[Community participation in health as an essential element for health system strengthening in the AmericasLa participación en salud como elemento indispensable para el fortalecimiento de los sistemas de atención de salud en las Américas]. / Participação em saúde como elemento indissociável para o fortalecimento dos sistemas de atenção à saúde nas Américas.

The present narrative review discusses the relevance and challenges of community participation in health for health system strengthening. Based on a definition of community participation in health as a dynamic process that gives people access and control over health resources through involvement and experience, the article summarizes information obtained from documents and debate at an international event (Seminario Internacional: Experiencias y Modelos de Participación en Salud en América Latina y el Caribe). In addition, the SciELO, PubMed and Google Scholar databases were searched using the terms "community participation", "community engagement", "social control" and "community health planning" to identify national or transnational review and opinion articles. Community participation in health is a current concept, acknowledged in the recommendations for health policies described in recent documents and publications. Around the world, the number of studies on the subject is growing; however, in the Americas, three countries (United States, Canada and Brazil) accounted for most of the scientific publications identified in the databases. The studies address timely questions and show consensus among investigators within each individual research group. However, the area lacks exchanges and comparative analyses that contrast different experiences transcending national borders and expanding knowledge on community participation in health. The creation of more spaces for the sharing of experiences and research is advised, as well as the establishment of professional and research networks in the field of community participation in health.

En esta revisión narrativa se analizan la relevancia y los retos de la participación en salud para el fortalecimiento de los sistemas de atención de salud. A partir de una definición de la participación en salud como un proceso dinámico que da a las personas acceso y control sobre los recursos de salud por medio de la intervención y la experiencia, en el artículo se sintetiza la información obtenida de documentos y en un debate realizado en el denominado Seminario Internacional: Experiencias y Modelos de Participación en Salud en América Latina y el Caribe. A este material se agregaron los resultados de búsquedas en las bases de datos SciELO, PubMed y Google Académico con los términos "community participation", "community engagement", "social control" y "community health planning". Se seleccionaron artículos de revisión y opinión de los ámbitos nacional o transnacional, sin límite de fecha ni de idioma. La participación en salud es un concepto actual, legitimado en las recomendaciones sobre políticas de salud descritas en documentos y publicaciones recientes. El número de estudios sobre el tema ha aumentado en todo el mundo, pero en las Américas, la mayoría de las publicaciones se concentran en tres países (Brasil, Canadá y Estados Unidos). En los estudios se abordan asuntos de actualidad y se demuestra el consenso existente entre los investigadores de cada grupo independiente. Sin embargo, en este campo no hay intercambios ni análisis comparativos que permitan contrastar las diferentes experiencias más allá de las fronteras nacionales y ampliar el conocimiento sobre la participación en salud. Se recomienda crear ámbitos de intercambio de experiencias y oportunidades de investigación, y establecer redes profesionales y de investigación en el campo de la participación en salud.

Bottom-up innovative responses to COVID-19 in Latin America and the Caribbean: addressing deprioritized populations.

Objective: To identify and describe innovative initiatives implemented as a response to the interruption of health services during the COVID-19 pandemic in Latin America and the Caribbean (LAC). Methods: This was a descriptive study that reviewed 34 initiatives implemented during the COVID-19 pandemic in LAC to address health services needs among deprioritized groups. The review of initiatives included four phases: a call for submissions of innovative initiatives from LAC countries; a selection of initiatives that had the ability to address health services gaps and that were innovative and effective; systematization and cataloging of the selected initiatives; and a content analysis of the information collected. Data were analyzed from September to October 2021. Results: The 34 initiatives show important variations regarding the target populations, the stakeholders involved, level of implementation, strategies, scope, and relevance of the innovative initiative. There was also evidence of the emergence of a bottom-up set of actions in the absence of top-down actions. Conclusion: The findings of this descriptive review of 34 initiatives implemented during the COVID-19 pandemic in LAC suggest that systematizing the strategies and lessons learned has the potential to expand learning for re-establishing and improving post-pandemic health services.

Impact of a Community-Based Pelvic Floor Kinesic Rehabilitation Program on the Quality of Life of Chilean Adult Women with Urinary Incontinence.

