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In this article, we present and empirically illustrate two concepts about vaccines and the way they are perceived by the Argentinean population and the easiness in accessing vaccination in developing countries. First, we focus on the perceptions of people about vaccines in general and develop a confidence index, and second, we analyze barriers to vaccination, measuring the burden citizens have when they intend to receive immunization (or as caretakers, trying to comply with the vaccination calendar of children and adolescents): for this second concept, we develop an access index. The data comes from representative annual surveys from Argentina from 2019 until 2022 (each one with approximately 7000 responders), which allows us to describe trends and check for changes in the confidence in vaccines and barriers towards vaccination. We find high confidence in vaccines in Argentina, although there is a "structural break" in the confidence for all years after 2020. Because we changed the questionnaire and methodology regarding the access to vaccines index in 2022, the discussion focuses on the cross-section of 2022, observing that barriers to vaccination tend to affect less educated caretakers.

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Introducción: Las barreras de acceso a los servicios de salud primario conforman estructuras sociales que agravan la situación de salud de los adolescentes, impactando negativamente en el ejercicio pleno de la salud sexual reproductiva, situando a los adolescentes en una población de riesgo social. Objetivo: Determinar las barreras en el acceso a los servicios primarios de Salud Sexual y Reproductiva de atención diferenciada a los adolescentes del Centro de Salud I - 4 Pampa Grande Tumbes 2018. Metodología: Estudio analítico de caso control, se entrevistaron a 288 adolescentes del tercero, cuarto y quinto de secundaria de la institución educativa pública Túpac Amaru del centro poblado Pampa Grande de Tumbes en el año 2019, entre experimento y control con una razón de 1 a 1. Se aplicaron cuestionarios anónimos para evaluar las barreras de accesibilidad a los servicios primarios de salud. Se recogieron variables: características sociodemográficas y culturales que son consideradas, como barreras de acceso a los servicios de salud. Se realizó un análisis descriptivo e inferencial con el programa SPSS® v.23. Resultados: La edad, sexo e ingreso económico están directa y significativamente relacionadas con la accesibilidad a los servicios de salud sexual y reproductiva (p<0.01 IC 95 %); La disposición de recursos económicos para asumir los costos de traslado al centro de salud (OR = 4,23); la utilización del transporte público (OR = 1,58), el conocimiento de los servicios de salud sexual y reproductiva (OR = 1,15) incrementan la probabilidad de acceder a los servicios de salud sexual y reproductiva de los adolescentes. Discusión: Las barreras socioeconómicas a los servicios de salud sexual y reproductiva de los adolescentes son modificables y dependen de la gestión en salud pública.

Introduction: The barriers to access to primary health services make up social structures that aggravate the health situation of adolescents, negatively impacting the full exercise of reproductive sexual health, placing adolescents in a population at social risk. Objective: To determine the barriers in the access to the primary services of Sexual and Reproductive Health of differentiated attention to the adolescents of the Health Center I - 4 Pampa Grande Tumbes 2018. Methods: Analytical case control study, 288 adolescents from the third, fourth and fifth grade of secondary school of the public educational institution Túpac Amaru in the Pampa Grande de Tumbes town center were interviewed in 2019, between experiment and control with a ratio of 1 to 1. Anonymous questionnaires were applied to assess accessibility barriers to primary health services. Variables were collected: sociodemographic and cultural characteristics that are considered as barriers to access to health services. A descriptive and inferential analysis was carried out with the SPSS® v.23 program. Results: Age, sex and economic income are directly and significantly related to accessibility to sexual and reproductive health services (p<0.01 95% CI); The availability of economic resources to assume the costs of transportation to the health center (OR = 4.23); the use of public transport (OR = 1.58), knowledge of sexual and reproductive health services (OR = 1.15) increase the probability of accessing sexual and reproductive health services for adolescents. Discussion: Socioeconomic barriers to sexual and reproductive health services for adolescents are modifiable and depend on public health management.

