A questão da causalidade em Epidemiologia / The issue of causality in Epidemiology

Resumo Este ensaio trata da questão da causalidade em epidemiologia a partir da década de 1970, cujo marco inicial aqui adotado foi a publicação de The causal thinking in health sciences, por M. Susser, até os dias de hoje, buscando elencar os vários movimentos filosóficos, teóricos e metodológicos que ao longo destes 50 anos buscaram refletir sobre o problema da causalidade na disciplina, tendo em vista o predomínio das pesquisas observacionais no campo. Partindo da contribuição seminal de Susser, foram discutidos vários movimentos, bem como as críticas a eles, tais como a proposta da adoção de lógica popperiana na década de 1980, a crítica aos modelos multicausais e a teoria ecossocial proposta por N. Krieger na década de 1990, as críticas à epidemiologia social também da década de 1990, a influência de J. Pearl e a adoção dos gráficos acíclicos direcionados como nova metodologia na questão da causalidade. A chamada revolução metodológica no início deste século e as críticas de filósofos e epidemiologistas a esta abordagem reducionista também foram revisadas, bem como as alternativas propostas nos últimos 10 anos, incluindo a perspectiva inferencialista, a triangulação de métodos e a defesa da epidemiologia social e de seus modelos de determinação.

Abstract This essay deals with the issue of causality in epidemiology from the 1970s onwards, whose starting point adopted here was the publication of The Causal Thinking in Health Sciences by M. Susser, up to the present day, seeking to list the various philosophical, theoretical and methods that throughout these 50 years have sought to reflect on the problem of causality in the discipline, in view of the predominance of observational research in the field. Starting from Susser's seminal contribution, several movements were discussed as well as their criticisms, such as the proposal to adopt Popperian logic on the 1980s, the criticism of multicausal models and the ecosocial theory proposed by N. Krieger in the 1990s, criticism of social epidemiology also in the 1990s, the influence of J.Pearl and the adoption of directed acyclic graphs as a new tool in the issue of causality. The so-called methodological revolution at the beginning of this century and the criticism of philosophers and epidemiologists to this reductionist approach were also reviewed, as well as the alternatives proposed in the last 10 years, including the inferentialist perspective, the triangulation of methods and the defense of social epidemiology and their determination models.

Clinical and epidemiological characteristics and individual experiences of illness in men with COVID-19: mixed method study

ABSTRACT BACKGROUND: Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, studies have shown that this disease has affected the male population on a significant scale in various parts of the world, making men one of the main risk groups. OBJECTIVE: To analyze the clinical and epidemiological characteristics and experiences of illness in men with COVID-19. DESIGN AND SETTING: A mixed sequential-explanatory study with cross-sectional and exploratory-descriptive approaches. METHOD: Data was collected from a small municipality located in the central-north region of the state of Bahia, Brazil. Primary quantitative data was extracted from compulsory notification forms from 598 men. Qualitative data from individual interviews of 30 men was analyzed by the Discourse of the Collective Subject method. RESULTS: The findings identified the characterization of reports of suspected and confirmed cases of COVID-19 in men, the organization of the healthcare system, and strategies for the control and combat of COVID-19 directed towards the men of the investigated municipality. They revealed the clinical characteristics based on the collective discourse of men with COVID-19. CONCLUSION: In men, the individual experience of disease explicitly explains the clinical markers of COVID-19 expressed by the self-reported syndromic approach. Additionally, this understanding also explains the behaviors observed in their search for health care, as well as the adoption of prevention and control measures and therapies recommended by health professionals.

Modos de vida de personas autistas del centro medicina integral (Cartagena Colombia / Ways of life of autistic people from the integral medicine center (Cartagena Colombia)

Objetivo: Caracterizar los modos de vida de las personas autistas del centro Medicina Integral en la ciudad de Cartagena-Colombia, a través de la epidemiología crítica en su vertiente de la determinación social de la salud. Metodología: Se realizó utilizando técnicas cuali-cuantitativas como la encuesta, la entrevista, la revisión bibliográfica-documental y la observación natural. La muestra estuvo constituida por 105 familias de personas autistas asistentes al centro Medicina Integral en la ciudad Cartagena Colombia y los resultados fueron procesados mediante el software de procesamiento de datos SPSS STATISTICS 25. Resultados: a nivel de los modos de vida de las familias de las personas autistas, las categorías del dominio general determinan la dinámica de los modos de vida. En las categorías de este dominio como la etnia, la clase social y el género del responsable familiar, predominaron la raza mestiza, la inserción social baja y el género masculino. A nivel educativo-laboral, hubo mayor tendencia a trabajos del nivel medio, bajo subordinación e informalidad. El acceso a salud es bueno, pues más del 90 % goza de este servicio en la cobertura. A nivel de exposiciones, son variados los procesos, se evidencian pocos apoyos, contaminación ambiental socioespacial en las familias, inequidad en el territorio, patologización y mitos acerca de la condición de autismo. Conclusiones: se pudo concluir que el autismo en Cartagena Colombia no es una condición aislada, pues se encuentra subsumido bajo sistemas del orden general, particular y singular, que condicionan al individuo y a sus familias