The pelvic floor forms the primary bottom tissue of the pelvic cavity. It comprises muscles that play a fundamental role in bowel and bladder emptying. Alterations of pelvic floor muscles will result in dysfunctions such as urinary incontinence (UI). Given the high prevalence of UI and its impact on the quality of life (QoL) in patients with pelvic floor muscle dysfunctions, it is necessary to implement public, community, and generalized programs focused on treating these dysfunctions. OBJECTIVE: To determine the effect of a community rehabilitation program on QoL, UI severity, and pelvic floor muscle strength in patients with UI. PATIENTS AND METHOD: A descriptive prospective cohort study. Twenty subjects between 44 and 75 years old with a diagnosis of UI, participants of a community kinesic rehabilitation program on the pelvic floor in Maipú, Santiago, Chile, were evaluated. These volunteers were intervened for six months, and QoL was measured with the 36-Item Short-Form Health Survey (SF-36) and International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) scales, UI severity with the Sandvick test, and pelvic floor muscle strength with the Oxford scale. Patients were followed up three months post-intervention. RESULTS: Significant improvements were observed in all scales after applying for the community kinesic rehabilitation program, and the changes were maintained at a 3-month follow-up. CONCLUSIONS: Since the improvement in QoL, UI severity, and pelvic floor muscle strength after the intervention, it is relevant to consider the implementation of community programs aimed at education, screening, and early rehabilitation of these patients.

Effectiveness of a course on family health in the knowledge of doctors of the Mais Médicos program

SUMMARY OBJECTIVE: The aim of this study was to analyze the effectiveness of the distance education course in family health in the knowledge of physicians from the Mais Médicos program. METHOD: This is a quantitative, quasi-experimental study, without a pretest and posttest control group, carried out from August 2019 to September 2021. In all modules, physicians responded to a pretest and posttest to verify their knowledge of the subject. RESULTS: There was a statistically significant difference in all modules with higher average scores in the posttests; the modules with the greatest emphasis are child health care: growth and development; approach to cancer in primary health care; and family health strategy and territorialization. CONCLUSION: The effectiveness of the distance education course was verified, as evidenced by the significant improvement of knowledge in all the modules studied.

Bottom-up innovative responses to COVID-19 in Latin America and the Caribbean: addressing deprioritized populations / Respuestas innovadoras a la COVID-19 generadas desde la base en América Latina y el Caribe: abordaje de grupos poblacionales desatendidos / Respostas inovadoras de baixo para cima à COVID-19 na América Latina e no Caribe com foco em populações não priorizadas

ABSTRACT Objective. To identify and describe innovative initiatives implemented as a response to the interruption of health services during the COVID-19 pandemic in Latin America and the Caribbean (LAC). Methods. This was a descriptive study that reviewed 34 initiatives implemented during the COVID-19 pandemic in LAC to address health services needs among deprioritized groups. The review of initiatives included four phases: a call for submissions of innovative initiatives from LAC countries; a selection of initiatives that had the ability to address health services gaps and that were innovative and effective; systematization and cataloging of the selected initiatives; and a content analysis of the information collected. Data were analyzed from September to October 2021. Results. The 34 initiatives show important variations regarding the target populations, the stakeholders involved, level of implementation, strategies, scope, and relevance of the innovative initiative. There was also evidence of the emergence of a bottom-up set of actions in the absence of top-down actions. Conclusion. The findings of this descriptive review of 34 initiatives implemented during the COVID-19 pandemic in LAC suggest that systematizing the strategies and lessons learned has the potential to expand learning for re-establishing and improving post-pandemic health services.

RESUMEN Objetivo. Detectar y describir iniciativas innovadoras instrumentadas como respuesta a la interrupción de los servicios de salud durante la pandemia de COVID-19 en América Latina y el Caribe (ALC). Métodos. Se trata de un estudio descriptivo en el que se examinaron 34 iniciativas instrumentadas durante la pandemia de COVID-19 en ALC para hacer frente a las necesidades de servicios de salud en grupos poblacionales desatendidos. La revisión constó de cuatro fases: convocatoria para la presentación de iniciativas innovadoras por parte de los países de la Región; selección de iniciativas capaces de abordar las deficiencias en los servicios de salud y que fueran innovadoras y eficaces; sistematización y clasificación de las iniciativas seleccionadas; y análisis del contenido de la información recopilada. Los datos se analizaron entre septiembre y octubre del 2021. Resultados. Las 34 iniciativas presentan importantes diferencias en cuanto a los grupos poblacionales destinatarios, las partes interesadas implicadas, el grado de aplicación, las estrategias, el alcance y la pertinencia de la iniciativa innovadora. También se constató el surgimiento de un conjunto de acciones generadas desde la base como respuesta a la ausencia de medidas aplicadas de forma descendente. Conclusión. Los resultados de esta revisión descriptiva de 34 iniciativas aplicadas en ALC durante la pandemia de COVID-19 sugieren que la sistematización de las estrategias y las enseñanzas extraídas podría ser útil para ampliar el aprendizaje con vistas al restablecimiento y la mejora de los servicios de salud pospandémicos.

