Medicina Social / Saúde Pública

Lung cancer is an important public health problem, and a large proportion of known carcinogens occurs in occupational settings. There have been very few studies of exposure to occupational carcinogens in developing countries. This is case-control study carried out on 12 hospitals in the Metropolitan Region of São Paulo, Brazil, from July 1989 to June 1990, to determine the extent to which time employed in an occupation affects incidence of lung cancer. Information on sex, age, race, socio-economic variables, smoke history and job history was obtained for 430 lung cancer cases, and 880 hospital controls. Jobs with similar exposure to carcinogens were grouped into 29 occupations. I used a Bayesian multiple imputation method to assign values for missing information on job history, and spline regression to model effects of continuous covariates. Occupational case-control studies are typically studies of multiple exposures, and the usual strategies to deal with multiple comparisons leads to an increased probability of making incorrect statements regarding null hypothesis. They often generate large and unstable estimates. An alternative is the use of a hierarchical model that can give estimates more plausible and stable than conventional estimates. Here I develop a two-stage hierarchical regression model. This model yields semi-Bayes incidence density ratio estimates for occupations by using a second-stage model to pull estimates toward each other when they have similar levels of carcinogen exposure. The first stage is a maximum-likelihood logistic regression on 29 occupations and covariates. The second-stage is a linear regression of occupational effects on 12 known carcinogenic substances or physical agents. The estimates obtained with one-stage maximum-likelihood logistic regression were very stable, having a small change when using the hierarchical regression model, on the contrary to that expected if their magnitude were just a multiple comparison artifact. I found an incidence density ratio of 1.65 (95% CI - 1.03 , 2.65) for working in agriculture after 1960, when the use of pesticides in large scale was introduced in Brazil, and an incidence density ratio of 2.18 (95% CI - 1.20 , 3.98) for working as a glass former or potter. Further studies on these occupations are recommended.

The subject of this research is how women feel about their children--how pleasurable and how burdensome they perceive their children to be. Although this is a relatively unstudied topic, a woman's perceptions of her children may affect her own well-being and that of her children. Therefore, it merits inquiry. The research is based on two surveys of women with children living at home--318 mothers from the State of Sao Paulo, Brazil and 549 women from the Chicago metropolitan area of the United States. The research model proposed that a woman's social class and cultural affiliation affect her perceptions of her children and her own well-being by regulating the objective conditions of her life and her perceptions of those conditions. The model was estimated using hierarchical multiple regression analysis. The findings suggest that cultural values, beliefs, and traditions influenced the Brazilian and U.S. women's perceptions of their children, especially by providing meaning to their social relations. Social class differences were interpretable only within the overall cultural framework. There was no evidence that a Brazilian woman's well-being was affected by her attitudes toward her children. Findings about Brazilian women's well-being may not be applicable to U.S. women, however, because of differences between the two countries in the meaning of social relations.

The objective of this thesis is to study the industrial wastewater pollution problem in Metropolitan Sao Paulo, Brazil, and to examine the applicability and consequences of alternative solutions for the problem, other than the traditional end-of-pipe approaches. After a brief description of the area, and identification of the interested parties, we presented several case studies of firms that adopted in-plant control measures designed to abate pollution, that were regarded as much cheaper than paying the user's charges to the public utility that owns the central treatment system. A methodology is proposed for estimating the industrial wastewater pollution loads in the region, taking into account the technological change and price elasticity of demand effects, using an input-output framework. Finally, the concept of near-optimality applied to the analysis of the industrial waste pollution control problem is discussed, using two case studies to illustrate the approach and its implications to the interested parties.