Goal: This work focused its objective on characterizing the ways of life of autistic people at the Integral Medicine Center in the city of Cartagena-Colombia, through critical epidemiology in its aspect of social determination of health. Methodology: It was carried out using qualitative-quantitative techniques such as the survey, the interview, the bibliographical-documentary review and natural observation. The sample consisted of 105 families of autistic people attending the Integral Medicine Center in the city of Cartagena, Colombia, and the results were processed using the SPSS STATISTICS 25 data processing software. Results: at the level of the lifestyles of the families of the autistic people, it is seen how the categories of the general domain determine the dynamics of lifestyles. In the characterization of categories of a particular order such as ethnicity, social class and the gender of the family leader, the mestizo race, low social insertion and the male gender prevailed. At the educational-labor level, the tendency to work at the middle level under subordination and informality with technical and basic studies predominates in more than 60%. Access to health is good, since more than 90% enjoy this service. At the level of exhibitions, the processes are varied, few supports are evident, socio-spatial environmental contamination in families, inequity in the territory, pathologization and myths about the condition of autism. Conclusions: it was possible to conclude that autism in Cartagena Colombia is not an isolated condition, but is subsumed under systems of the general, particular and singular order, which

Reflexión epistemológica para la investigación de los procesos de determinación social de la salud / Epistemological reflection for the investigation of the processes of social health determination / Reflexão epistemológica para a investigação dos processos de determinação da saúde social

Resumen Un debate central en la salud pública contemporánea gira en torno de los determinantes sociales de la salud, en las posturas de la Organización Mundial de la Salud y de la medicina social latinoamericana. Dado que, en la literatura sanitaria, se presentan múltiples críticas al modelo de dicha organización, así como a su énfasis positivista, a su reduccionismo de la ontología de lo social y a la linealidad de sus métodos, al tiempo que existen pocos textos en salud sobre el "realismo crítico" como fundamento epistemológico de la corriente latinoamericana, el presente trabajo tiene como objetivo describir algunos hitos históricos de la determinación social de la salud y las características del realismo crítico como principal postura epistemológica para esta corriente. Desde esta postura se evidencia una suerte de "ingenuidad" epistemológica en el modelo de la Organización Mundial de la Salud; también demuestra que la diferencia de ambos enfoques no es reductible a una semántica o estilo de abordaje de lo social en salud, y pone de manifiesto retos operativos para la corriente latinoamericana.

Abstract A central debate in contemporary public health revolves around the social determinants of health in the model of the World Health Organization (who) and Latin American social medicine. Considering that in the health literature there are multiple criticisms of the who approach such as its positivist emphasis, reductionism of the ontology of the social and linearity of its methods; at the same time that there is a low amount of health texts about "critical realism" as the epistemological foundation of the Latin American current; The present work exposes some historical concepts of the Latin American proposal and tries to deepen the development of its epistemological positioning from the "critical realism". Critical realism demonstrates a sort of epistemological "naivety" in the who model, demonstrates that the difference of both approaches is not reducible to a semantics or social approach of the health, and highlights operational challenges for the model Latin American

Resumo Um debate central em saúde pública contemporânea gira em torno dos determinantes sociais da saúde nas posições da Organização Mundial da Saúde (oms) e da medicina social latino-americana. Considerando que na literatura em saúde existem múltiplas críticas à corrente da oms, como ênfase positivista, reducionismo da ontologia do social e linearidade de seus métodos; embora exista uma baixa quantidade de textos sobre saúde sobre "realismo crítico" como fundamento epistemológico da corrente latino-americana; O presente trabalho expõe alguns conceitos históricos da proposta latino-americana e tenta aprofundar o desenvolvimento de seu posicionamento epistemológico a partir do "realismo crítico". O "realismo crítico" evidencia uma espécie de "ingenuidade" epistemológica no modelo da oms, demonstra que a diferença entre as duas abordagens não é redutível a uma semântica ou abordagem à saúde social e destaca os desafios operacionais para a modelo América Latina

Estudio de caso sobre salud y población femenina ocupada como manifestación del envejecimiento poblacional en Villa Clara / Case study on health and employed female population as population aging manifestation in Villa Clara

RESUMEN Fundamento: El comportamiento de la mortalidad y morbilidad de la población femenina ocupada, es relevante por el rol de la mujer en lo laboral y familiar en un contexto envejecido. Objetivo: Analizar el comportamiento de la mortalidad y morbilidad de la población femenina ocupada en la Empresa Contratista General de Obras de Villa Clara. Metodología: El análisis documental de datos oficiales sobre la mortalidad femenina condujo a realizar un estudio de caso en la Empresa Contratista General de Obras de Villa Clara, mediante el trabajo grupal y la aplicación de la escala de autovaloración Dembo-Rubistein. Resultados: La mayor morbilidad y discapacidad de las mujeres se justifica por los patrones de socialización, roles familiares, obligaciones, expectativas laborales y tipos de ocupación que generan situaciones de sobrecarga física y emocional con marcada influencia en su salud. Conclusiones: En las condiciones actuales se hace necesario atender a la mujer más allá de su salud reproductiva y tener en cuenta el costo que para ella, la familia y la sociedad representa, el tener que asumir determinados roles como cargos de dirección, el ser trabajadora, jefas de hogar, cuidadoras, lo que puede ocasionar una sobrecarga psicológica, física y de su salud en general.

