In order to estimate the prevalence of treatment non-adherence and associated factors among individuals with systemic arterial hypertension treated at family health care facilities, a cross-sectional study was performed with 595 patients. The dependent variable non-adherence was measured with a Medication Adherence Questionnaire (MAQ). A hierarchical logistic regression model was used to analyze socioeconomic, health care-related, personal, and treatment-related variables. Prevalence of non-adherence was 53%. Variables associated with non-adherence were: (1) socioeconomic--belonging to economic classes C, D, or E; work market participation in unskilled labor; (2) health care--out-of-pocket payment for medication; more than six months since last physician consultation; and (3) personal and treatment characteristics--previous interruption of treatment; being on treatment for less than three years; and presence of a common mental disorder. The study of determinants of non-adherence articulated in a hierarchical model suggests that social inequalities are either directly associated with non-adherence or mediated by personal and health services factors.

The present study was designed to further assess the validity of the cytological description of morphological lesions said to be related to Papillomavirus (HPV) infections in senior women. The casuistic comprised 196 cervical smears from a group of women with no clinical or morphological evidence of neoplasia, collected simultaneously with samples submitted to detection of HPV DNA by PCR in a previous study. Three experienced cytologists studied each slide in two different conditions, with an interval of 20 months between them. The first approach was performed under routine laboratory standards, whereas the second was guided by a list of 16 well-defined parameters indicative of HPV-related cytological lesions. When suspicious cases of HPV-related alterations were grouped with positive cases, they showed on average: sensitivity of 25.5%, specificity of 84.4% and positive predictive value (PPV) of 26.8%. When suspicious cases were grouped with negative cases, sensitivity decreased, whereas specificity and PPV increased, as expected. In the second reading, which followed a "guide-list", a decrease in sensitivity was observed, contrasting with a sharp increase of positive predictive value. Among the 16 cytomorphological criteria tested, "koilocytosis", "mild koilocytosis" and "condylomatous parabasal cells" yielded the best predictive value for HPV DNA detection by PCR. In conclusion, despite the low sensitivity, cytopathologic assessment of cervico-vaginal smears leads to a highly specific diagnosis of HPV infection in menopausal women, with PPV of 91.0% when directed by a guide-list of well-defined morphologic criteria.

VOLUME 33 NÚMERO 2 ABRIL 1999© Copyright Faculdade de Saúde Pública da USP. Proibida a reprodução mesmo que parcial sem a devida autorização do Editor Científico. Proibida a utilização de matérias para fins comerciais. All rights reserved.

Introduction: In March 2014, Brazil began its national HPV immunization campaign targeting girls ages 9-13. Objective: Describe determinants of parental decisions to vaccinate their daughters against HPV.Method: In this qualitative study, thirty semi-structured interviews were conducted at five health posts in São Paulo, Brazil. Interview questions explored parental opinions of disease prevention methods, vaccines in general, and the HPV vaccine. Interviews were analyzed using grounded theory. Results: Overall, parental knowledge about HPV and the vaccine was low, yet most eligible daughters had been vaccinated. Parents perceived the HPV vaccine to be normal, preventative, and protective. Parents viewed themselves as accountable for their children’s health, and saw the vaccine as a parenting tool for indirect control. Trust in healthcare professionals and an awareness of the dangers of “nowadays” (uncertainties regarding disease and sexual behavior) were also important in vaccine decision-making. These factors held more explanatory power for decisions to vaccinate than parental knowledge levels. This was the first study to qualitatively examine the perception of publically provided HPV vaccination among parents with eligible daughters in Brazil. The findings help interpret the greater than 90% coverage for the first HPV vaccine dose in Brazil. The results indicate that attempts to understand, maintain, or modify vaccination rates require the consideration of context specific factors, which influence both parent perspectives and vaccination decisions. Conclusion: HPV knowledge levels are not predictive of parental decisions to vaccinate daughters. Context specific factors from the sociocultural dimensions of parenting, sexuality, gender, and the healthcare system are more influential in vaccine decision-making.

Objectives:To estimate the fraction of head and neck cancer (HNC) attributable to tobacco and alcohol in cities in the Midwest, Southeast and South regions of Brazil. Methods: Case-control study including 1,594 cases of HNC and 1,292 hospital controls. The association of HNC with tobacco and alcohol was estimated by the odds ratio and respective 95% confidence intervals through non-conditional logistic regression, adjusted for age, sex, schooling, consumption of fruits and vegetables, alcohol drinking (to examine the tobacco effect), and tobacco smoking (to examine the alcohol effect). The proportions of HNC attributable to tobacco and alcohol were estimated through the attributable fraction (AF) calculation. Separate estimates were made for Goiânia (Midwest), Rio de Janeiro and São Paulo (Southeast) and Pelotas and Porto Alegre (South). Results: The HNC fraction attributable to smoking was slightly higher in Goiânia (AF = 90%) than in cities in the Southeast (AF = 87%) and South (AF = 86%). The HNC fraction attributable to the consumption of alcoholic beverages presented similar and higher results in the cities of Southeast (AF = 78%) and South (AF = 77%) than in Goiânia (AF = 62%). Conclusion: The HNC fractions attributable to smoking were more expressive than for alcohol consumption. Although with discrete distinctions between them, the AFs to tobacco smoking and alcohol consumption in HNC observed in the cities of these three Brazilian regions were similar to those obtained in Latin America studies, but they were higher than in other parts in the world.

