TEDE Coleção:

SISTEMA DE SAÚDE NO MARANHÃO: O PÚBLICO E O PRIVADO SOB A PERSPECTIVA DE GESTORES, GERENTES, EMPRESÁRIOS E PROFISSIONAIS DE SAÚDE

Mon, 30 Mar 2026 00:00:00 GMT

Título: SISTEMA DE SAÚDE NO MARANHÃO: O PÚBLICO E O PRIVADO SOB A PERSPECTIVA DE GESTORES, GERENTES, EMPRESÁRIOS E PROFISSIONAIS DE SAÚDE Autor: CAMPOS, Douglas Moraes Primeiro orientador: PINHO, Judith Rafaelle Oliveira Abstract: This thesis investigates the interactions between the public and private healthcare systems in Maranhão, based on the perspectives of managers, administrators, healthcare professionals, and business owners. The perspective situated from different positions “within the system” and these agents’ reflections on their daily work practices contributed to an understanding of tensions in the public-private relationship, particularly regarding the coordination of federal entities, human resource management, the role of Social Health Organizations (SHO), and the expansion of Low-Cost Clinics in the state capital. The analysis of these issues through the intertwining of the pathways traversed by these agents allowed for the contextualization of issues raised at the local-regional level. Grounded in the Social and Human Sciences in Health, the research employed mixed methods, combining semi-structured interviews and georeferencing in the capital, São Luís. The results highlight tensions between the Unified Health System (UHS) and the private sector, driven by the selective expansion of the market and the overload of the public network. In the study, SHO and Low-Cost Clinics, which are dependent on the public sector, are presented by their representatives as alternatives for unmet demands within the SUS. The participants emphasized that Primary Health Care (PHC) has been severely affected by hospital-centric policies, leading to the fragmentation of Health Care Networks (HCNs), the precariousness of employment relationships, and hospital overcrowding, even as hospital care expands in rural areas. This scenario unfolds in a context in which the state of Maranhão has progressively opened space, within the UHS framework, for private entities to operate in the provision of healthcare services and hospital management. Through georeferencing, it was demonstrated that the expansion of Low-Cost Clinics is not random; these entities occupy areas of high population density in the center and in some outlying areas of São Luís, located near Basic Health Units (UBS). In this sense, actions coexist within the territory in which the value of health differs: as a universal right and as an economic asset, access to which is mediated by payment. The analysis identifies the expansion of the private sector’s presence in healthcare provision and management within the UHS, reconfiguring care and creating tension around health as a right in the face of its commodification. Instituição: Universidade Federal do Maranhão Tipo do documento: Tese; Trabalho sob sigilo. Motivo: O sigilo se dá pois há artigos não publicados e que estão em processo de submissão em revistas científicas que exigem exclusividade na disponibilização dos dados. Data Provável de Liberação: 24 meses.