ABSTRACT Background: The mortality and morbidity behavior in employed female population is significant due to the role of women regarding work and family matters in an aging context. Objective: To analyze the mortality and morbidity behavior in employed female population at the Villa Clara General Work Contractor Enterprise. Methodology: The documentary analysis of official data on female mortality led to a case study at the Villa Clara General Work Contractor Enterprise, through group work and the application of the Dembo-Rubistein self-assessment scale. Results: The greater morbidity and disability of women is justified by socialization patterns, family roles, responsibilities, job expectations and types of occupation that generate some physical and emotional overload conditions with a marked influence on their health. Conclusions: At present, it is essential to give attention to women outside their reproductive health, also consider the cost that family and society represents for her, assuming different roles such as management positions, being a worker, heads of household, caregivers, which can produce a general psychological, physical and health overload.

Perfiles de transición epidemiológica-nutricional y carga de morbi-mortalidad por COVID-19 en Argentina: un estudio ecológico / Profiles of epidemiological-nutritional transition and burden of morbimortality from COVID-19 in Argentina: an ecological study / Perfis de transição epidemiológica-nutricional e carga de morbimortalidade por COVID-19 na Argentina: um estudo ecológico

Resumen: El objetivo de este trabajo fue identificar perfiles epidemiológico-nutricionales en Argentina, y comparar su carga de morbi-mortalidad por COVID-19. Se condujo un estudio ecológico multigrupal (24 unidades geográficas de Argentina). Se estimó el porcentaje de cambio 2005-2018 de indicadores de transición epidemiológica-nutricional, y sociodemográficos por unidad geográfica. Se condujo un análisis de componentes principales y análisis de clúster jerárquico para identificar agrupamientos geográficos que definan perfiles de transición epidemiológica-nutricional. Por grupo, se calcularon medidas resumen de incidencia acumulada (IA), mortalidad y tasa de letalidad por COVID-19 (semana epidemiológica 50), estableciendo comparaciones mediante prueba t de Student. Se identificaron tres perfiles denominados: (1) reemergencia de enfermedades infecciosas, (2) persistencia de enfermedades cardiovasculares con mejoras sociosanitarias y en estilos de vida, y (3) consolidación de la tríada obesidad-sedentarismo-enfermedades cardiometabólicas. La IA y mortalidad por COVID-19 promedio fue mayor en provincias con perfil 1, en comparación con el perfil 2 (IA: p = 0,0159; mortalidad: p = 0,0187) y el perfil 3 (IA: p = 0,0205). La letalidad resultó mayor en el perfil 3, que aglomera provincias con situación socioeconómica más desfavorable, estimándose diferencias significativas respecto al perfil 2 (p = 0,0307). En conclusión, existen distintos perfiles epidemiológico-nutricionales en Argentina, que tienden a diferenciarse en su situación epidemiológica de COVID-19. Las estrategias contra COVID-19 deberían considerar las características epidemiológico-nutricionales y sociodemográficas de base.

Abstract: The study aimed to identify epidemiological-nutritional profiles in Argentina and to compare the burden of morbimortality from COVID-19. A multigroup ecological study was conducted with 24 geographic units in Argentina. We estimated the percent change from 2005 to 2018 in indicators of the epidemiological-nutritional transition and sociodemographic indicators according to geographic unit. We performed principal components analysis and hierarchical cluster analysis to identify geographic groupings to define profiles in the epidemiological-nutritional transition. By group, we calculated summary measures of COVID-19 cumulative incidence (CI), mortality, and case fatality (epidemiological week 50), establishing comparisons via Student's t test. Three profiles were identified: (1) reemergence of infectious diseases, (2) persistence of cardiovascular diseases despite social, health, and lifestyle improvements, and (3) consolidation of the triad obesity-sedentarism-cardiometabolic diseases. Mean COVID-19 cumulative incidence and mortality were higher in provinces with profile 1 compared to profile 2 (CI: p = 0.0159; mortality: p = 0.0187) and profile 3 (CI: p = 0.0205). Case-fatality was higher in profile 3, which includes provinces with more unfavorable socioeconomic conditions, showing significant differences from profile 2 (p=0.0307). In conclusion, there are distinct epidemiological-nutritional profiles in Argentina which tend to differ in terms of their COVID-19 epidemiological situation. Strategies to fight COVID-19 should consider the underlying epidemiological, nutritional, and sociodemographic characteristics.