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Resumo O objetivo deste artigo é apreender os desafios nas vivências dos usuários e profissionais de Banco de Leite Humano no atendimento a homens transgêneros no contexto da amamentação sob à luz da Interseccionalidade. Estudo qualitativo descritivo-exploratório a partir de entrevistas realizadas com seis profissionais do Banco de Leite Humano, que atenderam previamente homens trans no contexto de amamentação, e dois homens trans bissexuais, que amamentaram ao peito. Os dados foram tratados pela Análise Temática com auxílio do software Atlas.ti versão 9.0. Observam-se lacunas nas esferas educacionais, institucionais e na gestão, associadas a questões pessoais e sociais, que reproduzem um modelo pré-concebido normativo, desconsiderando as singularidades requeridas no atendimento à população trans no contexto da amamentação. A cisheteronormatividade e a supremacia do profissional operam em âmbitos pessoais, sociais e institucionais para a segregação de homens transgêneros nos serviços de suporte à amamentação. A análise interseccional destes desafios permite uma visão global dos fatores de segregação e a implementação de políticas públicas promotoras da justiça social.

Abstract This article tried, from an intersectional standpoint, to grasp the challenges experienced by health professionals and service users of human milk banks in provision of care for transgender men chestfeeding. This exploratory, descriptive qualitative study drew on interviews of six human milk bank staff, who had previously assisted trans men in relation to chestfeeding and two bisexual trans men, who chestfed. The data was treated by thematic analysis, supported by Atlas.ti software, version 9.0. Lacunas in the educational, institutional and management spheres, associated with personal and social issues, reproduce a pre-conceived normative model and disregard the special demands of providing chestfeeding care for the trans population. Cisheteronormativity and "professional supremacy" operate in personal, social and institutional respects to segregate transgender men in lactation support services. Intersectional analysis of these challenges affords an overall view of segregative factors and enables public policies to be introduced to promote social justice.

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Among transgender, non-binary, and/or gender expansive (TNG) persons, interest in medical and/or surgical forms of gender affirmation is heterogenous, as is access to those forms of medically necessary health care. Yet, the literature characterizing TNG persons' interest in medical and/or surgical gender-affirming care, barriers to accessing that care, and how societal narratives and expectations impact TNG individuals' self-image and mental health, as well as their personal choices regarding gender-affirming care remains sparse. Here we present qualitative research exploring TNG participants' interest in gender-affirming care and how such interventions impact identity formation. We conducted loosely structured interviews with a convenience sample of 54 TNG persons in the U.S. and Canada from Facebook pages used to recruit TNG research participants. One-hour interviews were conducted by an openly TNG researcher; participants were compensated. The most frequently sought gender-affirming care was hormone therapy, followed by chest ("top") surgery, genital ("bottom") surgery, electrolysis, breast augmentation, hysterectomy, and voice training. Less commonly desired interventions included fertility preservation, facial feminization/masculinization, and vocal surgery. Participants described four main categories of access barriers: financial (e.g., cost of medical/surgical care, inadequate insurance), logistical (e.g., no local providers, gatekeeping policies around body size and mental health, pandemic-related delays), personal fears about sub-optimal outcomes (e.g., complications, loss of sensation, undesired aesthetic and/or functional results), and societal discrimination (e.g., familial rejection, job loss, safety concerns). Participants reported primarily seeking this healthcare for social legibility, alleviating dysphoria/pursuing euphoria, and/or gender exploration. All who sought gender-affirming care reported improved mental health-including depression, anxiety, dissociation, and eating disorders-and social relationships, though many struggled to find TNG-competent mental health providers. This work provides key insights into how gender-affirming care can contribute to improving mental health for TNG communities, which will assist health providers in optimally treating TNG patients.