ANÁLISE DE SOBREVIDA DE PACIENTES COM COVID-19 INTERNADOS EM HOSPITAIS DO BRASIL

Mon, 05 Feb 2024 00:00:00 GMT

Título: ANÁLISE DE SOBREVIDA DE PACIENTES COM COVID-19 INTERNADOS EM HOSPITAIS DO BRASIL Autor: MARTINS NETO, Carlos Primeiro orientador: OLIVEIRA, Bruno Luciano Carneiro Alves de Abstract: COVID-19 is an infectious disease caused by SARS-CoV-2. This virus has high transmissibility and can develop severe pneumonia that manifests as Severe Acute Respiratory Syndrome (SARS), which impacts patient survival. This thesis aimed to analyze the associated factors and potential interactions between predictors with the survival of patients hospitalized for SARS due to COVID-19 in Brazil. Data from adults and the elderly reported in the Influenza Epidemiological Surveillance Information System (SIVEP-Gripe) of the Ministry of Health were used. The first article analyzed the survival of patients hospitalized with COVID-19- related Severe Acute Respiratory Syndrome (SARS) and identified risk groups for COVID-19 mortality based on potential interactions among predictors. This was a retrospective longitudinal study using data from 1,756,917 cases admitted between February 16, 2020, and December 31, 2022. Survival tree analysis was employed to identify potential interactions among predictors. A separate model was constructed for each study year. The case fatality rate was 33.2%. Lower survival was observed among those who underwent invasive mechanical ventilation and were 80 years or older during the three years of the pandemic. Black and mixedrace individuals were predictors of death in the years 2020 and 2021, coinciding with increased healthcare system demand due to a higher number of cases. The objective of the second article was to analyze the influence of individual and contextual factors related to hospital and municipality care on the survival of patients with COVID-19-related Severe Acute Respiratory Syndrome (SARS). This study involved a hospital-based cohort of 159,948 cases admitted in 2022. Contextual variables were derived from the National Registry of Health Establishments, indicators from the municipalities that contribute to the Sustainable Cities Development Index - Brazil, and the Social Inequalities Index for COVID-19 proposed by the Center for Data Integration and Knowledge for Health (Cidacs/Fiocruz). The outcome was hospital survival within 90 days. Survival tree analysis and Cox regression were used to analyze survival. The survival tree identified 8 groups with varying probabilities of survival. Elderly patients who underwent invasive mechanical ventilation and were hospitalized in cities with low tax revenue percentages had a higher risk of death compared to adults (p < 0.001) who did not receive mechanical ventilation and were admitted to hospitals not affiliated with the Unified Health System (SUS). The objective of the third article was to analyze the influence of the organization and composition of hospital establishments - whether affiliated with the Unified Health System (SUS) or not - and their impact on the survival of patients with COVID-19-related Severe Acute Respiratory Syndrome (SARS). This study involved a hospital-based cohort of 159,948 cases admitted in 2022. In hospitals affiliated with the SUS, 32.7% of the patients progressed to death, compared to 21.4% in non-SUS services. The survival of patients hospitalized within the SUS was lower (p < 0.001), with predictors including invasive mechanical ventilation, age, hospital size, and ICU admission. Among patients in non-SUS hospitals, in addition to these variables, predictors also included region, ECG/bed monitoring rate, and physician/bed rate. It is concluded that individual and contextual factors influence the survival of these patients, revealing inequalities not only in direct patient care but also in the organization, functioning, and performance of hospital services. Therefore, it is necessary to review and modify the relationship between the Brazilian public and private healthcare systems and strengthen the public system further to reduce observed inequities. Instituição: Universidade Federal do Maranhão Tipo do documento: Tese

Os primeiros 1000 dias de vida: efeito de intervenções com Scorecards e da pandemia da covid-19 sobre indicadores maternos e infantis