Health effects from air pollution are a top ten cause of disability worldwide. Although research has linked air pollution to health, critical questions remain. This work examines key aspects of air pollution's impact on human health, including: (1) use of regional air quality modeling to estimate air pollution exposure in the United States (U.S.) for use in health studies; (2) relationships between air pollution and hospital admissions in the U.S., including estimates for populations and locations that cannot be studied using monitoring data alone; and (3) factors affecting vulnerability to health effects from air pollution exposure in São Paulo, Brazil. Most epidemiological studies use ambient monitors to estimate air pollution exposure, and while there is a growing body of research in industrializing nations, studies tend to be concentrated in North America and Europe. Use of ambient monitoring data is an efficient approach but restricts studies to locations and populations near monitors. The first project investigates the use of an emerging method, regional air quality modeling, to estimate air pollutant exposure in the U.S. The second project investigates the hypothesis that relationships between air pollution and health are not fully captured in studies relying exclusively on monitoring data, by using modeled and measured exposures to estimate health effects for populations without monitoring data. The third project investigates vulnerability to air pollution-related mortality in São Paulo, Brazil by sex, age, education, race, marital status, and neighborhood-level socioeconomic status (SES). I also examine whether the relationship between air pollution and mortality differs depending on the location at time of death, e.g., in-hospital versus out of hospital. Results from the first project demonstrate that exposure estimates derived from regional air quality modeling covered 50% more population compared to monitor-derived estimates. Counties with monitors were more urban, with a higher percentage of college graduates, and lower percentage of individuals living in poverty. Modeled estimates provided higher spatial and temporal resolutions, but model performance varied by pollutant, season, and location. Air quality models allow estimation of air pollution exposure for populations that differ demographically from those near monitors, but model output also have temporal and spatial biases that should be considered. The second project utilizes air quality modeling to estimate exposures and health impacts in areas and times with and without monitoring data, evaluate possible effect modification by community-specific characteristics (e.g., urbanicity, income), and investigate health effect estimates associated with short-term cumulative exposures. Higher cardiovascular effect estimates were observed in more urban counties. Compared to single day lags, higher respiratory health effect estimates were observed for multi-day lags measuring short-term cumulative exposures. Lag structures differed for respiratory and cardiovascular hospital admissions: the highest effect estimate for cardiovascular hospitalizations was observed at lag 01 (0.89% [PI: 0.51%, 1.28%] per 10µg/m3 PM2.5 [particulate matter with an aerodynamic diameter ≤2.5μ]), while the highest effect estimate for respiratory hospitalizations was observed at lag 06 (2.47% [0.29%, 4.69%] per 10µg/m3 PM2.5 ). Timing and pattern of exposure and health impacts may differ for respiratory and cardiovascular outcomes, and respiratory effect estimates based on a single day of exposure could underestimate the true effect. The third project contributes to knowledge of air pollution and health in São Paulo by investigating the role of individual- and community-level characteristics and the relationship between air pollution and mortality. Higher effect estimates for non-accidental mortality were observed for those with lower education: effects were 1.66% (0.23%, 3.08%), 1.51% (0.51%, 2.51%), and 2.82% (0.23%, 5.35%) higher for NO2, SO2, and CO exposure, respectively, in those with no education compared to those with postsecondary education. For cardiovascular mortality and PM10 exposure, effect estimates were 3.74% [0.044%, 7.30%] higher for no education compared to those with postsecondary education. Educational attainment is correlated with SES, but consistent trends of increasing health risks associated with pollutant exposure and residential SES were not observed. Positive, statistically significant associations between all air pollutants and mortality were observed for in-hospital deaths, whereas non-hospital deaths generally exhibited positive but not statistically significant associations. Scientific understanding of how air pollution affects health, including potentially vulnerable populations, requires new methods and analysis to answer questions that cannot be addressed with traditional approaches. Benefits from this research include the ability to estimate exposures for populations in times and locations without ambient monitors. This work provides some of the first estimates of air pollution-health risk using ambient modeling, estimates of risk for understudied rural populations, and potentially improved estimates for urban settings. The findings also provide evidence regarding which populations face the highest health burdens from air pollution.