RESUMO Objetivo. Identificar e descrever iniciativas inovadoras implementadas em resposta à interrupção dos serviços de saúde durante a pandemia de COVID-19 na América Latina e no Caribe (ALC). Métodos. Este estudo descritivo analisou 34 iniciativas implementadas durante a pandemia de COVID-19 na ALC para atender às necessidades de serviços de saúde entre grupos que haviam perdido prioridade. A análise das iniciativas incluiu quatro fases: chamada pública para a apresentação de iniciativas inovadoras de países da ALC; seleção de iniciativas inovadoras e efetivas capazes de abordar lacunas nos serviços de saúde; sistematização e catalogação das iniciativas selecionadas; e análise de conteúdo das informações coletadas. Os dados foram analisados de setembro a outubro de 2021. Resultados. As 34 iniciativas apresentam variações importantes com relação às populações-alvo, partes interessadas envolvidas, nível de implementação, estratégias, escopo e relevância da iniciativa inovadora. Também houve evidências do surgimento de um conjunto de ações de baixo para cima (bottom-up) na ausência de ações de cima para baixo (top-down). Conclusão. Os resultados desta análise descritiva de 34 iniciativas implementadas durante a pandemia de COVID-19 nos países da ALC sugerem que a sistematização das estratégias e das lições aprendidas tem o potencial de ampliar as oportunidades de aprendizado para reestabelecer e aprimorar os serviços de saúde pós-pandemia.

Participação em saúde como elemento indissociável para o fortalecimento dos sistemas de atenção à saúde nas Américas / Community participation in health as an essential element for health system strengthening in the Americas / La participación en salud como elemento indispensable para el fortalecimiento de los sistemas de atención de salud en las Américas

RESUMO A presente revisão narrativa discute a relevância e os desafios da participação em saúde para o fortalecimento dos sistemas de atenção à saúde. Partindo de uma definição de participação em saúde como um processo dinâmico que dá às pessoas acesso e controle sobre os recursos de saúde por meio de envolvimento e experiência, o artigo sintetiza informações obtidas em documentos e debate em um evento internacional (Seminario Internacional: Experiencias y Modelos de Participación en Salud en América Latina y el Caribe). A esse material, foram agregados os resultados de buscas nas bases SciELO, PubMed e Google Acadêmico utilizando os termos "community participation", "community engagement", "social control" e "community health planning". Foram selecionados artigos de revisão e de opinião em âmbito nacional ou transnacional, sem limite de data ou idioma. A participação em saúde é um conceito atual, legitimado nas recomendações para políticas de saúde descritas em documentos e publicações recentes. Em todo o mundo, cresce o número de estudos sobre o assunto; porém, nas Américas, três países (Estados Unidos, Canadá e Brasil) concentram a maioria das publicações. Os estudos abordam questões oportunas e demonstram consenso entre os pesquisadores de cada grupo independente. Entretanto, a área carece de intercâmbios e análises comparativas que contrastem diferentes experiências que transcendam as fronteiras nacionais e ampliem o conhecimento sobre a participação em saúde. Aconselha-se a criação de espaços de troca de experiências e oportunidades de pesquisa, bem como o estabelecimento de redes profissionais e de pesquisa no campo da participação em saúde.

ABSTRACT The present narrative review discusses the relevance and challenges of community participation in health for health system strengthening. Based on a definition of community participation in health as a dynamic process that gives people access and control over health resources through involvement and experience, the article summarizes information obtained from documents and debate at an international event (Seminario Internacional: Experiencias y Modelos de Participación en Salud en América Latina y el Caribe). In addition, the SciELO, PubMed and Google Scholar databases were searched using the terms "community participation", "community engagement", "social control" and "community health planning" to identify national or transnational review and opinion articles. Community participation in health is a current concept, acknowledged in the recommendations for health policies described in recent documents and publications. Around the world, the number of studies on the subject is growing; however, in the Americas, three countries (United States, Canada and Brazil) accounted for most of the scientific publications identified in the databases. The studies address timely questions and show consensus among investigators within each individual research group. However, the area lacks exchanges and comparative analyses that contrast different experiences transcending national borders and expanding knowledge on community participation in health. The creation of more spaces for the sharing of experiences and research is advised, as well as the establishment of professional and research networks in the field of community participation in health.

