Validation of a web-based questionnaire to assess the dietary intake of Brazilian children aged 7-10 years.

BACKGROUND: The Food Intake and Physical Activity of School Children (CAAFE) comprises an online questionnaire to self-report diet and physical activity of Brazilian schoolchildren. BACKGROUND: The present study aimed to assess the validity (matches, omissions and intrusions) and moderating factors of the CAAFE. METHODS: Direct observation was made of foods consumed (five public schools) and child self-reporting on the CAAFE. Additional data included school grade, gender, body mass index, completion of food diary, socioeconomic status and access to computer. Data were analysed using regression. RESULTS: In total, 602 children participated in the study [mean (SD) age 9.5 (1.24) years; 53.6% boys]. On average, there were 43% matches, 29% intrusions and 28% omissions. Matches doubled in third grade compared to the second grade (P = 0.004); matches almost tripled for afternoon snack compared to morning snack (P < 0.001); and matches were 69% higher for children with access to a computer at home (P < 0.01). Intrusions decreased by almost one-half in fifth compared to fourth grades (P = 0.004). Omissions declined significantly in the third and fourth grades but increased in the fifth grade. Omissions were 47% lower for children in the highest income and lower among children who completed the food diary. No differences were found for gender or body mass index. CONCLUSIONS: Children older than 8 years old, who owned a computer and completed a food diary, performed better in the CAAFE. A high incidence of disagreement was found in relation to the schools and the type of meal. Overall matches (43%), intrusions (29%) and omissions (28%) indicate that further studies are required to improve the validity of the CAAFE.

Qualitative analysis of the contributions of nutritionists to the development of an online instrument for monitoring the food intake of schoolchildren.

BACKGROUND: The Consumo Alimentar e Atividade Fisica de Escolares (CAAFE) questionnaire is an online research tool that has been developed to enable the self-report of physical activity and diet by Brazilian schoolchildren aged 7-10 years. Formative research was conducted with nutritionists during the development of the web-based questionnaire. The suggestions and insights obtained were used to design a tool to monitor schoolchildren's food consumption based on the concept of healthy and unhealthy food indicators. The present study aimed to report the focus group discussions conducted with nutritionists concerning the CAAFE questionnaire. METHODS: Focus group discussions were conducted using a semi-structured questionnaire, and these were then analysed thematically. RESULTS: Twenty-four nutritionists participated (four focus groups; average per group: six people); the majority (n = 22) had experience with 7-10-year-old children. Four themes emerged: (i) healthy and unhealthy food indicators; (ii) suggestions for the online instrument; (iii) potential applications; and (iv) challenges for its construction. CONCLUSIONS: Comments made by nutritionists enabled the construction of an instrument that is able to answer questions related to food consumption in schools and at home.

Case report of a haemovigilance investigation using phylogenetic analysis of HIV-1 in Brazil.

OBJECTIVES: The aim of this work is to provide the first report of a transfusion-acquired HIV-1 infection and to verify transmission from the donor to the recipients using phylogenetic analysis of HIV-1 DNA sequences in a Brazilian blood bank. BACKGROUND: Although haemovigilance procedures based on phylogenetic analysis of HIV have been reported in several countries, this type of study has yet to be conducted in Latin America. MATERIALS AND METHODS: Upon identifying a HIV-1-positive repeat blood donor by enzyme immunoassay (EIA) blood screening, all recipients of the donor's previous donation were identified and tested for HIV-1 by EIA, nucleic acid amplification test and HIV-1 DNA sequencing and phylogenetic analysis. RESULTS: One of the recipients tested positive for HIV-1. The phylogenetic analysis showed a high genetic similarity among the viruses, thus supporting the hypothesis of transmission from the donor to the recipient. CONCLUSIONS: Phylogenetic analysis of HIV-1 DNA sequences has been a decisive tool in verifying suspected transmission of the virus from blood donor to recipient in Brazil.

Test-retest reliability and external validity of the previous day food questionnaire for 7-10-year-old school children.