Fri, 26 Jan 2024 00:00:00 GMT

Título: Os primeiros 1000 dias de vida: efeito de intervenções com Scorecards e da pandemia da covid-19 sobre indicadores maternos e infantis Autor: RODRIGUES, Elisa Santos Magalhães Primeiro orientador: THOMAZ, Erika Barbara Abreu Fonseca Abstract: Despite investments in the first 1000 days of life, high rates of infant mortality and morbidity affect populations in middle- and low-income countries, in which access and quality of health services for the mother-baby dyad are still rights. denied. This thesis studied the effect of interventions with scorecards and the COVID-19 pandemic on maternal and child indicators, in the period of the first 1000 days of life. Article 1: The scorecards bring together dimensions of health services for monitoring and evaluation in social accountability processes, but there is no evidence of improvements in maternal and child health indicators in the first 1000 days of life. A systematic review with meta-analysis (PROSPERO: CRD42018105841) explored 29 online databases, without location and language restrictions (2018-2023). Two evaluators in consensus included original articles, experimental, time series and before and after, with interventions using scorecards for the community and, as outcomes, use or coverage of: 1) Pregnancy: home visit by Community Health Agents ( ACS); at least four consultations; and received some prenatal care; 2) Childbirth: coverage of institutional births and births carried out by trained professionals; 3) Postpartum: CHW home visit and postpartum consultation; 4) Child health: coverage and verification of vaccination and breastfeeding records in the first hour of life. The methodological quality of the Quality Assessment Tool for Quantitative Studies studies was assessed. In Stata 14·0, fixed or random effect meta-analyses (I2 > 50% or P value of the Q test <0.10) generated measures of associations by odds ratio (OR) and difference in difference (DID) and their intervals of confidence (95% CI). Of the 5,562 documents found, nine constituted a qualitative synthesis of results on 17,571 women of reproductive age, 4,996 households, 7,985 records of pregnant women, 6,548 who had children in the last six weeks. The studies were strong (n=2), moderate (n=4) and weak (n=3). The scorecards supported cycles of monitoring indicators of the use, supply and quality of maternal and child services, based on dialogue between services and communities. The interventions increased the number of home visits by Community Health Agents (CHA) during pregnancy (ORpooled=2.96; 95% CI: 2.02-4.34), but did not affect the other indicators. Social accountability interventions with scorecards enhanced the monitoring actions of health services by local communities and expanded the reach of CHW visits to pregnant women. Article 2: What is the effect of the COVID-19 pandemic, a health crisis, with global social and economic impacts on the nutritional status of children under two years of age and enrolled in the income transfer program. An ecological Interrupted Time Series study was carried out, with monthly data between January 2008 and June 2021. The analysis units were the macro-regions of Brazil and the time- dependent variables were low weight for age, stunting and overwheight extracted from the Sistema de Vigilância Alimentar e Nutricional (SISVAN). The analyzes were performed in RStudio. The Prais-Winsten regression estimated the trend and monthly percentage variation (MPV) and, SARIMA modeling, the effect of the pandemic - series interruption variable on the time-dependent variables, adjustments in trend and seasonality, calculating the Coefficients of Regression (CR), considering α=5%. The rates of stunting and overweight were the highest in all regions of Brazil in 2021. Significant increasing trends were observed for: underweight for age in the Midewst (MPV=3.46%; p< 0.001), Southeast (MPV=4.16%; p<0.001) and South (MPV=1.45%; p<0.001) regions; stunting in the Midwest (MPV=8.53%, p<0.001) and in the Southeast (MPV=8.14%, p<0.001) regions. There was a reduction in stunting (MPV= -4.35%; p=0.02) in the Northeast and overwheight in the Northeast (MPV=-4.53; p<0.001), Midwest (MPV=- 5.69; p<0.001) and Southeast (MPV=-2.99; p=0.03). The pandemic was associated with an increase in: i) low weight for age in the South (CR=0.94; p<0.001) and Southeast (CR=1.97; p<0.001); ii) stunting in the Midwest (CR=2.4; p=0.01), South (CR=2.15; p<0.001) and Southeast (CR=2.96; p<0.001); and iii) overwheight in the North (CR=1.51; p=0.04), Midwest (CR=2.29; p=0.01), South (CR=2.83; p<0.001) and Southeast (CR=0.72; p=0.04). The COVID-19 pandemic has intensified the double burden of malnutrition in the Midwest, South and Southeast regions. In the North region, there was an increase in overwheight, while in the Northeast region high rates of malnutrition indicators remained after the pandemic. Instituição: Universidade Federal do Maranhão Tipo do documento: Tese

Síndrome metabólica em diferentes fases da vida: predição e importância de seus componentes

Fri, 29 Nov 2024 00:00:00 GMT

Título: Síndrome metabólica em diferentes fases da vida: predição e importância de seus componentes Autor: COSTA JÚNIOR, Antonio Luís Rodrigues Primeiro orientador: FRANÇA, Ana Karina Teixeira da Cunha Abstract: Objectives: To propose predictive models to Metabolic Syndrome (MetS) in adolescents and to evaluate the most important MetS components in adults. Methods: The data used were from two cohorts of the RPS Consortium: Ribeirão Preto-SP, initiated in 1978-1979, and São Luís-MA, initiated in 1997-1998. Adolescents aged 18-19 years from this cohort (n=2,064) and adults aged 23-25 years and 37-39 years from that cohort (n=1,098) were evaluated. The criteria of Cook et al. (2003), De Ferranti et al. (2004), International Diabetes Federation - IDF (2005) and Joint Interim Statement (2009) were used to diagnose MetS. Artificial neural networks (ANNs) were trained to predict MetS in adolescents, based on noninvasive clinical and anthropometric data, and also to determine the relative importance of MetS components. Results: The prevalence of MetS in adolescents ranged from 5.7% to 12.3%, and was 12.1% at 23-25 years and 41.6% at 37-39 years. The ANN that included age, sex, waist circumference (WC), weight, and systolic and diastolic blood pressure showed better performance and discriminatory power in predicting MetS in adolescents (sensitivity 89.8% and accuracy 86.8%). The most important component for the diagnosis of MetS at 23-25 years was systolic blood pressure, and at 37-39 years of age, it was HDL. The least relevant was WC, at the first time point, and triglycerides, at the second. Therefore, systolic and diastolic blood pressure, and HDL were among the most important components for the diagnosis of MetS. Conclusions: Predicting MetS through non-invasive, easy and quick measurements, as well as knowing the relative importance of each component of MetS in each lifetime, allows the targeting of public health policies, with the concentration of resources for controlling and reducing the prevalence of MetS. Instituição: Universidade Federal do Maranhão Tipo do documento: Tese