RESUMEN En esta revisión narrativa se analizan la relevancia y los retos de la participación en salud para el fortalecimiento de los sistemas de atención de salud. A partir de una definición de la participación en salud como un proceso dinámico que da a las personas acceso y control sobre los recursos de salud por medio de la intervención y la experiencia, en el artículo se sintetiza la información obtenida de documentos y en un debate realizado en el denominado Seminario Internacional: Experiencias y Modelos de Participación en Salud en América Latina y el Caribe. A este material se agregaron los resultados de búsquedas en las bases de datos SciELO, PubMed y Google Académico con los términos "community participation", "community engagement", "social control" y "community health planning". Se seleccionaron artículos de revisión y opinión de los ámbitos nacional o transnacional, sin límite de fecha ni de idioma. La participación en salud es un concepto actual, legitimado en las recomendaciones sobre políticas de salud descritas en documentos y publicaciones recientes. El número de estudios sobre el tema ha aumentado en todo el mundo, pero en las Américas, la mayoría de las publicaciones se concentran en tres países (Brasil, Canadá y Estados Unidos). En los estudios se abordan asuntos de actualidad y se demuestra el consenso existente entre los investigadores de cada grupo independiente. Sin embargo, en este campo no hay intercambios ni análisis comparativos que permitan contrastar las diferentes experiencias más allá de las fronteras nacionales y ampliar el conocimiento sobre la participación en salud. Se recomienda crear ámbitos de intercambio de experiencias y oportunidades de investigación, y establecer redes profesionales y de investigación en el campo de la participación en salud.

Primary care for people with Parkinson's disease in Brazil: A referral flowchart based on risk of falls.

Background: People with Parkinson's disease (PD) need to exercise to have a better quality of life. The risk of falling needs to be considered when choosing and implementing exercise interventions. Flowcharts are used to facilitate referrals in Brazilian primary care network, but there is no specific one for PD. Aim: To develop a referral flowchart for people with PD in Brazilian primary care based on the risk of falls and scientific evidence in the context of a multidisciplinary approach. Methods: The development of the referral flowchart was accomplished in three steps; (1) relevant literature was reviewed (2) semi-structured interviews (in focus groups) were conducted with primary health care professionals to investigate the current care for people with Parkinson's disease, and (3) the information obtained from the previous steps were analyzed to inform the development of the referral flowchart. Results: The fall risk-based flowchart uses the 3-step-fall-prediction tool. The primary health care professional should refer the person with a low risk of falls to activities with minimal supervision and those with a higher risk of falls to specialized neurology services. Neurology services are also the referral target for persons presenting significant mobility restrictions (i.e., restricted to a wheelchair or bed). The referral occurs according to what is available in Brazilian primary care. Conclusion: This flowchart might be the first step to build a multidisciplinary approach for people with Parkinson's disease in Brazilian primary care. The next stage of this study is the validation and subsequent implementation of the flowchart through the primary care at Unified Health System in Brazil.

Knowledge of basic attention professionals about prevention and early detection of breast cancer in the state of Goiás

The role of Basic Health Care (BHC) professionals is essential in the primary and secondary prevention of breast cancer. The aim of this study was to characterize BHC professionals in the Health Regions of a federative unit and to assess their knowledge about breast cancer. This was a prospective study carried out with BHC professionals from the state of Goiás. Phase 1 ­ Preparation of material and training of the team. Phase 2 ­ Agreement of actions between executing team and coordination of health regions. Phase 3 ­ Presentation of project at the collegiate meeting. Phase 4 ­ Qualification of BHC professionals with different learning methods and application of questionnaires, evaluating the contribution of the action. A total of 1,133 professionals were included; mean age was 36.3 years, and they were predominantly women (87.6%), working as community health agents (59.2%) and at public service (76.3%). Only 53.8% of professionals identified the female sex as a risk factor for breast cancer, while 90% identified family history as an important factor for the development of the disease. Important changes in physical examination that can occur in patients with the disease, such as skin retraction, skin bulging and nipple injury, were mentioned as a risk factor only by 35.3%, 31.3% and 39.7%, respectively. BHC professionals who participated in the project had less than ten years of professional experience and significant restrictions of knowledge about primary and secondary prevention of breast cancer. They still experience difficulties in accessing mammography and specialized care.