The aim of this study was to assess the reliability and external validity of the Previous Day Food Questionnaire (PDFQ) designed to obtain a report of the foods eaten on the previous day by schoolchildren. Participants were 7-10-year-old school children of the first four grades of a public school in Southern Brazil (N=227). Test-retest reliability was evaluated by kappa coefficient for two administrations of the PDFQ on the same day to the same children. External validity of the PDFQ was evaluated via sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) using trained observers of the food eaten on the previous day as gold standard. The association between responses from observed food intake with those from reported food intake on PDFQ was evaluated by multivariate logistic regression, controlled for school grade, gender, time of the eating, and the variation between first and second PDFQ applications. For the reliability study, the analyses stratified by school eating occasions (3 a day) indicated that agreement level was moderate or better for all food categories. PDFQ's sensitivity ranged from 57.1% (vegetables) to 93.3% (rice), whereas its specificity ranged from 77.8% (bread/pasta) to 98% (meats). Both, PPV and NPV were reasonably high. PDFQ was highly associated with observed food intake, with effect magnitude several times larger than any other factor analyzed for all foods. PDFQ also showed good test-retest reliability, suggesting that it may generate reliable and valid data for assessing food intake at the group (school) level.

Screening for latex sensitization by questionnaire: diagnostic performance in health care workers.

BACKGROUND: Latex allergy has emerged as a major cause of allergic reactions in health care workers. However, information is limited regarding the diagnostic methods available. OBJECTIVE: The aim of this study was to investigate diagnostic performance (sensitivity, specificity, and predictive values) of screening for natural rubber latex sensitization by questionnaire among health care workers, using skin prick test (SPT) as the gold standard for diagnosis. METHODS: The study population consisted of 260 randomly selected health care workers from the public health units in the city of Florianopolis, Brazil. The subjects were recruited from 2 groups: those who used latex gloves in their work (140) and those who were not exposed to latex (120). The mean (SD) age of the study population was 38.6 (0.6) years. Logistic regression analysis was used to predict SPT result from the questionnaire on previous symptoms of latex sensitization. RESULTS: Symptoms of (1) dryness, fissuring, swelling, pruritus, or cutaneous rash on the hands, and (2) pruritus of the oral mucosa or local redness after eating certain fruits (avocados, bananas, kiwis, chestnuts, mango, melons, or peaches) were the most sensitive and specific questionnaire items, respectively. The combination of these items with a cutoff point derived from the logistic regression led to 100% sensitivity and specificity for the prediction of SPT results in the population studied, with 95% confidence intervals of 51.7% to 100% for sensitivity and 98.1% to 100% for specificity. CONCLUSION: A questionnaire applied in a group of health care workers displayed excellent screening performance for latex sensitization.

Income inequalities and self-reported maternal health status: cross-sectional national survey.

The objective of this study was to examine income inequalities in the self-reported health status of women during the postnatal period. We analysed data from a cohort of 18,523 birth mothers of children who participated in the Millennium Cohort Study. Data on income and self-reported health status were collected during face-to-face interviews conducted at 9 months postpartum. Total take-home household income from employment, government and other sources was estimated and equivalised to reflect household composition, while self-reported health status was converted into a dichotomous measure. Complex survey logistic regression models were used to explore the association between equivalised household income and fair or poor self-reported health status. Compared with mothers with equivalised household income in the first quintile (bottom 20%) of the income distribution, mothers in the third (OR 0.69; 95% CI 0.59-0.81), fourth (OR 0.43; 95% CI 0.38-0.50) and fifth (OR 0.32; 95% CI 0.27-0.37) quintiles had a decreased likelihood of reporting fair or poor health status (P < 0.001). However, following adjustment for other predictors of postnatal health status, only mothers with equivalised household income in the fifth quintile (top 20%) had a decreased likelihood of reporting fair or poor health status (OR 0.72; 95% CI 0.58-0.90; P = 0.004). We conclude that this study provides support for the existence of an income gradient for postnatal health status. Efforts to reduce income inequalities in adverse maternal health outcomes are likely to require macro and microeconomic initiatives.