Resumo: O objetivo deste trabalho era identificar perfis epidemiológico-nutricionais na Argentina, e comparar a sua carga de morbimortalidade por COVID-19. Foi desenvolvido um estudo ecológico multigrupal (24 unidades geográficas da Argentina). Foi avaliado o percentual de mudança 2005-2018 de indicadores de transição epidemiológica-nutricional, e sociodemográficos, por unidade geográfica. Foi feita uma análise de componentes principais e de cluster hierárquico para identificar agrupamentos geográficos, definindo perfis de transição epidemiológica-nutricional. Por grupo, foram calculadas medidas de resumo de incidência acumulada (IA), mortalidade e taxa de letalidade por COVID-19 (semana epidemiológica 50), estabelecendo comparações mediante teste t de Student. Foram identificados três perfis: (1) reemergência de doenças infecciosas, (2) persistência de doenças cardiovasculares com melhorias sociossanitárias e nos estilos de vida, e (3) consolidação da tríade obesidade-sedentarismo-doenças cardiometabólicas. A IA e a mortalidade média por COVID-19 foi maior nas províncias com perfil 1, comparado com o perfil 2 (IA: p = 0,0159; mortalidade: p = 0,0187) e o perfil 3 (IA: p = 0,0205). A letalidade resultou maior no perfil 3, que abrange províncias com situação socioeconômica mais desfavorável, sendo encontradas diferenças significativas com relação ao perfil 2 (p = 0,0307). Em conclusão, existem distintos perfis epidemiológico-nutricionais na Argentina, que tendem a diferenciar-se na sua situação epidemiológica de COVID-19. As estratégias contra a COVID-19 deveriam considerar as características epidemiológico-nutricionais e sociodemográficas de base.

Exploratory Google Trends study of user concerns about oral problems / Estudio exploratorio de Google Trends de las preocupaciones de los usuarios sobre los problemas orales

Introduction: More and more people search for health information on the internet and oral health is no exception. Objective: To analyze the changes in the relative volumes of internet searches regarding the most common oral diseases and / or injuries according to the World Health Organization. Methods: Google Trends was used to provide data on the volume of searches on Google for the most common terms of comparison based on diseases and / or oral injuries according to WHO. The period of time chosen was from 2004 to 2019. Five search terms were compared in relation to dental caries, periodontopathies, dental trauma, oral cancer, oral manifestations of HIV, noma, cleft lip and palate, tooth loss, toothache. Results: The search volume measured during the 2004-2019 period, indicated that the comparative terms of higher relative search volumes were: "tooth decay" was the most searched in Jamaica, "gingivitis" in Paraguay, "broken tooth" in the United States, "mouth cancer" in the United Kingdom, "HIV symptoms" in Zimbabwe, "cancrum oris" and "cleft palate" in Ghana, no teeth in the United States, "toothache" in Trinidad and Tobago. In the comparison of the five terms of higher relative search volumes in the study, "gingivitis" was the term with the highest relative search volumes. Conclusion: The results obtained confirm the interest in oral diseases and / or injuries through the internet, the search term with the highest frequency of search was "gingivitis", followed by "cleft palate", "tooth decay", "no teeth" and for broken tooth(AU)

Introducción: Cada vez más personas buscan información sobre salud en internet y la salud oral no es una excepción. Objetivo: Analizar los cambios en los volúmenes relativos de búsqueda en internet respecto a las enfermedades y/o lesiones orales más comunes según la Organización Mundial de la Salud. Métodos: Se utilizó Google Trends para proporcionar datos sobre el volumen de búsquedas en Google de los términos de comparación basados en enfermedades y/o lesiones orales más comunes según la Organización Mundial de la Salud. El periodo de tiempo elegido fue de 2004-2019. Se compararon cinco términos de búsqueda en relación a dental caries, periodontopathies, dental trauma, oral cancer, oral manifestations of HIV, noma, cleft lip and palate, tooth loss, toothache. Resultados: El volumen de búsqueda medido durante el periodo 2004-2019 señaló que los términos comparativos de mayores volúmenes relativos de búsqueda fueron: "tooth decay", el más buscado en Jamaica; "gingivitis", en Paraguay; "broken tooth" y "no teeth", en Estados Unidos; "mouth cancer", en Reino Unido; "HIV symptoms", en Zimbabue; "cancrum Oris" y "cleft palate", en Ghana; "toothache" en Trinidad y Tobago. En la comparación de los cinco términos de mayores volúmenes relativos de búsqueda en el estudio, "gingivitis" ocupó el primer puesto. Conclusión: Los resultados obtenidos confirman el interés por las enfermedades y/o lesiones orales a través del internet, el término de búsqueda con mayor frecuencia de búsqueda fue "gingivitis", seguido de "cleft palate", "tooth decay", "no teeth" y por "broken tooth"(AU)

Análisis de complejidad en la caracterización de episodios de morbilidad materno-infantil / Analysis of complexity in the characterization of maternal and child morbidity episodes

Introducción: La salud materno-infantil constituye una prioridad bien definida en el sistema sanitario de Cuba, por lo que el estudio de problemas sanitarios complejos resulta de incuestionable valor. Objetivo: Caracterizar a féminas con infecciones asociadas a la asistencia sanitaria o preeclampsia, desde el paradigma de la complejidad. Métodos: Se desarrolló una investigación compleja trietápica en el Hospital Provincial Ginecoobstétrico Mariana Grajales Coello de Santiago de Cuba, que incluyó un análisis de serie temporal y un estudio observacional, descriptivo y transversal, para lo cual se tomaron 1 896 pacientes diagnosticadas con infecciones asociadas a la asistencia sanitaria, desde el año 2004 al 2017, y 140 gestantes con preeclampsia, registradas en el quinquenio 2013-2017; además, se consideraron variables clínicas, epidemiológicas, humorales, ecográficas y anatomopatológicas. Se efectuaron análisis de series temporales (descomposición estacional, análisis espectral e identificación de componentes de la serie), de componentes principales y de redes neuronales; a la vez que se identificaron los patrones estacionales específicos y microbiológicos para las infecciones asociadas a la asistencia sanitaria. Resultados: La edad, la historia obstétrica y las fluctuaciones de la tensión arterial resultaron ser factores predictores de importancia relacionados con la preeclampsia, además de los fallos renal y hepático como agravamientos y/o complicaciones de dicha entidad clínica. Conclusiones: La utilización de métodos de análisis multinivel reveló el complejo entramado que se establece entre las variables clínicas, epidemiológicas, sociales y ambientales en relación con las infecciones asociadas a la asistencia sanitaria y la preeclampsia, lo que se evidenció con los hallazgos anatomopatológicos.