Community intervention in the Nursing education: experience report / Intervención comunitaria en la educación en enfermería: relato de experiencia / Intervenção comunitária na educação em enfermagem: relato de experiência

ABSTRACT Objective: To report the implementation and results of community intervention projects used as a strategy for teaching and developing people and communities in the training of community health nursing specialists at the Centro de Formação de Saúde Multiperfil (Multi-profile Health Training Center), Angola. Method: Report of experience of the use of community intervention projects in nursing. Results: Community intervention projects have contributed to the learning of students and to the promotion of health, citizenship and the empowerment of individuals and communities. Its implementation is in the fourth year, and 16 projects have already been developed in 2 distinct neighborhoods, and this year the intervention will cover a third. Conclusions: Nursing teaching should adopt strategies that lead the student not only in the path of professional autonomy, but, above all, in the empowerment of people and communities. Community intervention is undoubtedly important in this area.

RESUMEN Objetivo: Informar de la implementación y resultados de proyectos de intervención comunitaria utilizados como estrategia de enseñanza y desarrollo de personas y comunidades, en la formación de enfermeros especialistas en enfermería de salud comunitaria, en el Centro de Formación de Salud Multiperfil, Angola. Método: Relato de experiencia de la utilización de proyectos de intervención comunitaria en enfermería. Resultados: Los proyectos de intervención comunitaria contribuyeron al aprendizaje de los estudiantes y a la promoción de salud, la ciudadanía y el empoderamiento de personas y comunidades. Su implementación está en el cuarto año, y ya se han desarrollado 16 proyectos en 2 barrios distintos, mientras que este año la intervención abarcará un tercero. Conclusiones: La enseñanza en enfermería debe adoptar estrategias que conduzcan al estudiante no sólo en el camino de la autonomía profesional, sino especialmente en la capacitación de las personas y comunidades. La intervención comunitaria es claramente importante en este ámbito.

RESUMO Objetivo: Relatar a implementação e resultados de projetos de intervenção comunitária utilizados como estratégia de ensino e desenvolvimento de pessoas e comunidades, na formação de enfermeiros especialistas em enfermagem de saúde comunitária, no Centro de Formação de Saúde Multiperfil, Angola. Método: Relato de experiência da utilização de projetos de intervenção comunitária em enfermagem. Resultados: Os projetos de intervenção comunitária contribuíram para a aprendizagem dos estudantes e para a promoção da saúde, cidadania e empoderamento de pessoas e comunidades. A sua implementação está no quarto ano, e já foram desenvolvidos 16 projetos em 2 bairros distintos, sendo que este ano a intervenção abrangerá um terceiro. Conclusões: O ensino em enfermagem deve adotar estratégias que conduzam o estudante não só no caminho da autonomia profissional mas, sobretudo, na capacitação das pessoas e comunidades.

Community health needs assessment and action planning in seven Dominican bateyes.

Haitians and persons of Haitian descent living in the Dominican Republic are often relegated to living in deeply impoverished communities called bateyes. Despite obvious needs and some NGO presence in the bateyes, little assessment has been done to identify specific needs as understood and experienced by community members themselves. This article describes a community health needs assessment and action planning process developed and implemented by university researchers, NGO staff, and community members to identify needed areas for community-based health intervention in seven Dominican bateyes. Surveys and focus groups were used to collect data about the needs and assets of the bateyes and their residents around the following broad topics: demographics, health, education, financial/economy, legal issues, and transportation/infrastructure. These data were then used to guide an action-planning process that identified clean water, access to food and nutritional diversity, and economic development as primary and immediate needs in the communities. The process, its outcomes, and lessons learned are discussed.

Barriers related to non-adherence in a mammography breast-screening program during the implementation period in the interior of São Paulo State, Brazil.

Mammography is the best exam for early diagnosis of breast cancer. Developing countries frequently have a low income of mammography and absence of organized screening. The knowledge of vulnerable population and strategies to increase adherence are important to improve the implementation of an organized breast-screening program. A mammography regional-screening program was implemented in a place around 54.238 women, aged 40-69 years old. It was proposed to perform biannual mammography free of cost for the women. We analyze the first 2 years of the implementation of the project. Mammography was realized in 17.964 women. 42.1% of the women hadn't done de mammography in their lives and these women were principally from low socio-economic status (OR=2.99), low education (OR=3.00). The best strategies to include these women were mobile unit (OR=1.43) and Family Health Program (OR=1.79). The incidence of early breast tumors before the project was 14.5%, a fact that changed to 43.2% in this phase. Multivariate analysis showed that the association of illiterate and the mobile unit achieve more women who had not performed mammography in their lives. The strategies to increase adherence to mammography must be multiple and a large organization is necessary to overpass the barriers related to system health and education.