This thesis is based on my practicum I completed at the Physical Fitness Research Center of São Caetano do Sul. I sought to answer three questions: (1) What are the strategies and outcomes of international community-based interventions aimed at promoting physical activity in children and adolescents that have been implemented to date?; (2) What is Agita São Paulo's community-based model for partnering with organizations to promote physical activity in children and youth?; and (3) How has Agita leveraged the sociocultural influence of futebol and the hosting of mega sporting events such as the 2014 FIFA World Cup and 2016 Summer Olympics to influence physical activity in children and youth? This project is descriptive in nature and included an extensive literature review and the administration of two semi-structured interviews and seven self-administered surveys to staff members (i.e. planners and coordinators) of the Agita São Paulo program (n=9). Interviews were transcribed and surveys were translated from Portuguese to English. Thematic content analysis was then employed to search for common and recurring themes. In addition, data were recorded from participants observations of daily operations and attendance at daily meetings held at the Agita São Paulo's research center. My observations were recorded and served as another source of data to verify my findings. Findings from my research indicate that the Agita program has been successful in large part due to its wide network of intersectoral (e.g. state secretariats and universities) and intrasectoral (e.g. service organizations such as the Rotary Club and Lions Club) partnerships. The Agita program uses an adaptable mobile management style (see Fig. 2) that allows the program to change its focus based on needs of a given community or region. For example, if intrapersonal factors have been successfully targeted, resources and efforts may be redirected to address components in the physical environment. Social marketing and non-paid media have contributed to the visibility and successful dissemination of Agita's messaging. The intervention program hosts two annual mega events to increase its visibility: Agita Galera and the walking parade to celebrate World Day for Physical Activity. Agita has marketing plans with World Cup and Olympics organizers in the form of cartoons and posters to be displayed publicly, t-shirts, and mega-events that will attempt to involve spectators and the local community to participate in physical activity and exercises. Unfortunately my research concluded before these events took place so I cannot speak with certainty that these proposed actions will even be implemented. At the start of my research, I believed that the spectacle of mega sporting events would induce some increase in physical activity of the population; however, my findings suggest otherwise. Across my key informant interviews, informants were skeptical that Brazil's hosting of the World Cup and the Olympics would bring about any positive changes related to physical activity among the general population. As a result, and serendipitously through my own personal experience living in São Paulo, I proposed that CELAFISCS turn to a more innovative use of social media (i.e. YouTube workout videos) to try and reach more of the general population. While the program has traditionally used print media such as sticker, flyers, posters, and cartoons, the Agita program has been underutilizing online social media sites. This method is cost-effective, has the potential to reach a wide range of people in the general population, and is not subject to the corruption of politicians that so many Brazilians have a disdain for. The key themes I identified in exploring the success and lessons learned of the Agita program included the pioneering efforts of Agita in placing physical activity on the public policy agenda; the dissemination of strong scientific evidence-based research; and the clear, simple messaging of Agita and leveraging of the unpaid media marketing to disseminate messaging through strategic partnerships. Ongoing challenges for Agita include and financial self-sustainability, program evaluation, and lack of domestic recognition for Agita's many achievements. Despite these obstacles, Agita continues to be a model for promoting physical activity in youth through community partnerships and social marketing across public schools, government entities, and sport clubs. Promising future directions for strengthening the Agita program include more proactive efforts in procuring partnerships and alternative funding opportunities as well as utilizing an established Internet presence to explore online social media networks to more creatively promote physical activity in the community.

O Estado do Rio de Janeiro apresenta o maior coeficiente de morbidade e mortalidade por tuberculose, com uma taxa quase duas vezes maior do que a taxa brasileira. A cidade do Rio de Janeiro, por sua vez, vem apresentando, desde o inicio da década de 1980, uma tendência de aumento das taxas anuais de morbidade. A este crescimento da tuberculose nas últimas décadas estão relacionados fatores como: a periferização da Região Metropolitana do Rio de Janeiro, gerando aumento do contato social e da transmissão do bacilo; o empobrecimento da população repercutindo nas condições sanitárias e no estado nutricional precários; a desestruturação do programa de controle da tuberculose, dificultando o diagnóstico precoce da tuberculose e o controle de sua transmissão e, finalmente, o surgimento da epidemia da AIDS. Este trabalho objetiva realizar uma análise do quadro de morbidade e mortalidade por tuberculose no Rio de Janeiro, buscando caracterizar a configuração atual da endemia na cidade. Utilizou-se dados do Sistema de Informação sobre Agravos de Notificação (SINAN- 1995 a 1999) e do Sistema Informação sobre Mortalidade (SIM - 1988 a 1998), indicadores sócio-econômicos (IDH, escolaridade, mortalidade infantil) e demográficos (densidade demográfica, área líquida, população favelada) do Censo de 1991 e a Contagem Populacional de 1996. Para apresentar as características epidemiológicas da doença no município, foram utilizados gráficos e mapas do município categorizados e distribuídos por bairros. As taxas médias de morbidade e de mortalidade (1995,1996 e 1997) por bairro, foram correlacionadas com indicadores de saúde, sócio-econômicos e demográficos que caracterizam as condições de vida de uma população. Avaliou-se o efeito isolado da taxa de incidência de AIDS na variação da taxa de morbidade de tuberculose através do emprego de regressão linear...Os resultados da análise dos bancos dados do SINAN e do SIM mostraram um aumento das notificações de casos e óbitos de 1995 até 1997. Os casos e óbitos notificados por sexo e faixa etária caracterizam a distribuição epidemiológica tradicional da tuberculose, com taxas mais altas entre os homens e nas faixas de adultos jovens e idosos. As zonas norte e centro/portuária apresentaram as taxas mais altas, seguidas pela zona oeste e os bairros de Copacabana e Botafogo na zona sul. O uso de  indicadores selecionados mostrou uma forte correlação com a taxa de incidência de AIDS...A distribuição espacial da tuberculose, sem o efeito da AIDS, apresenta uma distribuição espacial característica dos bairros mais pobres da cidade, com as maiores incidências de casos nos bairros da zona da Leopoldina e zona oeste da cidade. Os resultados identificaram áreas de concentração de casos e óbitos de tuberculose oferecendo informações importantes para ações estratégicas de saúde pública.