Introduction: The maternal and child health constitutes a very defined priority in the health system of Cuba, reason why the study of complex health problems is of unquestionable value. Objective: To characterize women with infections associated with the health assistance or pre-eclampsia, from the paradigm of complexity. Methods: A complex three phase investigation was carried out in Mariana Grajales Coello Provincial Gynecoobstetric Hospital in Santiago de Cuba that included a temporary series analysis and an observational, descriptive and cross-sectional study, for which 1 896 patients diagnosed with infections associated with the health assistance, from 2004 to 2017, and 140 pregnant women with pre-eclampsia, registered in the five year period 2013-2017 were selected, also, clinical, epidemiological, humoral, echographic and pathologic variables were considered. Temporary series analysis (seasonal factorization, spectral analysis and identification of the series components), of main components and neural network were carried out; at the same time that the specific seasonal and microbiological patterns were identified for the infections associated with health assistance. Results: The age, obstetric history and fluctuations of blood pressure were important prediction factors related to pre-eclampsia, besides renal and hepatic failure as worsenings and/or complications of this clinical entity. Conclusions: The use of multilevel analysis methods revealed the complex structure that is established between the clinical, epidemiological, social and environmental variables in connection with the infections associated with health assistance and pre-eclampsia, what was evidenced with the pathologic findings.

Enfermedad periodontal: enfoques epidemiológicos para su análisis como problema de salud pública / Periodontal disease: epidemiological approaches for its analysis as a public health concern

RESUMEN La forma como los problemas de salud son definidos permiten desarrollos conceptuales y metodológicos diferentes, lo cual conduce a determinados resultados y a abordajes analíticos y preventivos específicos para afrontar los problemas. Este ensayo pretende mostrar algunos de los principales enfoques epidemiológicos con que ha sido abordado el proceso salud-enfermedad bucal y en particular la enfermedad periodontal. En relación a esta última se proponen diferentes enfoques para su comprensión los cuales han estado influenciados por el modelo biológico-curativo cuyo alcance es limitado y centrado en la identificación de factores de riego y en demostrar relaciones causales; sin embargo desde la epidemiología social se muestran alternativas más integrales que incluyen en el análisis los determinantes sociales de la salud que condicionan e inciden en el proceso salud enfermedad de las comunidades.(AU)

ABSTRACT The way how health problems are defined allow conceptual and methodological developments that lead to different outcomes and specific analytical and preventive approaches to confront problems. This essay aims to show some of the main epidemiological approaches that have been used to address the oral health-disease process, in particular the periodontal disease. Regarding the latter, different approaches to their understanding are proposed, which have been influenced by the biological-curative model, whose scope is limited and focused on the identification of risk factors and on demonstrating causal relationships. However, more comprehensive alternatives are also portrayed from social epidemiology that include social determinants in the analysis of the health-disease process, which affects and influences this process in the communities.(AU)

Epidemiología, equidad en salud y justicia social / Epidemiology, health equity and social justice / Epidemiologia, equidade em saúde e justiça social

Resumen Esta investigación teórica tiene como propósito evidenciar el vínculo de algunas maneras de entender la Epidemiología (epidemiología moderna, epidemiología social anglosajona y la epidemiología social latinoamericana) con teorías de justicia social en el marco de dos grandes tradiciones políticas y de pensamiento: el liberalismo y la teoría crítica de la sociedad, con el fin de aportar elementos para ampliar la discusión epistemológica, ética y política de la Epidemiología como disciplina científica y su contribución en la reducción de inequidades en salud.

Abstract The aim of this paper is show the link between some ways of understanding epidemiology (modern epidemiology, american and european social epidemiology and latinoamerican social epidemiology) and some theories about social justice in a framework of two politics tradition: the liberalism and the critical theory of society, with the purpose to provide elements to the epistemologic, etic and politic discussion of the epidemiology as a scientific discipline.

Resumo Esta pesquisa teórica tem como objetivo evidenciar o vínculo de algumas maneras de entender a Epidemiologia (epidemiologia moderna, epidemiologia social e epidemiologia social latino-americana) com teorias de justiça social no marco de duas grandes tradições políticas e de pensamento: o liberalismo e a Teoria crítica da sociedade, com a extremidade de elementos para a ampliação da epistemologia, a ética ea política da Epidemiologia como a disciplina científica e sua contribuição para a redução de desigualdades em saúde.

