Factors associated with exclusive breastfeeding: the role of primary health care

The aim of this study was to assess the association between promotion, protection, and support for breastfeeding in primary health care services and prevalence of exclusive breastfeeding in the first six months of life. A cross-sectional study was conducted in a representative sample of 1,029 mothers of infants younger than six months treated at primary health care facilities in the city of Rio de Janeiro, in southeastern Brazil. Prevalence ratios (PR) were estimated by Poisson regression. Prevalence of exclusive breastfeeding was 58.1%. Factors associated with increased prevalence of exclusive breastfeeding were: white skin color (PR = 1.20; 95% CI: 1.05-1.36); schooling (PR = 1.19; 95% CI: 1.05-1.35); marital status (married or in common-law marriage) (PR = 1.72; 95% IC:1.02-2.90); previous breastfeeding (PR = 1.27; 95% CI: 1.08-1,49); exclusive breastfeeding at the time of hospital discharge (PR = 2.01; 95% CI: 1.20-3.36); group support for the mother (PR = 1.14; 95% CI: 1.01-1.28); and orientation on breastfeeding (PR = 1.20; 95% CI: 1.08-1.33). Prevalence of exclusive breastfeeding decreased 17% per month in the infant's life. Support groups and orientation by primary health care for breastfeeding were associated with increased exclusive breastfeeding prevalence.     

Symptoms of postpartum depression and early interruption of exclusive breastfeeding in the first two months of life

This study evaluates the association between postpartum depression and interruption of exclusive breastfeeding in the first two months of life. Cohort study of 429 infants < or = 20 days of age to four primary health care units in Rio de Janeiro, Brazil. Interruption of exclusive breastfeeding (outcome) was defined as the introduction of water, other types of liquids, milk, or formulas or any food. Postpartum depression was assessed using the Edinburgh Post-Natal Depression Scale. Associations between variables were expressed as prevalence ratios (baseline) and risk ratios (follow-up), with their respective 95% confidence intervals, estimated by Poisson regression with robust variance. Children of mothers with postpartum depressive symptoms were at higher risk of early interruption of exclusive breastfeeding in the first and second months of follow-up (RR = 1.46; 95%CI: 0.98-2.17 and RR = 1.21; 95%CI: 1.02-1.45, respectively). Considering mothers that were exclusively breastfeeding at the first month, postpartum depression was not associated with interruption of exclusive breastfeeding in the second month (RR = 1.44; 95%CI: 0.68-3.06). The results indicate the importance of maternal mental health for the success of exclusive breastfeeding.     

Organization of traditional Primary Health Care and the Family Health Program in large cities in Rio de Janeiro State, Brazil

This article analyzes the organization of traditional Primary Health Care and the Family Health Program (FHP) in the 22 municipalities of Rio de Janeiro State, Brazil, with more than 100,000 inhabitants each in 2005. The methodology included visits to the municipalities, interviews with health managers, and analysis of national databases. Four summary variables were defined: the Primary Health Care model and inclusion of the FHP; institutionalization of the FHP; organization of traditional primary care; and organization of the FHP. Classification of the municipalities according to the four variables showed widely diverse situations and the predominance of a parallel model for inclusion of the FHP. The municipalities with the best structural conditions for primary care are located in the interior of the State, besides those that have had the FHP implemented for more than six years and that practice various modalities of Primary Health Care organization. The majority of the municipalities with the worst situation in relation to the FHP are located in Greater Metropolitan Rio de Janeiro. In light of the results, the article discusses the challenges facing the FHP as a strategy for structuring primary health care in large cities, particularly in metropolitan areas.     

Variables associated with underreporting of AIDS patients in Rio de Janeiro, Brazil, 1996

OBJECTIVE: The underreporting of AIDS cases in the municipality of Rio de Janeiro, Brazil, is significant. The study intends to analyze the factors associated to this event. METHODS: Using data provided by the Hospital Information System for the year of 1996, in Rio de Janeiro city, and by the National Surveillance System, patients were randomly selected and their medical records reviewed to verify an AIDS diagnosis. A multinomial model was used to perform an analysis of the variations on the chances of underreporting of AIDS cases versus reporting and on the chances of underreporting without evidences to fulfill the case definition of AIDS versus reporting. RESULTS: No significant associations were found between the variables such as "age", "marital status", "level of education", "occupation", and "severity of illness" and the underreporting of AIDS cases. The variable "female gender" showed a strong association with hospitalization without evidence of an AIDS diagnosis. A strong association was found between two or more admissions in an inpatient unit care and reporting. The existence of a epidemiological surveillance department in the hospital is inversely associated with the underreporting of AIDS cases. CONCLUSION: The significant association between organizational variables and underreporting of AIDS cases found in the study point out to the need of standardization of the surveillance procedures, the especial need for the creation and maintenance of surveillance departments in hospitals to improve the quality of the health information system and, therefore, AIDS prevention and care.     