Las necesidades de salud y la respuesta social en una localidad rural: Metáforas y dilemas frente al consumo de alcohol / Health needs and social response in a rural town: Metaphors and dilemmas regarding the use of alcohol

Antecedentes El consumo nocivo de alcohol se identifica como un problema de salud pública. El éxito de la respuesta del sistema de salud a las necesidades depende de los programas, los actores que los ejecutan y del grado de aceptabilidad de la población receptora. Objetivo Conocer la percepción sobre cómo enfrentan los actores políticos, civiles, mercantiles y del sistema de salud las necesidades de salud derivadas del consumo nocivo de alcohol en una zona rural, con la intención de brindar información para la toma de decisiones en políticas de salud dirigidas a la atención de este problema. Metodo Estudio de caso con enfoque cualitativo, realizado en una localidad rural de Morelos, en la cual sus habitantes identificaron que el consumo de alcohol representaba un problema de salud. Resultados Se analiza el discurso y se identifican las metáforas que utiliza la población para darle sentido a este fenómeno y los dilemas que enfrentan. Discusión y conclusión Se discuten las diferencias en la manera en que se percibe el consumo de alcohol y cómo éstas dificultan la implementación de acciones de prevención y atención del abuso del mismo así como la regulación de la venta. Se concluye que para el diseño de políticas públicas que respondan a las necesidades de salud en este tema se requiere tomar en cuenta la naturaleza dilemática del pensamiento social de los individuos que intervienen en dicha respuesta, la cual debe rebasar la prestación de los servicios de salud e incorporar los determinantes sociales (económicos, políticos y culturales).

Background Harmful alcohol use is identified as a public health problem and the success of the health system response to needs will depend on the programs, the actors who implement them and their degree of acceptability among the recipient population. Objective To determine the perception of how political, civil, commercial and health system actors meet the health needs derived from harmful alcohol use in a rural area, with the aim of providing information for decision-making in health policies to cope with this problem. Method Case study with a qualitative approach, conducted in a rural town of Morelos, in which its inhabitants identified the fact that alcohol posed a health problem. Results Discourse is analyzed by identifying the metaphors used to make sense of this phenomenon and the dilemmas faced. Discussion and conclusion The authors discuss the differences in the way it is perceived and how they prevent the implementation of actions to prevent and deal with alcohol abuse and sales regulations. They conclude that designing public policies that respond to the health needs in this area requires taking into account the dilemmatic nature of the social thinking of the individuals involved in this response, which goes beyond health service provision, and incorporating social determinants (economic, political and cultural).

Orphans of the Mexican drug war: insights on a public health challenge / Huérfanos víctimas de la lucha contra el narcotráfico en México: apreciaciones sobre un reto en materia de salud pública

OBJECTIVE: To describe how the Government of Mexico and other direct stakeholders perceive children orphaned by the drug war; to determine the current measures addressing this as a public health problem; and to compare these measures to international frameworks so that relevant recommendations can be identified. METHODS: This was an exploratory, descriptive case study using qualitative methods. Semi-structured interviews were performed with key informants at the federal, state, and municipal government levels in Mexico, as well as non-governmental organizations, and other institutes working with orphans. Participants were identified with a purposive snowball sample. RESULTS: No official definition of "orphan" was identified; nor was there a shared perception among the key informants of what constitutes being an orphan. An official, collective definition is important because it modifies the quantity of children categorized as such within the target population. Although most of the interviewees perceive that the number of orphans and vulnerable children (OVC) has increased in the last 6 years, they acknowledged there is no reliable data to prove it. The increase, they believe, is due not to the drug war, but to a loss of family cohesion. Stakeholders recommend improving public policies, currently identified as the most difficult barrier to overcome due to a perceived inability to modify existing laws. However, the General Law for Victims was recently passed by the Government of Mexico and addresses many of the challenges identified. CONCLUSIONS: When compared to the international frameworks, there are three major issues in Mexico's current situation: coordination among and within stakeholders; emphasis on using community solutions; and putting in place preventive programs. For two of these problems, the General Law of Victims offers solutions.

