply of diagnostic procedures in the Brazilian territory. Moreover, there is a broad collaboration between services through the outsourcing of multiple diagnostic techniques to address this issue. Finally, this work corroborates the importance of mapping services for the diagnosis and treatment of individuals with RDs to propose actions for the better supply and distribution of these procedures.

Association of coffee intake and its polyphenols with mammographic findings in women who visited the Brazilian Public Health Service.

Objective: this study aimed to evaluate if there is an association of intake of coffee and its polyphenols with mammographic findings in women treated at a breast care service unit of the Unified Health System (SUS), Brazil. Research methods and procedures: this was a cross-sectional study with 532 women treated at a health service. The participants were divided according to their mammographic reports into two groups: without and with altered findings. Two 24-h dietary recalls were applied and coffee consumption was categorized into three groups (less than 1 cup, 1 to 3 cups, and more than 3 cups). Phenolic acids were determined using the Phenol Explorer program. The intake of polyphenols was calculated by adding the values obtained from the total amount of coffee consumed during the day. The Multiple Source Method (MSM) was applied to analyze the usual intake. Results: of the 532 women, 178 (33.5 %) had altered mammographic findings. The participants' average daily coffee intake was 193.4 mL. No significant association was found between coffee consumption and mammographic findings. However, it was found that the second tertile of polyphenols was a protective factor for breast changes. Conclusion: Coffee polyphenols are protective against breast changes in the group evaluated and, thus, can help prevent breast cancer.

Fetal Open Surgery for Occipital Encephalocele: First Experience in a Tertiary Public Hospital in Brazil

AbstractOccipital encephalocele is a rare neural tube defect characterized by an opening in the occipital bone, resulting in herniation of meninges and brain tissue. Current treatment consists of surgical repair in the postnatal period. The main objective of intrauterine surgery for encephalocele is to decrease/stop the progression of the brain herniation and reversal of microcephaly, contributing to better perinatal outcomes. We reported the first experience of a fetal open surgery for occipital encephalocele in a Brazilian Public Health Service. The surgery took place with gestational age of 27 + 2 weeks of pregnancy. Careful dissection was performed between the skin and the dura that herniated through the bone defect, and the redundant tissue was removed and the dura was opened for access to neural tissue. Cesarean section was indicated prematurely at 34 + 4 weeks due to significant thinning of the myometrial wall with risk of uterine rupture. The newborn was discharged from the neonatal intensive care unit at 21 days after delivery and from the hospital at 30 days in good conditions. Fetal open surgery for encephalocele is still an experimental therapy with maternal–fetal risks; however, the postnatal follow-up is critical for the assessment of the real benefits of this surgery.

Implementation of health promotion in prenatal care at a public health service in Brazil

Prenatal care is the assistance to women throughout pregnancy, birth and puerperium which is an important tool of primary care in the prevention of maternal and child injuries. Prenatal care programs must be horizontal and multidisciplinar according to Ministry of Health's protocols in order to achieve improvements in maternal and child morbidity and mortality indicators. This study is an original interventional project that occurred at a public primary care service in a town of Bahia, Brazil. It was noted some aspects that could be adapted to the Ministry of Health protocols such as shared appointments based on scientific evidence, introduction of prenatal dental care and education actions carried out in a multidisciplinary way. All strategies were implemented in the prenatal care using very low cost tools such as conversation wheels and physical activity schedule. Conversation wheels between pregnant women and caregivers are included in the health humanization policy in Brazil. They are strategies for permanent education in health. Conversation wheels aimed to valorize pregnant women and their life experience in order to build an environment rich in learning and approached them to the health service. The encouragement of physical activity promotes well-being, a sense of belonging and improvements in risk factors for prevalent diseases during pregnancy. Continuing education promotes autonomy's pregnant women. Finally, the involvement of primary care professionals who address different aspects of health promotes co-responsibility and commitment to the adequacy of services offered to the population. The integration of health prevention and promotion actions should be seen as a stimulus to build relationships of trust and bond between users, managers and health professionals. Thus, the implementation of primary care actions during pregnancy expands the woman's connection with the health service at this stage of life and can contribute to better maternal and neonatal outcomes.