Strengthening the implementation of Health in All Policies:A methodology for realist explana-tory case studies / 中国卫生政策研究

To address macro-social and economic determinants of health and equity, there has been growing use of intersectoral action by governments around the world. Health in All Policies ( HiAP) initiatives are a special case where governments use cross-sectoral structures and relationships to systematically address health in policymaking by targeting broad health determinants rather than health services alone. Although many examples of HiAP have e-merged in recent decades, the reasons for their successful implementation-and for implementation failures-have not been systematically studied. Consequently, rigorous evidence based on systematic research of the social mechanisms that have regularly enabled or hindered implementation in different jurisdictions is sparse. We describe a novel meth-odology for explanatory case studies that use a scientific realist perspective to study the implementation of HiAP. Our methodology begins with the formulation of a conceptual framework to describe contexts, social mechanisms and out-comes of relevance to the sustainable implementation of HiAP. We then describe the process of systematically explai-ning phenomena of interest using evidence from literature and key informant interviews, and looking for patterns and themes. Finally, we present a comparative example of how Health Impact Assessment tools have been utilized in Swe-den and Quebec to illustrate how this methodology uses evidence to first describe successful practices for implementa-tion of HiAP and then refine the initial framework. The methodology that we describe helps researchers to identify and triangulate rich evidence describing social mechanisms and salient contextual factors that characterize successful prac-tices in implementing HiAP in specific jurisdictions. This methodology can be applied to study the implementation of HiAP and other forms of intersectoral action to reduce health inequities involving multiple geographic levels of govern-ment in diverse settings.

Capital Social: dados descritivos de estudo de base populacional e associação com comportamentos simultâneos de risco à saúde / Social Capital: descriptive data from population-based study and relationship with lifestyle

O objetivo deste trabalho foi apresentar dados descritivos sobre indicadores de capital social (CS) na população de um município de médio porte do Paraná, Brasil e analisar suas possíveis associações com a exposição simultânea a comportamentos de risco à saúde. Realizou-se estudo transversal de base populacional que incluiu 1.081 pessoas de 40 anos ou mais do município de Cambé-PR. Foram analisados dados sobre indicadores de CS e de quatro comportamentos (inatividade física no lazer, irregular consumo de frutas e verduras, tabagismo e consumo abusivo de álcool), sendo posteriormente verificados a associação entre os indicadores de CS e a quantidade de comportamentos de risco à saúde (dados agregados). Observou-se maior prevalência de nenhum comportamento de risco entre os que haviam participado nos últimos 12 meses de alguma atividade cívica/comunitária (15,5% vs 7,8% dos que não haviam participado), enquanto a prevalência de três ou quatro comportamentos de risco foi maior entre os que referiram não ter nenhum amigo (18,1% vs 24,3% dos que referiram quatro ou mais amigos) e entre os que percebiam menor frequência de ajuda entre as pessoas do bairro (23,6% entre os que consideravam que as pessoas no bairro se ajudam somente algumas vezes, raramente ou nunca vs 15,5% daquelas que consideravam que a ajuda entre as pessoas do bairro acontecia sempre ou quase sempre). Em geral, as pessoas com melhores indicadores de CS apresentavam menor quantidade de comportamentos de risco à saúde. Recomenda-se que as políticas públicas de promoção de comportamentos saudáveis se apropriem da ideia/conceito de CS.

The aim of this study was presenting descriptive data on indicators of social capital (SC) in representative sample of the population aged 40 years or more from a mid-size city in southern Brazil and the association of SC indicators with simultaneous exposure to risk health behaviors. We conducted a population-based cross-sectional study that included the population of 40 years or more (n=1081). The survey instrument consisted information on indicators of SC and four health behaviors (physical inactivity in leisure time, irregular consumption of fruits and vegetables, smoking and alcohol abuse). We verified the association between CS indicators and the amount of behavior health risk (aggregate). Higher prevalence of zero risk behavior was observed among those who participated in the last 12 months some civic or community activity (15.5% vs 7.8% of those who had not participated). The prevalence of three or four risk behaviors was higher among those who reported having no friends (18.1% vs 24.3% of those reporting four or more friends) and among those who reported less often help among people of neighborhood (23.6% among those who felt that people in the neighborhood to help only sometimes, rarely or never, vs 15.5 % of those who that felt help from people in the neighborhood occurred always or almost always). In general, people with better SC indicators had a lower amount of risk health behaviors. It is recommended that public policies consider the SC as an important aspect in the promotion of healthy behaviors.

Social epidemiology, education, and health promotion in infectious disease

This short communication discusses a project in Rio de Janeiro involving an attempt at imparting clinical and social epidemiology knowledge through educational initiatives. In small groups, social epidemiology was discussed in the context of a clinical/epidemiological project on various infectious diseases. Relevant knowledge was produced collaboratively by a multidisciplinary team of clinical research and project participants, comprising patients, relatives, friends, and health workers. An improvement in the learning capacity of participants was observed, fostering active appropriation of scientific knowledge. In dealing with infectious disease, social epidemiology contributes to the development of new strategies for collaborative research and disease prevention.