OBJETIVO: Describir cómo el Gobierno de México y otros interesados directos perciben el tema de los niños huérfanos como consecuencia de la lucha contra el narcotráfico; determinar las iniciativas actuales que abordan este tema como un problema de salud pública; y comparar estas iniciativas con los marcos internacionales con objeto de poder determinar las recomendaciones pertinentes. MÉTODOS: Se trata de un estudio de casos exploratorio y descriptivo que utilizó métodos cualitativos. Se llevaron a cabo entrevistas semiestructuradas con informantes clave a escalas federal, estatal y municipal del gobierno de México, así como con organizaciones no gubernamentales y otras instituciones que colaboraban con los huérfanos. Los participantes fueron seleccionados mediante un muestreo intencionado de bola de nieve. RESULTADOS: No se encontró ninguna definición oficial de "huérfano"; ni existía entre los informantes clave una percepción compartida de lo que constituye ser un huérfano. Es importante que exista una definición oficial y colectiva porque modifica la cantidad de niños clasificados como tales entre la población examinada. Aunque la mayor parte de los entrevistados perciben que el número de niños huérfanos y vulnerables (NHV) ha aumentado en los seis últimos años, también reconocen que no existen datos fidedignos que lo demuestren. Creen que el aumento no se debe a la lucha contra el narcotráfico sino a una pérdida de la cohesión familiar. Los interesados directos recomiendan mejorar las políticas públicas, que actualmente se consideran como la barrera más difícil de superar, dada la incapacidad percibida para modificar las leyes existentes. Sin embargo, el Gobierno de México aprobó recientemente la Ley General de Víctimas, que aborda muchos de los retos señalados. CONCLUSIONES: En comparación con los marcos internacionales, existen tres asuntos principales en la situación actual de México: la coordinación entre y dentro de los distintos grupos de interesados directos; el énfasis en el empleo de soluciones comunitarias; y la implantación de programas preventivos. La Ley General de Víctimas ofrece una solución para dos de estos problemas.

Constituição e perfil de uma comunidade atendida por estratégia de saúde da família / Constitution and profile of a community assisted by the family health strategy

Objetivou-se conhecer o perfil socioeconômico e a formação da comunidade visando subsidiar o planejamento em saúde. Trata-se de uma pesquisa qualitativa e descritiva. Para a coleta de dados, utilizou-se a Estimativa Rápida Participativa e como fonte de dados observação de campo, entrevistas com informantes-chave e análise documental. Ocorreu em 2008, na área de abrangência da Unidade de Saúde da Família São José, do município de Santa Maria, Rio Grande do Sul. Os dados foram trabalhados por meio da análise de conteúdo. Os resultados da pesquisa descrevem a formação, constituição, recursos da comunidade e dimensões dos determinantes sociais da saúde. A conformação da comunidade revela um território singular, ao mesmo tempo complexo e heterogêneo, favorecendo a intersetorialidade. Os determinantes sociais da saúde encontrados permitiram identificar vulnerabilidades, grandes disparidades socioeconômicas e também culturais. Esse dinamismo ecomplexidade deveriam ser considerados em todas as ações em saúde ali desenvolvidas, principalmente noplanejamento local.

The objective was to know the socio-economic profile, and the constitution of the community, aiming to subsidize health care planning. It is a qualitative, descriptive research. The data collection consisted in the use of Rapid Participative Assessment and as data source field observation, interviews with key-informants and document analysis were used. It occurred in 2008 in the coverage area of São José Family Health Unit, in Santa Maria, Rio Grande do Sul. The data was analyzed through content analysis. The survey results describe the formation, constitution, community features and dimensions of social determinants of health. The conformation of the community reveals a singular territory, while complex and heterogeneous, favoring the intersetctoral approach. The unveiled social determinants of health enabled the identification of vulnerabilities, great social, economic and cultural disparities. Such dynamics and complexity should be considered in all actions in health developed in the area, mainly in the local planning

Incidence trend for breast cancer among young women in Goiânia, Brazil / Tendência de incidência de câncer de mama entre mulheres jovens em Goiânia, Brasil

CONTEXT AND OBJECTIVE: It has been suggested that there has been a large increase in breast cancer incidence among young women over the last decade. The aim of this study was to describe the incidence of breast cancer among young women up to 39 years of age in Goiânia, between 1988 and 2003, and to compare this with other age groups. DESIGN AND SETTING: Retrospective study using the database of the Population-based Cancer Registry of Goiânia, State of Goiás, Brazil. METHODS: The incidence was calculated according to age groups: up to 39 years, 40 to 59 years and 60 years and over. Average annual percentage changes (AAPCs) were estimated for the different age groups using Poisson regression. RESULTS: Over this period, 3,310 new cases were recorded. The standardized incidence was 2.89/100,000 in 1988 and increased to 6.37/100,000 in 2003 (R² = 0.52) for the group aged up to 39 years (p < 0.003). For the group from 40 to 59 years old, the incidence was 14.39/100,000 in 1988 and 41.70/100,000 in 2003 (R² = 0.85; p < 0.001). For the group aged 60 years and over, it was 17.62/100,000 and 28.49/100,000, respectively (R² = 0.67; p < 0.001). The AAPCs were 5.22 percent, 5.53 percent and 4.54 percent for the age groups up to 39, 40 to 59 and 60 years and over, respectively. CONCLUSIONS: The incidence of breast cancer among young women in Goiânia has been increasing significantly, although this change was similar to the increase in other age groups.