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BACKGROUND: The present study assesses the time intervals from symptom discovery to treatment start and describes the health service use experiences of uninsured patients with cancer of the breast, cervix uteri, testicle, and prostate before their arrival to the cancer hospital. METHODS: This cross-sectional study included 1468 patients who were diagnosed between June 2016 and May 2017 and received treatment for the selected cancers in two of the largest public cancer hospitals in Mexico City, financed through Seguro Popular. Data was collected through a survey administered via face-to-face interviews with patients and a review of their medical files. RESULTS: The median time between detection (symptom discovery or first abnormal screening test) and treatment start was 6.6 months. For all types of cancer, the longest interval was the diagnostic interval -between the first use of healthcare services and the confirmation of cancer. Less than 20% cancer patients were diagnosed in the earliest stages that are associated with the best chances of long-term survival. The participants described a high use of private services for their first consultation, the use of several different types of health services and multiple consultations before arrival to the cancer centers, and 35% perceived being misdiagnosed by the first doctor they consulted. CONCLUSIONS: Most cancer patients treated in the two largest public institutions available for the uninsured faced long delays to get diagnosed and started treatment at advanced stages. Strengthening quality and access for effective early cancer diagnosis and treatment is key to improve patient outcomes in low and middle-income settings.

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ABSTRACT BACKGROUND: Many factors may negatively impact physical activity (PA), but studies lack evidence of individual predictors of perceived barriers to PA among adults in primary healthcare units. OBJECTIVE: To analyze associations between sociodemographic characteristics, health conditions, leisure-time physical activity (LTPA), PA counseling and perceived barriers to LTPA among adult patients in primary healthcare units of the National Health System in Brazil. DESIGN AND SETTING: Cross-sectional study on a representative sample of adults in primary healthcare units in São José dos Pinhais, Paraná, Brazil. METHODS: This study was conducted in 2019, among 779 adults (70% women). Barriers to LTPA, sociodemographic characteristics (sex, age, marital status, skin color, education and income), health conditions (body mass index, hypertension, diabetes, dyslipidemia, coronary disease and medications), LTPA level and PA counseling received were measured using validated, standardized procedures. The data were analyzed using chi-square and Mann-Whitney U tests. RESULTS: The most prevalent barriers were "feeling too tired" (53%) and "lack of time" (52%). PA counseling was inversely associated with "lack of time" (45% versus 57%; P < 0.001) but positively associated with "injury or disease" (38% versus 29%; P = 0.008). There was an inverse linear trend between the number of barriers and LTPA (walking and total) (P < 0.001). Most barriers differed in comparisons of sociodemographic characteristics, health conditions, LTPA and counseling (P < 0.05). CONCLUSIONS: The barriers vary according to the individual predictors. Counseling strategies need to be specific for each barrier and may be promising for promoting LTPA within primary healthcare.

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Introducción: La discapacidad se considera un problema de salud a nivel mundial. Las personas con discapacidad física son susceptibles de padecer distintos problemas de salud. A pesar de ser un grupo priorizado, el acceso a los servicios de salud es menor que el de la población en general, debido a barreras de distintos tipos. Objetivo: Describir las barreras y facilitadores de acceso a la atención primaria de salud en personas con discapacidad física. Métodos: Se realizó una revisión bibliográfica cuya metodología estuvo basada en la búsqueda, selección, revisión, interpretación y síntesis de la evidencia científica relacionada con el problema de investigación. Se utilizó como fuente de literatura científica primaria la publicada en las bases de datos Scielo, Redalyc, Latindex y PudMed en los últimos 5 años, con los términos de búsqueda MeSH en idoma español, inglés y portugués. Desarrollo: Se identificó un total de 67 documentos de los cuales se empleó 46 en la investigación realizada. Los restantes 21 manuscritos fueron excluidos por presentar deficiencias metodológicas que limitaban su utilización. Las principales barreras son las condiciones físicas de las unidades de salud; el funcionamiento del Sistema de Salud; el acceso de las personas con discapacidad a la atención primaria de salud; y las características del paciente y su entorno familiar. El principal facilitador es el relacionado con el Sistema de Salud. Conclusiones: El acceso de las personas con discapacidad física a los servicios de salud está condicionado por situaciones que se interpretan como barreras o facilitadores. En este sentido los factores relacionados con el sistema de salud nacional y con las características y el entorno de la persona con discapacidad pueden comportarse como barrera o como facilitador, en dependencia de su expresión(AU)