Validity of four indirect methods to measure adherence in primary care hypertensives.

High blood pressure (HBP) is one of the most important risk factors for morbidity and mortality in the world. Non-adherence to medication is associated with the lack of control of HBP. The objective of this study was to assess the validity of four indirect methods for measuring adherence to medication to control HBP in primary health care. A random sample of 120 hypertensive patients who were undergoing treatment for at least 2 months in a primary care unit in Florianópolis (Brazil) were included in the study. The independent variables were four indirect methods to measure adherence to medication: knowledge regarding the HBP medication, the blood pressure level, attitude regarding the medication intake (Morisky-Green test) and self-reported adherence. The classification of HBP was based on criteria established by the Brazilian Ministry of Health. The gold standard used for measuring adherence was the pill count. Logistic regression was used to estimate sensitivity (highest value of 88.2% for self-report), specificity (highest value of 70.7% for HBP control), positive predictive value (highest value of 46.4% for HBP control) and negative predictive value (highest value of 79.1% for Morisky-Green test) for each of the indirect methods. No indirect method of measuring adherence had a good positive predictive value for adherence, which was best predicted by patients' age and whether they managed to control HBP. The results also revealed low treatment adherence (31.2%) and low control of HBP (37.6%). Non-adherence was mainly associated with side effects of the treatment.

Motivational effects of 12-week moderately restrictive diets with or without special attention to the Glycaemic Index of foods.

Low glycaemic index (GI) diets may facilitate weight loss via behavioural and/or endocrine mechanisms. This study investigated whether the outcomes of the Weight Watchers POINTS Weight-Loss System could be improved by encouraging dieters to select low GI, high-carbohydrate foods. Ninety-six women (age 20-72 years; BMI 25-40 kg/m2) were recruited as they started the Weight Watchers POINTS programme for 12 weeks. Weekly classes were randomized so that seven (forty-five women) followed the regular programme while seven others (fifty-one women) followed a revised programme encouraging the selection of low GI foods. Anthropometric and biochemical parameters were measured before and after the 12-week diets. Participants rated hunger and desire to eat using visual analogue scales on 1 d per week, several times per d. Attrition was the same in both groups (32 v. 30 %), as well as many benefits (5 % weight loss, decreases in insulinaemia and blood lipids, waist and hip circumferences, blood pressure). Hunger and desire to eat were rated consistently lower in the low GI group over the 12-week diet. Group differences in subjective sensations were especially large in the afternoon. The 12-week weight management yielded many significant anthropometric and biochemical benefits that were not improved by encouraging dieters to select low GI foods. The subjective benefits (lower hunger and desire to eat) of the low GI diet may be a worthwhile contribution to the motivation of dieters that might affect adherence to the diet over the long term.

Meals, snacks and food choices in Brazilian shift workers with high energy expenditure.

OBJECTIVE: To describe the food intake of garbage collectors, who works in three shifts, in terms of meal and snack frequency, content, time distribution and the contribution of various popular foods to the total diet. METHODS: Sixty-six Brazilian garbage collectors, who work in morning, afternoon, and night shift, participated in the present study. The quantitative methods used were a combination of one 24-h recall and two 24-h records during three nonconsecutive work days. The qualitative method used was the food-based classification of eating episodes model modified in order to define meals or snacks in three categories of events: meals with three food groups of high nutrient density (three HND meals), meals with two food groups of high nutrient density (two HND meals) and snacks, composed of only one food category of high nutrient density. RESULTS: The total number of eating events per day was significantly higher for night shift workers. Over 24-h, 'two HND meals' were the most common events and contributed the most energy, in all three shifts. Night shift workers ate more at dawn and less in the morning than other shifts. In all three shifts, meat was the most important food contributing to energy intake. CONCLUSION: Different work schedules did not affect the relative frequency of meal types and snacks or their contribution to daily energy intake, but affected the daily distribution of eating events, with a redistribution of intake from day to night in night shift workers.