Impact of a Well Baby Care Program on the promotion of exclusive breastfeeding

A historical cohort of children born between January 2000 and December 2002 from low-income families attending a primary health care facility on the periphery of Pelotas, Rio Grande do Sul, Brazil, was studied in relation to prevalence of exclusive breastfeeding. Analysis was based on a life table focusing on interruption of exclusive breastfeeding (month-by-month after birth) as the target outcome. Among the 112 children followed up from birth by the Well Baby Program, prevalence of exclusive breastfeeding in the first month of life was 95.0%, declining progressively to 81.0%, 64.0%, 53.0%, 39.0%, and 35.0%, respectively, from the second to the sixth month after birth. Median duration of exclusive breastfeeding was four months. Median duration of exclusive breastfeeding and prevalence among six-month-old infants were both higher than the Brazilian national rates and indicate the Program's adequacy in promoting breastfeeding. However, more effort should be made to increase the prevalence of exclusive breastfeeding until the sixth month of life.     

Perceptions of managers and health professionals about health care to elderly victims of violence in the city of Rio de Janeiro (RJ, Brazil)

This article presents the vision of managers and health professionals about the care of elderly victims of violence in Rio de Janeiro, showing the specificities of this attention in pre-hospital, hospital and rehabilitation areas, including mental health services. Based on a qualitative methodology, 20 semi-structured interviews with managers and health professionals were produced. The analysis considered the perceptions about violence against elderly, and the specificities of attention provided by SUS services to elderly victims. The State, the family and the social support organizations emerged as structuring categories of the network of care for elderly victims of violence. All attention areas presented insufficient care services or specific programs for the elderly victims of accidents and violence. Also there was a precarious network of social support for care of dependent elderly. With few exceptions elderly are treated as anyone else in public health services, without the priority set by the Statute of the Elderly. The family is called to participate in the care for the elderly in all areas of care. Abandonment, neglect, physical and psychological abuse against seniors cases were reported.     

Survival of hemodialysis patients: modeling differences in risk of dialysis centers.

OBJECTIVE: Dialysis is the most common renal replacement therapy for patients with end stage renal disease. This paper considers survival of dialysis patients, aiming to assess quality of renal replacement therapy at dialysis centers in Rio de Janeiro, Brazil, and to investigate differences in survival between health facilities. METHODS: A Cox proportional hazards model, allowing for time-varying covariates and prevalent data, was the basic method used to analyze the survival of 11,579 patients on hemodialysis in 67 health facilities in Rio de Janeiro State from January 1998 until August 2001, using data obtained from routine information systems. A frailty random effects model was applied to investigate differences in mortality between health centers not explained by measured characteristics. RESULTS: The individual variables associated with the outcome were age and underlying disease, with diabetes being the main isolated risk factor. Considering covariates of the health unit, two factors were associated with performance: bigger units had on average better survival times than smaller ones and units which offered cyclic peritoneal dialysis performed less well than those that did not. There were significant frailty effects among centers, with relative risks varying between 0.24 and 3.15, and an estimated variance of 0.43. CONCLUSIONS: Routine assessment based on health registries of the outcome of any high technology medical treatment is extremely important in maintaining quality of care and in estimating the impact of changes in therapies, units, and patient profiles. The frailty model allowed estimation of variation in risk between centers not attributable to any measured covariates. This can be used to guide more specific investigation and changes in health policies related to renal transplant therapies.     

Variables associated with breast cancer in clients of primary healthcare units

An epidemiological survey in ten family health units in the municipality of Teresópolis, Rio de Janeiro State, Brazil, in 2003, investigated the distribution pattern of breast cancer risk factors. 698 women 25 to 88 years of age were interviewed (112 rural and 586 urban). As for factors associated with breast cancer, 36.1% were 50 years or older, 3.7% had a first-degree family history, and 0.4% had a prior diagnosis of breast cancer. As for other factors, prevalence was higher in women with a history of abortion (38.5%), breastfeeding of less than one year (37.4%), prolonged use of oral contraceptives (41.1%), low physical activity (58.7%), and obesity (30%). Although the latter factors are still under investigation and the measures found in studies show weak associations, they are relevant to public health, not only for breast cancer control but also for other diseases, since their prevalence is high in the population.     