Foram analisados 4115 casos notificados por doença meningocócica (DM) no período de 1976 e 1994 no município do Rio de Janeiro, com base nas fichas de investigação epidemiológica da Coordenação de Epidemiologia da Secretaria Municipal de Saúde, visando caracterizar a DM evolutivamente nesse município foram definidos 3 períodos epidemiológicos de 1976-1979, de 1980-1986 e de 1987-1994, considerados, respectivamente, como pós-epidêmico, endêmico e epidêmico. Estes períodos se diferenciaram basicamente pelas taxas de incidências. 

O presente trabalho é parte de uma pesquisa "A Atenção Primária à Saúde (APS) como estratégia para (re) configuração das Políticas Nacionais de Saúde: a perspectiva de seus profissionais e usuários". Trata-se de uma pesquisa qualitativa realizada em um Centro de Saúde da cidade de Campinas durante os anos de 2014 e 2015. O período de campo e registro do material coletado teve duração aproximada de um ano. A cartografia, proposta inicialmente por Gilles Deleuze e Felix Guatarri, serviu como o referencial metodológico proposto, assim como para compor os analisadores, que permitiram a leitura do material de campo. Foram eles: Território, Reterritorialização e Desterritorialização. Os resultados dessa pesquisa demonstram que a cartografia traz conceitos e dinâmicas muito interessantes como método de pesquisa; o conceito de território, trazido pelo referencial proposto, possibilita novas formas de ver e pensar o trabalho no SUS e suas dinâmicas; Os territórios existenciais atravessam constantemente o serviço de saúde, interagindo com as relações pessoais e profissionais; estratégias que possibilitam a desterritorialização estão presentes nos serviços, colaborando com novas formas de relação e expansão territorial de cada um; o processo de trabalho e as forças envolvidas muitas vezes reduzem a potencialidade dos territórios existenciais de cada trabalhador ou trabalhadora e sua capacidade de promover uma expansão territorial.

Este estudo procura resgatar a história da SMS (Secretaria Municipal de Saúde) do município de Campinas SP, no período anterior à implementação do SUS (Sistema Único de Saúde). Usa como fonte de informações, documentos arquivados junto ao CEDOC (Centro de Documentação) do CETS (Centro de Estudos dos Trabalhadores da Saúde) da SMS de Campinas SP e entrevistas abertas com sujeitos que foram atores centrais da história da SMS no período estudado. Em forma de depoimento busca descrever a atenção à saúde prestada no município desde os anos 1950 até 1988, correlacionando o perfil demográfico e as características sócio-econômicas da população, suas formas de organização e lutas políticas nos diferentes períodos analisados, considerando o modelo de atenção à saúde vigente no país e a conjuntura política municipal e nacional. Destaca as lutas sociais dos anos 1970 quando implantado um modelo de atenção baseado na Medicina Comunitária e dos anos 1980 quando implantado o Pró-Assistência 1. Conclui apontando para a importância do tripé formado pelos usuários, técnicos e trabalhadores da saúde e gestores da saúde, na elaboração, implantação e defesa de propostas implementadas em Campinas e outros municípios e que fizeram parte do Movimento Nacional pela Reforma Sanitária que levou à consagração do SUS na Constituição Federal e, em seguida, à sua implementação.