Comparison of three insulin bolus calculators to increase time in range of glycemia in a group of poorly controlled adults Type 1 diabetes in a Brazilian public health service

BackgroundA main factor contributing to insufficient glycemic control, during basal/bolus insulin therapy, is poor self-management bolus. Insulin bolus administration frequency is strongly associated with glycated hemoglobin (A1c) in Type 1 Diabetes (T1D). In the present study, we analyzed the performance of two-bolus calculator’s software that could be accessible to T1D patients from a Public Health Service to improve glycemic time in range (TIR) and A1c.MethodsThis prospective, controlled, randomized, parallel intervention clinical trial was carried out with 111 T1D participants on basal/bolus therapy [multiple daily insulin injections (MDI) or subcutaneous infusion pump (CSII)] with basal A1c ≥ 8.5% for 24 weeks. Patients were divided into 3 groups: 2 interventions: COMBO® (bolus calculator) and GLIC (mobile application) and 1 control (CSII group). Anthropometrics and metabolic variables were assessed on basal, 3 and 6 months of follow-up.ResultsTIR was increased in 9.42% in COMBO group (29 ± 12% to 38.9 ± 12.7%; p < 0.001) in 8.39% in the GLIC® group (28 ± 15% to 36.6 ± 15.1%; p < 0.001) while remained stable in CSII group (40 ± 11% to 39.3 ± 10.3%). A1c decrease in 1.08% (p < 0.001), 0.64% (p < 0.001) and 0.38% (p = 0.01) at 6 months in relation to basal in the COMBO, GLIC and CSII respectively. Daily basal insulin dose was reduced by 8.8% (p = 0.01) in the COMBO group.ConclusionThe COMBO and a mobile applicative (GLIC) bolus calculator had a similar and a good performance to optimize the intensive insulin treatment of T1D in the public health system with increase in the TIR and reduction in A1C without increase hypoglycemia prevalence.

Increment of Maternal Mortality Among Admissions for Childbirth in Low-risk Pregnant Women in Brazil: Effect of COVID-19 Pandemic?

To assess the possible impact of the COVID-19 pandemic on maternal mortality among admissions for childbirth in 2020 in relation of the last 10 years. An ecological study with pregnant women who underwent hospital births at the Brazilian unified public health service (SUS, in the Portuguese acronym) in Brazil from 2010 to 2020. The mortality among admissions for childbirth was obtained based on the number of admissions for childbirth with reported death as outcome divided by the total number of admissions. The underlying gestational risk and route of delivery were considered based on the national surveillance system. The average mortality for the period between 2010 and 2019 (baseline) was compared with the rate of deaths in 2020 (1st pandemic year); the rate ratio was interpreted as the risk of death in 2020 in relation to the average of the previous period (RR), with 95% confidence intervals (CIs). In 2020, the 1st year of the COVID-19 pandemic, 1,821,775 pregnant women were hospitalized for childbirth and 651 deaths were reported, which represents 8.7% of the total hospitalizations and 11.3% of maternal deaths between 2010 and 2020. There was an increase in maternal mortality after births in 2020 compared with the average for the period between 2010 and 2019, specially in low-risk pregnancies, both in vaginal (RR = 1.60; 95%CI:1.39-1.85) and cesarean births (RR = 1.18; 95%CI:1.04-1.34). Maternal mortality among admissions for childbirth according to SUS data increased in 2020 compared with the average between 2010 and 2019, with an increment of 40% in low-risk pregnancies. The increase was of 18% after cesarean section and of 60% after vaginal delivery.

Homeopathy and health assistance in public facilities.