[Allocation of health care resources in the state of Santa Catarina, Brazil: a contribution to a discussion on health financing]. / Distribuição de recursos de saúde no Estado de Santa Catarina, Brasil: um subsídio para discussões sobre o financiamento em saúde.

OBJECTIVE: To describe the health situation in municipalities in the state of Santa Catarina, Brazil, in 1996, and to investigate how that correlated with federal health spending in 1997. METHODS: Multiple regression analysis was used to investigate the association between federal health care funding and proportional mortality, supply of health services (hospitals and outpatient clinics), and the municipality's population (number of inhabitants). Also investigated was the association between mortality from broad groups of causes and socioeconomic structure, supply of health services, and the municipality's population. RESULTS: The multiple regression analysis showed an association between proportional mortality due to: 1) infectious diseases and: infant mortality, number of non-doctor medical professionals per 10,000 inhabitants, and number of physicians per 10,000 inhabitants (negative association); 2) chronic degenerative diseases and: percentage of individuals 60 years and older, infant mortality (negative association), and number of non-doctor medical professionals per 10,000 inhabitants (negative association); and 3) external causes of death and: the municipality's population, number of hospitals per 10,000 inhabitants (negative association), and percentage of children younger than 1 year. Health spending per inhabitant in 1997 was mainly associated with the municipality's population, number of outpatient clinics per 10,000 inhabitants, Swaroop and Uemura mortality rate, and deaths due to chronic degenerative diseases in 1996. CONCLUSIONS: Municipalities with a better morbidity and mortality profile and a better health services structure received more federal health care resources. To improve this situation, special strategies should be considered in order to ensure additional resources for municipalities that have poorer health indicators.

Sexual attitudes and number of partners in young British men.

The relationship between sexual attitudes and number of heterosexual partners in a survey-based and nationally representative random sample of 551 British men aged 16-25 years was examined. The main predictor of the number of partners in the last 5 years was the time since the first sexual intercourse, whereas age, marital status, education, social class, smoking, and alcohol consumption contributed on a smaller but significant level. Sexual attitudes were summarized in terms of three underlying dimensions which could be described as permissiveness, attitudes toward sexual relations of same-sex partners, and importance of orgasm for sex. None of these was a significant predictor of the number of partners in the last 5 years. Both permissiveness and number of partners were associated with the age of first sexual intercourse and other background variables indicating opportunities for social contact. In conclusion, common factors of sexual attitudes and the number of sexual partners are not directly related but rather jointly predicted by a very similar set of background variables such as age, time since first sexual intercourse, social class, smoking, and alcohol consumption. Given the absence of a significant relationship between sexual attitudes and number of young men's partners, promoting safer sex may be a more sensible strategy than trying to change these attitudes.

The reduction of HIV transfusion risk in southern Brazil in the 1990s.

A retrospective study of blood donor records was undertaken to obtain risk estimates for transfusing HIV-contaminated blood due to an infectious window period in a large blood bank in the south of Brazil in the 1990s. An incidence/window period model was used to estimate HIV incidence and risk of seroconversion among 11 286 repeat donors with 8917 person-years of follow-up. Separate estimates were calculated for the periods of 1991-94, 1995-96 and 1997-99. Although the residual risk of HIV-positive transfusion decreased from 1 : 5000 in 1991-94 and 1 : 3794 in 1995-96 to 1 : 48 777 in 1997-99, this is still almost 10 times higher than in developed countries. The risk reduction is likely to have resulted from improved donor selection. Despite a 10-fold reduction in the risk of transfusing HIV-contaminated blood because of the screening test's failure to detect the virus during the infectious window period in the 1990s, additional measures are urgently needed to reduce the risk further. To this end, PCR screening of pooled blood donations might be considered in areas of high HIV prevalence when justified by cost-effectiveness calculations.

Clinical, provider and sociodemographic determinants of the number of antenatal visits in England and Wales.