Health records: evaluation of patient health charts in primary care, Rio de Janeiro, Brazil

With the purpose of contributing to the evaluation of primary care, a study was conducted based on the quality of patients' health charts, considering the records for care provided in 4 municipalities with more than 100 thousand inhabitants each in the State of Rio de Janeiro, Brazil, in 2004. This was a cross-sectional study based on primary data collected from direct consultation of patient charts. A two-stage, probabilistic cluster sample was selected from primary care facilities and consultations/patient charts. We checked the completeness of attributes pertaining to the identification of users receiving care and the characteristics of the care itself (weight, blood pressure, Pap tests, and blood glucose) on the charts of women over 19 years of age with hypertension and/or diabetes. User identification showed a low presence of social attributes, and only half of the charts had recorded the opening date. Records of process characteristics in care provided to women with hypertension and diabetes failed to conform to Brazilian Ministry of Health guidelines. Analysis of completeness suggests dubious quality in the continuity of the care provided and difficulties in management practice for primary care and implementation of the Family Health Strategy.     

Obstetric nursing in prenatal consultation

This study consists of a report about a research project which started in August, 1997. The project involved teachers from the maternal-paediatrics department with Faculdade de Enfermagem--UERJ (Nursing Faculty with State University of Rio de Janeiro) and professionals from the municipal health center in Rio de Janeiro--SMS/RJ. The introduction of prenatal nursing consultation as a new subject in the nursing graduation course, as well as its formation, and implementation in the referred municipal health center is reported in this paper. This study also proposes a review of the current biomedical consultation model, in order to motivate reflection, break paradigms, and increase the prenatal consultation process in Rio de Janeiro.     

Evaluation of outpatient care for people with HIV/AIDS in Rio de Janeiro, from the user's perspective

This article analyzes perceptions by people with HIV/AIDS towards five specialized units under the State Health Department, Rio de Janeiro, concerning the care provided there. The research was based on both quantitative and qualitative methods. Data from 228 questionnaires and 19 semi-structured interviews were analyzed. The results generally indicated a positive evaluation on the part of this group of health care users. One conclusion was that the positive evaluation was actually related to the quality of the services available to them. However, users seem to have low expectations toward the level of services public clinics generally provide.     

Spatial analysis of early neonatal mortality in the municipality of Rio de Janeiro, 1995-1996]

The objective of this study was to establish the spatial distribution of the early neonatal mortality rate (0-3 days) in the municipality of Rio de Janeiro for 1995-1996, identifying the best explanatory factors for spatial variations. By considering Rio de Janeiro's 153 neighborhoods as ecological units of analysis, socioeconomic and maternal indicators were analyzed according to place of residence. Spatial statistical analysis was performed using the Cliff & Ord methodology, appropriate for lattice data. From the 0-3 day mortality thematic map, we clearly identified two clusters of high early neonatal mortality rates. Spatial dependence was also confirmed by the statistical results of the spatial analysis. The variables that explain the clusters are the proportions of "adolescent mothers", "slum-dwellers", and "heads of households below the poverty level". Spatial statistics provided a better understanding of the geographic distribution of early neonatal mortality and suggested potential hypotheses for further investigation, which could support preventive programs and contribute to a decrease in infant mortality.     

Maternal care and breastfeeding experience of women suffering intimate partner violence

OBJECTIVE: To describe maternal care and breastfeeding experience of women suffering intimate partner violence. METHODOGICAL PROCEDURES: A qualitative study was conducted in 11 women suffering intimate partner violence during pregnancy. Women aged 16-41 years were recruited in a hospital in the city of Rio de Janeiro between January and March 2005. Data were collected through in-depth interviews using a life history approach and complemented by a semi-structured guide. ANALYSIS OF THE RESULTS: Women expressed mixed feelings of loneliness and good moments regarding maternal care and breastfeeding experience. Most had early cessation of breastfeeding and the reasons reported included: the need to resume their working activities, lack of information on breastfeeding and the violence experienced by these women. CONCLUSIONS: The study shows a need to approach women as key actors of a nursing model, offering opportunities to listen to their concerns as well as to provide care to intimate partner violence victims and differentiated support.     

The impact of leprosy elimination strategy on an endemic municipality in Rio de Janeiro State, Brazil

Various strategies for eliminating leprosy as a public health problem have evolved in the last 20 years. In some countries, especially highly endemic ones, the WHO target rate for leprosy elimination fell far short. The current study aimed to analyze the impact of different strategies for reducing leprosy prevalence in Duque de Caxias, a highly endemic municipality in Rio de Janeiro State, Brazil. The study observed the evolution of traditional operational indicators for the disease and their trends in the last 14 years. The indicators were calculated using the National Communicable Diseases Database (SINAN). Strategies that focused on decentralization of patient care and/or localized campaigns were associated with earlier case detection, reduction in prevalence, and shorter patient time in the active registry. An increase in the annual detection rate could be related to the existence of hidden prevalence or individuals with asymptomatic infection. New complementary strategies are needed to eliminate the disease in Duque de Caxias.     