Homeopathy has a long tradition of use in Latin America, particularly in Brazil, where it has been used since 1840.&#x0D; Prescription of homeopathic medicines by specialized medical doctors in Brazilian public health services was legally established in 1988, and has been recently confirmed with the publication of the National Policy on Integrative and Complementary Practices by the Ministry of Health. Together with long-time and well succeed 25-years experience in developing educational programs to teach medical doctors after their graduation, it is time to teach the essentials of homeopathy to primary care doctors working in public health services. This Program would enable doctors to use homeopathy in a small number of conditions and to refer patients with more complex situations to homeopathic doctors in special centers. This strategy could be an important step in reducing social exclusion of people to accessing health care and in the expansion of homeopathy for the benefit of mankind.

Relationship between tooth loss, nutritional status and consumption of macro and micronutrients in elderly people from southern Brazil

Maintaining a functional natural dentition plays an important role in keeping a satisfactory nutritional status. The aim of this study was to evaluate the relationship between oral health conditions determined by the presence of edentulism and the number of missing teeth, nutritional status and consumption of nutrients by the elderly. This cross-sectional study comprised 494 independent elderly of both genders, over 60 years of age, registered at the Brazilian public health service in Londrina, southern Brazil. The data collection included: oral examinations; anthropometric measurements by calculating the Body Mass Index (BMI); analysis of food consumption based on a multiple pass 24-hour dietary recall and a food intake frequency questionnaire; and structured interviews to obtain sociodemographic information. Multiple linear regression, the Fisher’s Exact test, chi-square and Mann‑Whitney tests, were applied at a 5% significance level. The prevalence of edentulism was 47.3%; this predominated in females, age group from 65 to 74 years, low education level and low/medium economic classification. A larger number of underweight and fewer number of overweight elderly were recorded among the edentulous versus dentate participants (&lt; 0.0001). Significantly lower consumption of several nutrients, as well as fruit, was recorded among the edentulous group. In particular, carbohydrates, vitamins (B1, B9 and C), and the majority of the minerals studied were associated with a larger number of missing teeth. In conclusion, tooth loss was associated with the food consumption pattern of some macro- and micronutrients and the nutritional status of the Brazilian elderly.

Time Perspective and Quality of Life in Persons Living with HIV in the Brazilian Context

Background: Time perspective can be an important variable for the understanding the quality of life of people living with HIV/AIDS. Aims: The objective was to examine the relation between quality of life and time perspective among persons living with HIV receiving care from public health services in Brazil. Methods: Data were collected at four public health services in Brazil. Hierarchical regression analyses were then performed for each of six quality of life domains. Results: The subscales associated with high quality of life in physical and level of independence domains were low past-negative and high future orientation; psychological and environmental domains were low past-negative, high past-positive and high future orientations; social relations domain were high past-positive and high future orientations; and spirituality, religion and personal beliefs domain was low past-negative orientation. Conclusion: The hypothesis that time constructs have implications for the experience of the disease and for evaluation of quality of life was proven determined by positive orientations like future and past-positive and past-negative orientation.

Contextual influence on poor self-rated health in patients with Chagas disease: multilevel study.

Chagas disease (CD) is recognized by the World Health Organization as one of the thirteen most neglected tropical diseases in the world. Self-perceived health is considered a better predictor of mortality than objective measures of health status, and the context in which one lives influences this predictor. This study aimed to evaluate the prevalence and individual and contextual factors associated with poor self-rated health among CD patients from an endemic region in Brazil. It is a multilevel cross-sectional study. The individual data come from a cross-section of a cohort study named SaMi-Trop. Contextual data was collected from publicly accessible institutional information systems and platforms. The dependent variable was self-perceived health. The analysis was performed using multilevel binary logistic regression. The study included 1,513 patients with CD, where 335 (22.1%) had Poor self-rated health. This study revealed the influence of the organization/offer of the Brazilian public health service and of individual characteristics on the self-perceived health of patients with CD.