Esta comunicação discute um projeto desenvolvido no Rio de Janeiro, Brasil, que vincula epidemiologia clínica e epidemiologia social por meio de iniciativas educacionais. Abordagens da epidemiologia social foram utilizadas num projeto clínico-epidemiológico em doenças infecciosas, no qual a construção do conhecimento envolveu os próprios participantes (pacientes, familiares, amigos e trabalhadores da saúde) juntamente com a equipe multidisciplinar de pesquisas clínicas. Foi observada uma melhoria na capacidade de aprendizagem dos participantes que contribuiu para a apropriação ativa do conhecimento científico. Ao lidar com doenças infecciosas, a epidemiologia social favorece o desenvolvimento de novas estratégias de investigação colaborativa e de prevenção da doença.

Salud de la población desde la perspectiva de los determinantes sociales en salud / Population health from the social determinants of health perspective

La salud de la población es un concepto cuyo significado no se ha establecido de manera clara; por el contrario, su definición, e incluso existencia, ha generado debate entre diferentes autores. Si bien es clara la necesidad de implementar una definición adecuada, estructurada, aplicable y que sea de aceptación global, no existe un consenso con respecto a esta temática. Teniendo en cuenta que la salud de la población tiene una dinámica especial, se hace una revisión de la literatura científica para describir el papel de los factores sociales determinantes en salud desde la perspectiva de la epidemiología y la medicina social, con el objetivo de plantear una definición que tenga en cuenta las causas individuales de salud-enfermedad desde los factores de riesgo y las causas de la población enfocadas en dichos factores, para construir un concepto más objetivo y que tenga en cuenta todos los componentes que lo puedan influenciar.

Population health is a concept that has not been clearly established, its definition and even its existence has generated debate among different authors. While it is clear the need to implement an adequate, applicable, structured definition that can be globally accepted, there is no consensus on this subject. Given that population health has a special dynamic, we reviewed the literature to describe the role of social determinants of health from the perspective of epidemiology and social medicine, with the aim to propose a definition that takes into account individual healthdisease causes from risk factors and population causes with social determinants approach, to build a more objective definition that encompasses all the components that may influence it.

Capital social en el trabajo: Análisis psicométrico de una escala breve en español entre trabajadores de la salud mexicanos / Social capital at work: psychometric analysis of a short scale in Spanish among Mexican health workers

La mayoría de estudios sobre capital social y salud se realizan con grandes encuestas en hogares, olvidando que muchas interacciones entre los individuos ocurren en el ambiente laboral. Este estudio tuvo como objetivo evaluar las propiedades psicométricas de una escala en español para la medición del capital social en el trabajo. La escala de Kouvonen y colaboradores fue traducida al español y evaluada mediante la teoría clásica de las pruebas, la teoría de respuesta a los ítems y análisis factorial confirmatorio. Participaron 152 trabajadores de la salud mexicanos de diferentes contextos socioculturales. La consistencia interna fue alta (alfa de Cronbach= 0.88). El capital social en el trabajo se correlacionó adecuadamente con dos dimensiones del Cuestionario de Contenido del Trabajo. Se detectó un efecto techo y se cuantificó la dificultad de los ítems. El análisis factorial confirmatorio mostró los componentes teóricamente esperados de vinculación, puente y confianza del capital social en el trabajo. La escala tuvo un aceptable comportamiento psicométrico, por lo que podrá ser utilizada en futuros estudios.

Most studies on social capital and health are carried out with large home-based surveys, neglecting that many interactions among individuals occur in the workplace. The objective of this study was to explore the psychometric properties of a scale in Spanish used to measure social capital at work. The scale designed by Kouvonen et al was translated into Spanish and tested under classical test theory, item response theory, and confirmatory factorial analysis; 152 public health workers from different socio-cultural contexts participated in the survey. Internal consistency was high (Chronbach's alpha = 0.88). Social capital at work correlated properly with two Job Content Questionnaire dimensions. A ceiling effect was detected and item difficulty was quantified. The confirmatory factor analysis showed the expected theoretical components of social capital: bonding, bridging and trust. The scale has acceptable psychometric properties, thus it can be used in future studies.

Transdisciplinary research strategies for understanding socially patterned disease: the Asthma Coalition on Community, Environment, and Social Stress (ACCESS) project as a case study / Estratégias transdisciplinares de pesquisa para entender uma doença social: o projeto Asthma Coalition on Community, Environment, and Social Stress (ACCESS) como estudo de caso

As we have seen a global increase in asthma in the past three decades it has also become clear that it is a socially patterned disease, based on demographic and socioeconomic indicators clustered by areas of residence. This trend is not readily explained by traditional genetic paradigms or physical environmental exposures when considered alone. This has led to consideration of the interplay among physical and psychosocial environmental hazards and the molecular and genetic determinants of risk (i.e., biomedical framing) within the broader socioenvironmental context including socioeconomic position as an upstream "cause of the causes" (i.e., ecological framing). Transdisciplinary research strategies or programs that embrace this complexity through a shared conceptual framework that integrates diverse discipline-specific theories, models, measures, and analytical methods into ongoing asthma research may contribute most significantly toward furthering our understanding of socially patterned disease. This paper provides an overview of a multilevel, multimethod longitudinal study, the Asthma Coalition on Community, Environment and Social Stress (ACCESS), as a case study to exemplify both the opportunities and challenges of transdisciplinary research on urban asthma expression in the United States.