CONTEXTO E OBJETIVO: Tem sido sugerido que há um grande aumento na incidência do câncer de mama em mulheres jovens na última década. O objetivo deste estudo é descrever a incidência do câncer de mama em mulheres jovens (até 39 anos) em Goiânia, entre 1988 e 2003, comparando com os demais grupos etários. DESENHO E LOCAL: Estudo retrospectivo utilizando o banco de dados do Registro de Câncer de Base populacional de Goiânia/Goiás, Brasil. MÉTODOS: As incidências foram calculadas de acordo com os grupos etários: até 39 anos, 40 a 59 anos e, 60 anos acima. A mudança da média percentual anual (MMPA) foi estimada para os diferentes grupos usando a regressão de Poisson. RESULTADOS: No período, foram registrados 3.310 novos casos. A incidência padronizada foi de 2,89/100.000 em 1988 tendo aumentado para 6,37/100.000 em 2003 (R² = 0,52) para o grupo com até 39 anos (p < 0,003). Para o grupo de 40 a 59 anos a incidência foi de 14,39/100.000 em 1988 e de 41,70/100.000 em 2003 (R² = 0,85; p < 0,001); para o grupo de 60 anos e acima foi de 17,62/100.000 e 28,49/100.000, respectivamente (R² = 0,67; p < 0,001). A MMPA foi de 5,22 por cento, 5,53 por cento e 4,54 por cento para os grupos etários de até 39 anos, 40 a 59 e 60 ou mais, respectivamente. CONCLUSÕES: A incidência de câncer de mama em mulheres jovens em Goiânia vem aumentando significativamente, entretanto esse aumento é semelhante ao observado nos demais grupos etários.

Instalação da disciplina de Atenção Básica em Saúde na Faculdade de Medicina da Universidade de São Paulo (2003-2006) / Implementation of the discipline Basic Care at the Faculty of Medicine of the University of São Paulo

INTRODUÇÃO: A disciplina de Atenção Básica em Saúde constitui um programa interdepartamental na Faculdade de Medicina da USP, apoiada por três Unidades Básicas de Saúde com o Programa de Saúde da Família. Este estudo avalia sua instalação. MÉTODOS: Questionários de avaliação de ambiente, Delphi e de auto-avaliação com escala de capacidades. Resultados:Cento e sessenta e dois primeiranistas em 2004 (93 por cento), 142 em 2005 (81 por cento) e 129 terceiranistas (74 por cento) responderam. Orientar a utilização dos serviços de saúde, visitar famílias, promover saúde, oferecer suporte e identificar situações de risco, entre primeiranistas, e "consulta médica com adultos" e "reunião de grupo com pacientes", com alunos do terceiro, alcançaram o nível "fiz o procedimento com ajuda de alguém". Capacidades adquiridas: realidade social e de saúde, trabalho do agente comunitário, entendimento do Programa de Saúde da Família, Atenção Primária e Sistema de Saúde. As percepções de ambiente diferiram entre os locais ou equipes. DISCUSSÃO: As avaliações sugerem razoável conhecimento e capacitação para o trabalho dos agentes comunitários. O vocabulário dos alunos incorporou SUS, PSF e Atenção Básica. CONCLUSÃO: A disciplina alcançou avaliação positiva no seguimento de pessoas, famílias e comunidades.

INTRODUCTION: The discipline Basic Care is an interdepartmental program of the Faculty of Medicine of the São Paulo University, supported by three local Basic Care Units offering the Family Health Program. This study evaluates its implementation. METHODS: Questionnaires aimed at evaluation of the environment, Delphi and self-assessment with a competence scale. Results:One hundred and sixty two freshmen in 2004 (93 percent), 142 in 2005 (81 percent) and 129 third year students (74 percent) responded. Among the freshmen, provide orientation about how to use the health services, household visits and health promotion, offer support and identify risk situations, and among the third year students "medical appointments with adults" and "group meetings with patients" reached the level "procedure performed with guidance of somebody". Acquired capacities were sense of the social and health reality, perform Health Agent functions and understand the Family Health Program, Basic Care and Health System. The perception of the environment differed between local Units or Teams. DISCUSSION: The evaluation suggested reasonable capacity for performing the functions of a Health Agent. The terms Health System, Family Health Program and Basic Care were part of the vocabulary of the students. CONCLUSION: The discipline reached a positive evaluation with regard to following-up individuals, families and the community.