Worldwide, the global incidence of head and neck cancer (HNC) patients is growing. GLOBOCAN estimates that more than 1.2 million new cases of HNC will be diagnosed and approximately 680 thousand deaths are anticipated worldwide in 2040. 1 Tumor location and treatment can induce poor nutritional intake and weight loss in HNC patients. Most of them experience symptoms that impact on nutritional status inclusive of mucositis, xerostomia, trismus, dysphagia, dysgeusia and lack of appetite, amongst others. 2,3 Given that undernutrition and weight loss can increase risk of delay in treatment, complications and mortality,

ELUF NETO, J. et al. Tratamento da hipertensão e declínio da mortalidade por acidentes vasculares cerebrais. Rev. Saúde publ., S. Paulo, 24:332-6,1990.RESUMO: É discutida a possível relação causa-efeito entre o declínio da mortalidade por acidentes vasculares cerebrais (AVC) e o melhor tratamento da hipertensão arterial. Para isto são revistos criticamente na literatura internacional os possíveis artefatos estatísticos para a enumeração dos AVCs, a letalidade e a incidência de AVC a prevalência de outros fatores de risco como hipercolesterolemia, tabagismo, ingestão de sódio, potássio e álcool, a obesidade e também a contribuição da assistência médica. , a mortalidade por AVC é bastante alta, sendo que em 1985 ocorreram 73.205 óbitos por estas afecções (9,3% do total de óbitos). Para o mesmo ano, 7,9% dos óbitos foram devidos à doença isquémica do coração (doença coronária). Já para o Estado de São Paulo no mesmo ano, a proporção de óbitos por doença coronária era ligeiramente superior (11,2%) a de óbitos por AVC (10,6%). Comparando a mortalidade por AVC no Município de São Paulo com a observada em 27 países industrializados, para o ano de 1980, embora ela venha declinando, as taxas ajustadas por idade observadas para São Paulo se posicionaram em terceiro lugar para homens, e em segundo para mulheres, só abaixo da Bulgária e da Hungria (sexo masculino) e da Bulgária (sexo feminino) 25 . DESCRITORES:Nos Estados Unidos, a mortalidade por AVC vem caindo desde o início do século 32,35 , mas é possível que tenha havido um diagnóstico excessivo da doença como causa de morte no início do sécu-lo. Uma grande proporção de mortes súbitas que, hoje, com os desenvolvimentos dos procedimentos diagnósticos para doenças cardiovasculares, é atribuída à doença coronária, pode ter sido anteriormente diagnosticada como "apoplexia" 36.Por outro lado, patologias encefálicas (tumor cerebral, hematoma subdural ou hidrocefalia de pressão normal) podem também ter sido erroneamente diagnosticadas como AVC e esta causa ter sido apresentada nos atestados de óbito como a causa básica da morte 30 . Nos países em desenvolvimento, este fenômeno de redução do "sobrediagnóstico" (overdiagnosis) pode estar ocorrendo agora e, eventualmente, os AVCs poderiam ser ainda uma "forma de morrer", isto é, uma afecção terminal mencionada como causa básica da morte em locais com precária assistência médica. Ao menos nos países desenvolvidos os hábitos diagnósticos parecem não ter sofrido alteração substancial desde os anos 40, e a mortalidade por AVC continua a cair apesar das alterações que pudessem advir das várias revisões da Classificação Internacional de

OBJETIVO: Estimar a magnitude e identificar padrões de mudança na mortalidade por câncer de próstata no estado de São Paulo e nas 17 redes regionais de atenção à saúde, segundo grupos etários a partir dos 50 anos, no período de 2000 a 2015. MÉTODOS: As taxas de mortalidade ajustadas por idade (por 100 mil homens) foram calculadas pelo método direto usando a população mundial de Segi como padrão. A análise de regressão Joinpoint foi utilizada para calcular as variações percentuais anuais médias (AAPC), com intervalo de confiança de 95% (IC95%), por rede regional e grupo etário (50–59, 60–69, 70–79 e 80 anos ou mais). RESULTADOS: Para o estado de São Paulo, as taxas ajustadas de mortalidade foram de 15,2, 13,3 e 11,9/100 mil homens, respectivamente, nos períodos de 2000 a 2005, 2006 a 2010 e 2011 a 2015, com tendência de decréscimo significativo (AAPC = -2,10%; IC95% -2,42 – -1,79) a cada ano. Das 17 redes, 11 apresentaram reduções médias anuais significativas, que variaram entre -1,72% e -3,05%. A partir dos 50 anos, verificou-se redução mais acentuada nos grupos de 50 a 59 (AAPC = -2,33%; IC95% -3,04 – -1,62) e 60 a 69 anos (AAPC = -2,84%; IC95% -3,25 – -2,43). CONCLUSÕES: Embora as reduções na mortalidade ainda sejam discretas, indicam progresso nas ações de controle do câncer de próstata. Ações de rastreamento e mudanças nas condutas terapêuticas nas últimas décadas podem estar modificando a incidência e a sobrevida, resultando em mudanças no perfil de mortalidade. Estudos mais detalhados serão úteis na compreensão dos fatores que levam às variações inter-regionais encontradas. DESCRITORES: Neoplasias da Próstata, mortalidade. Mortalidade, tendências. Distribuição por Idade. Distribuição Temporal.