Com o aumento da asma observado em nível mundial nas últimas três décadas, também ficou claro que se trata de uma doença social, conforme evidenciado por indicadores demográficos e socioeconômicos agrupados por áreas residenciais. Esta tendência não pode ser explicada apenas por paradigmas genéticos tradicionais ou influência física do ambiente, quando considerados isoladamente. Por isso passou-se a considerar a interação entre riscos ambientais físicos e psicológicos e os determinantes de risco moleculares e genéticos (i.e. enquadramento biomédico) no âmbito de um contexto socioambiental mais amplo, incluindo a posição socioeconômica como "causa das causas" (i.e. enquadramento ecológico). Estratégias de pesquisa transdisciplinares ou programas que acolhem esta complexidade por meio de uma estrutura conceitual comum integrando teorias, modelos, medidas e métodos analíticos específicos das diversas disciplinas à pesquisa atual da asma podem representar contribuições particularmente significantes a uma melhor compreensão de uma doença social. Este artigo em forma de relato de caso pretende dar uma visão geral de um estudo longitudinal usando vários níveis e métodos - o Asthma Coalition on Community, Environment and Social Stress (ACCESS) -, para mostrar as oportunidades e desafios de um estudo transdisciplinar investigando a expressão urbana da asma nos Estados Unidos.

Desigualdades socioeconómicas en salud bucal: caries dental en niños de seis a 12 años de edad / Socioeconomic inequalities in oral healt: dental caries in 6 to 12 year-old children

Objective. To explore the association between caries indices in primary and permanent dentition and socioeconomic indicators at the individual and ecologic levels in 6-12 year old children. Materials and methods. A comparative analysis of two dataseis depicting oral health status in Campeche, México, with 2,939 children distributed equally by age and sex, was carried out. Oral health indices were contrasted at different cut-off points in primary and permanent dentitions (dmft, DMFT, dmft+DMFT and SiC indices) with independent variables such as place of residence (urban, marginal-urban) and mother's highest level of schooling (years of formal education) as socioeconomic variables (SES), as well as other sociodemographic variables using models of binary logistic regression in STATA 8.2®. Results. The mean age was 8.85 ± 1.83 years and 56.6% were girls. Nine models were generated in which changes in socioeconomic variables were linked to changes in oral health features in this community (both in terms of prevalence and severity), except for DMFT > 0 at 12 years of age. Conclusions. In general, children of lower SES had greater caries experience and higher caries severity, in both primary and permanent dentitions. The relationships between oral health disparities and independent variables were confirmed in children living in geographically contiguous areas.

Objetivos. Explorar la existencia de desigualdades en la salud bucal a través de indicadores socioeconómicos, a nivel individual y ecológico, en una población de niños de seis a 12 años de edad. Material y métodos. Se realizó un análisis comparativo de dos estudios transversales de salud bucal en Campeche, México. Se incluyeron 2,939 niños distribuidos de igual manera por edad y sexo. Los resultados de dichos estudios fueron combinados y usados para explorar desigualdades socioeconómicas en salud bucal. La salud bucal fue medida a través de diferentes puntos de corte en índices de caries (ceod, CPOD, ceod + CPOD y SiC). Las variables independientes incluidas en el estudio fueron el área de residencia (urbana, conurbana) y la escolaridad de la madre (años de estudio), así como otras variables sociodemográficas que sirvieron para ajustar los modelos. Se generaron modelos de regresión logística binaria en STATA 8.2®. Resultados. Los nueve modelos generados revelaron que los cambios en las variables socioeconómicas se relacionaron con las manifestaciones de salud bucal en esta comunidad, tanto en términos de prevalencia como de severidad. La única excepción fue al comparar el indicador de caries CPOD > 0 a los 12 años de edad. Conclusiones. En general, los niños de menor posición socioeconómica tuvieron mayor experiencia y severidad de caries dental en la dentición temporal y permanente. Las discrepancias encontradas de los indicadores de caries a través de las variables independientes de interés ponen en evidencia las desigualdades sociales en salud bucal entre grupos viviendo en localidades contiguas.

SIDA y estratos sociales en México: la importancia del bisexualismo / AIDS and social stratus in Mexico: importance of bisexualite

Se analiza la prevalencia del SIDA en México y la frecuencia de los riesgos de transmisión sexual según estrato socioeconómico de los pacientes. El estudio se basó en las notificaciones obligatorias de SIDA, recibidas entre 1982 y septiembre de 1988 por la Secretaría de Salud. Se encontró que los casos de SIDA están acumulándose con mayor celeridad entre los estratos bajos, donde también hay una mayor frecuencia del riesgo bisexual como del heterosexual. Estos hallazgos se explican en el contexto de los valores sexuales así como en las condiciones de vida propias a los estratos bajos en el país. Se recomienda que las campañas de prevención se diferencien para atender a las peculiaridades propias de los distintos estrados sociales en México

The prevalence of AIDS in Mexico and the frequency of sexually transmitted risks was analyzed in relation to the socioeconomic strata of the patients. The study was based on the obligatory notifications of AIDS received by the Ministry of Health between 1982 and september of 1988. The findings show that Aios is accumulating more rapidly among the low socioeconomic strata, where the bisexual and heterosexual risk factprs are also more frequent. These findings are explained in the context of the sexual mores and living conditions of the low social strata of the country. The study leads to the recommendation of diversified preventive activities that meet the peculiarities of the various social strata in Mexico.