The objective of this study was to measure the independent effects of clinical factors and non-clinical factors, such as provider and sociodemographic characteristics, on the number of antenatal visits made by women in England and Wales. The study was based on a survey of the secondary case records of 20,771 women with singleton pregnancies who were delivered between 1 August 1994 and 31 July 1995. The women in the survey attended one of nine maternity units in Northern England and North Wales selected within those areas to reflect geographical variations, as well as variations in the size and teaching status of the institution. A multivariate Poisson regression model was developed to examine differences in the number of antenatal visits made by women with different clinical and non-clinical characteristics. After controlling for non-clinical factors, primiparous women identified as high risk at booking made 1.0% more visits than primiparous women identified as low risk at booking (p = 0.196). Multiparous women identified as high risk at booking made 3.5% more visits than their low risk counterparts (p<0.001). High risk-defining criteria during antenatal care led to a 0.3% weekly increase in the number of antenatal visits amongst primiparous women (p <0.001) and a 0.4% weekly increase in the number of antenatal visits amongst multiparous women (p < 0.001). Several notable results, not reported elsewhere in the literature, were revealed by the regression analyses. After all independent variables were controlled for, women who were booked into urban teaching hospitals made 10% fewer antenatal visits than the women who were booked into the urban non-teaching hospitals. Women of Pakistani origin made 9.1% fewer antenatal visits than women of white British origin. Similar results were revealed for women of Indian origin and women from other ethnic groups. Non-smokers made 6.0% more antenatal visits than smokers. The planned pattern of antenatal care, number of carers seen, gestation at first presentation and maternal age also had significant independent impacts on the number of antenatal visits. The study highlights the sizeable impact of non-clinical factors on the antenatal care delivery process and indicates ways in which variations in antenatal care might be reduced.

Residual transfusion risk for hepatitis B and C in southern Brazil, 1991-99.

A retrospective study of 139188 blood donor records for the period 1991-99 was conducted in the largest blood bank in the federal state of Santa Catarina, in southern Brazil. The incidence/window method, based on 11286 repeat donors with 8917 person-years of follow-up, was used to estimate the residual risk for transfusing hepatitis B and C due to infectious window periods for early, mid and late years of the decade. The residual risk for transfusing HBsAg contaminated blood decreased almost three times over the 1990 decade but still remains very high at 1 : 2077 (95% confidence limits 1 : 1075-1 : 4624), with a corresponding incidence of 3.00 (1.35-5.77) per 1000 person-years. Similarly, although residual risk for hepatitis C was reduced more than 30 times in late 1990s, compared with the earlier period, the risk of 1 : 13721 (1 : 7102-1 : 30820) and corresponding incidence of 0.51 (0.23-0.99) per 1000 person-years are still very high compared to developed countries. In addition to vaccination against hepatitis B and health promotion efforts aimed at reduction of hepatitis transmission, special measures such as PCR screening of pooled blood donations might be needed to rapidly achieve a further residual risk reduction in high prevalence areas.

Effectiveness of a mass immunization campaign against serogroup C meningococci in children in the federal state of Santa Catarina, Brazil.

In addition to vaccine efficacy studies, there is a pressing need to evaluate vaccine effectiveness in a way that takes into account the limitations of health care systems in certain settings. An attempt to reach this objective was exemplified by a vaccination campaign against serogroup C meningococci in the federal state of Santa Catarina, in Brazil. A polysaccharide vaccine against serogroup C meningococci was administered to all individuals between 6 months and 14 years of age in March, 1996, in the municipalities that had the highest incidence of meningococcal disease in the previous year. All cases of the disease due to this serogroup observed in Santa Catarina during a 1-year period before and after the vaccination were included in the analysis. The cumulative incidence rate ratio was calculated for the unvaccinated compared to the vaccinated area. As a second step, the ratio of this quantity for the period before and after the vaccination, i.e. the ratio of the rate ratios (RRR), was calculated. One minus RRR was used to estimate the vaccine effectiveness. In the general population, the vaccine effectiveness was 74.3% (95% confidence intervals 52.7% to 99.6%). In children 6 months to 14 years, vaccine effectiveness was 93.1% (85.2% to 100%). Vaccine effectiveness could not be confirmed within more specific age bands, probably due to the lack of statistical power. It is concluded that group C meningococcal vaccine is effective in reducing the occurrence of meningococcal disease in children 6 months to 14 years of age, and that the ratio of rate ratios (RRR) in a useful method to evaluate vaccine effectiveness.