Quality of body mass measurement in Rio de Janeiro public health centers in 1996

The main purpose of the study was to evaluate the quality of body mass measurement of children under 5 years of age treated in 21 health care units in the city of Rio de Janeiro. A total of 38 health care professionals were observed, 292 children were weighed, and 41 scales were calibrated. Almost all of the mechanical scales were positioned improperly. The procedure of weighing the child "undressed" was not performed in 29.9% of the cases on adult beam scales. Almost all of the scales were calibrated (98%) and showed a high correlation coefficient (0.999). There were no important differences between body mass values obtained by the health care professionals and those read by the observer. Thus, nutritional classification using either value showed a perfect correlation (Kappa correlation coefficient = 1). Although some procedures in obtaining body mass values were unsatisfactory, they did not affect the nutritional classification of children in the present study.     

The decision of women for cesarean birth: a case study in two units of the supplementary health care system of the State of Rio de Janeiro

Cesarean section rates are very high in Brazil mainly in private hospitals, probably due to socioeconomic and cultural factors. The objective of this study was to describe socioeconomic, demographic, cultural and reproductive characteristics of women in the postpartum period and the factors that had determined their decision for caesarean section in two units of the supplementary health care system of the State of Rio de Janeiro. The study population was composed of 437 women that had vaginal or caesarean childbirths in the two selected units. Data were collected by means of interviews with mothers and consultation of hospital records. The factors associated with the decision for cesarean section as mode of delivery were evaluated using non-conditional logistic regression analysis and following the hierarchic models established at three definite moments. Although 70% of the women had no initial preference for cesarean section, 90% of them had this mode of birth. It was verified that, despite their initial desire, the interaction with the health services resulted in cesarean section as mode of birth. Educative actions directed to pregnant women and to the public at large as well as changes in the childbirth care model can be promising strategies for reverting this picture.     

Tuberculosis in Rio de Janeiro prisons, Brazil: an urgent public health problem

The tuberculosis incidence rate in prisons in Rio de Janeiro State, Brazil, was 30 times higher in 2004 than in the general population and is probably underestimated, particularly given the difficult access to care in the prison setting. To obtain a better estimate, a survey used systematic X-ray screening and showed a prevalence rate of 4.6% in one such detention facility, A (n = 1,052). Two additional surveys, in facilities B (n = 590) and C (n = 1,372), showed even higher prevalence rates (6.3% and 8.6% respectively). A comparison of socio-demographic characteristics between A, B, and C showed a heterogeneous prison population. As compared to facility A, inmates in B and C come from poorer urban communities and have more frequent histories of incarceration and tuberculosis. These differences, consistent with the prevalence data, imply the necessary adaptation of tuberculosis control programs to each detention facility's epidemiological and socio-demographic profile.     

Hospital leaflets and the dynamics of constructing their meanings: the perspective of health professionals

Based on interviews in a hospital in Rio de Janeiro, the authors analyze strategies, interests, assumptions, and concerns among producers of patient information leaflets on infectious diseases. Most such publications followed a linear communications model, according to which health messages produce a sole and single effect on their audience. Visual communications are seen as a field of knowledge over which physicians have no "command", but which raises great expectations on their part, principally in light of the limits of written language for an illiterate patient population. The most frequent concerns relate to the "adequacy of the language" (a denotative, non-semantic function of language) and on the increase in "dissemination". Leaflets are generally linked to the professional experience of providing health care, but the lack of pertinent research prior to the production of such publications leads to simplifications and generalizations concerning the patients' most common doubts and questions, reinforcing the stereotyping of the clientele based on their lacks and needs. In two exceptional leaflets, interaction with the clientele appears and expands the relationship between the health care professionals and the values and decisions made in distinct sociocultural contexts.     

Evolution of neonatal mortality in the state of Rio de Janeiro, Brazil

This paper reports the results of a study on neonatal mortality in the State of Rio de Janeiro (1979-1993), according to major causes of death, by age and region of residence. The authors suggest criteria for grouping neonatal deaths according to causes, taking into consideration frequency and preventability. For deaths which occurred in the first day of life, immaturity and fetal growth retardation were the only causes of death that showed significant decline. An increase in deaths due to respiratory affections of the fetus and newborns was observed. Causes of death said to be reducible by "adequate control of pregnancy and attention at delivery" and "early diagnosis and treatment" remained unaltered. The authors noted that a decrease in death rates took place starting with the 1-6 day age group. The comparison with other countries called attention to the high rates of neonatal death in Rio de Janeiro. It also pointed out an increase in the proportion of deaths classified as "respiratory problems of the newborn", demonstrating lack of specificity in defining the basic cause of death.