The relationship between rainfall and human leptospirosis in Florianópolis, Brazil, 1991-1996.

The relationship between serologically confirmed cases of leptospirosis and the amount of rainfall in greater Florianôpolis, in southern Brazil, was studied retrospectively for the period 1991 to 1996. Maximum daily and total monthly rainfall for present and previous months were statistically significant predictors of the number of cases of leptospirosis in Poisson regression models. However, daily maximum rainfall data showed a much better model fit than total monthly rainfall. For each millimeter increase in maximum daily rainfall for the month above the average for the period studied, there was an increase of 0.55% in the number of leptospirosis cases relative to the period average. For the past month's daily maximum, this increase was 0.21%. Maximum daily rainfall during the month is a sensitive indicator of large amounts of rain falling in a brief period of time. This may cause flash floods and, thus, disseminate pathogenic Leptospira among the human population, particularly in densely populated areas with large rodent populations and without adequate drainage. This situation is typical for the association of tropical rainstorms and the spread of leptospirosis among slum dwellers.

HIV associated culture proved tuberculosis has increased in north central London from 1990 to 1996.

OBJECTIVES: To examine rates of culture proved tuberculosis in HIV infected patients in three specialist centres in north central London. METHODS: Cases of tuberculosis in patients with previously documented HIV infection from 1990 to 1996 were identified retrospectively from microbiological/clinical records at Chelsea and Westminster, St Mary's, and University College London Hospitals. RESULTS: Between 1990 and 1996 202 cases of culture proved tuberculosis were identified at the three centres. Of these, 132/202 (65.3%) occurred in homosexual/bisexual men, 41/202 (20.3%) were in patients with heterosexual contact in sub-Saharan Africa, and 29/202 (14.4%) were in "others." Overall 148/202 (73.3%) had pulmonary tuberculosis. The total number of HIV infected individuals seen at the three centres increased from 4298 in 1990 to 5048 in 1996. Rates of tuberculosis in the three centres increased from 0.46% in 1990 to 0.83% in 1996. Part of this increase was due to an increase in tuberculosis among Africans from 1993 to 1996. CONCLUSIONS: Rates of HIV associated tuberculosis increased in these three centres in north central London between 1990 and 1996. In part this was due to an increase in the number of African patients with HIV infection attending the three centres. In addition, there was circumstantial evidence of recent transmission among homosexual men with HIV infection. Prospective "real time" surveillance of tuberculosis in HIV infected patients is needed in order to detect case clustering and to improve tuberculosis control.

HIV seroprevalence among blood donors in southern Brazil in the decade of 1990.

The objective of this study was to establish the time trend in HIV seroprevalence among blood donors to a large blood bank in southern Brazil during the decade of 1990, and compare it to other data sources from the same region. To this end, a retrospective study of blood donor records in HEMOSC (Center of Hematology and Hemotherapy of Santa Catarina), federal state of Santa Catarina, Brazil, was conducted for the period 1991 through 1999. Annual seroprevalence of HIV among blood donors and its time trend for the entire period were calculated. The HIV seropositive fraction doubled every 3 years, reaching 4 new cases per 1,000 donors per year by the end of the decade, or roughly twice the national average. The increase occurred particularly among female blood donors, those over 46 years of age, and those residing in the Florianópolis metropolitan area. We conclude that, in the decade of 1990, the frequency of HIV in southern Brazil increased in the population seeking to donate blood. Possible reasons for this increase include an increased use of blood donation as a means to obtain HIV testing or increased transmission among low risk populations. The effect of increased transfusion risk of HIV transmission requires urgent attention.