Introduction: Disability is considered a health problem worldwide. People with physical disabilities are susceptible to different health problems. Despite being a prioritized group, access to health services is lower than that of the general population, conditioned by the presence of different types of barriers. Objective: To describe the barriers and facilitators of access to primary health care in people with physical disabilities. Methods: A bibliographic review was carried out whose methodology was based on the search, selection, review, interpretation and synthesis of the scientific evidence related to the research problem. It was used as a source of primary scientific literature published in the databases Scielo, Redalyc, Latindex and PudMed in the last 5 years, with the MeSH search terms in Spanish, English and Portuguese. Results: A total of 67 documents were identified, of which 46 were used in the research carried out. The remaining 21 manuscripts were excluded due to methodological deficiencies that limited their use. Conclusions: The access of people with physical disabilities to health services is conditioned by situations that are interpreted as barriers or facilitators. In this sense, the factors related to the national health system and the characteristics and environment of the person with a disability can act as a barrier or as a facilitator, depending on their expression(AU)

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O artigo evidencia as barreiras de acesso ao Lazer por parte do Estado e seus impactos na juventude negra do bairro Jardim Brasil, na Zona Norte da cidade de São Paulo. Baseado em dados, apresenta o que configuram as barreiras visíveis e invisíveis de lazer, evidenciando sua percepção e interpretação acerca dessas barreiras: como as identificam e como são impactados por elas. A pesquisa se vale do método qualitativo de caráter exploratório, explicativo, combinado com pesquisa bibliográfica e pesquisa de campo com 14 jovens autodeclarados negros na faixa etária de 18 a 29 anos, através da aplicação de entrevista semiestruturada, com questões abertas e fechadas para análise de discurso. A delimitação do estudo permeia o questionamento de como a ausência de políticas públicas de lazer impacta diretamente a juventude negra do Jardim Brasil. De acordo com os dados apresentados e as percepções dos jovens negros entrevistados, conclui-se que há uma significativa presença de barreiras de acesso ao lazer para tal público que compromete a noção de pertencimento e/ou identificação pelo equipamento cultural bem como de suas respectivas programações.

The present work aims to evidence the leisure constraints created by the State and its impacts on black youth of Jardim Brasil, a neighborhood in the North zone of São Paulo city. Based on evidence we highlight what are the visibles and invisibles leisure constraints highlighting their perceptions and interpretations about the access barriers: as the way they identified it and also how they are affected by it. We employed the qualitative method of exploratory character, combined with bibliographic and field research with 14 self declared black young people between the ages of 18 to 29 years old, by conducting semi structured interviews with open and closed questions and analysed according to the discourse analysis. The delimitation of the study permeates the questioning of how the lack of leisure policies directly affected the black youth of Jardim Brasil. According to the data presented and the perceptions of the young black people interviewed, it is concluded that there is a significant presence of leisure constraints for this public, which compromises the notion of belonging and/or identification by cultural equipment as well as their respective programming.

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BACKGROUND: Following the 2016 Peace Agreement with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate more than 13,000 guerrilla fighters into its healthcare system. Despite a subsidized healthcare insurance program and the establishment of 24 Espacios Territoriales de Capacitación y Reincorporación (ETCRs-Territorial Spaces for Training and Reintegration) to facilitate this transition, data has shown that FARC ex-combatants access care at disproportionately lower rates, and face barriers to healthcare services. METHODS: Semi-structured interviews were conducted with FARC health promoters and healthcare providers working in ETCRs to determine healthcare access barriers for FARC ex-combatants. Analysis was completed with a qualitative team-based coding method and barriers were categorized according to Julio Frenk's Domains of Healthcare Access framework. RESULTS: Among 32 participants, 25 were healthcare providers and 7 self-identified as FARC health promoters. The sample was majority female (71.9%) and worked with the FARC for an average of 12 months in hospital, health center, medical brigade, and ETCR settings. Our sample had experiences with FARC across 16 ETCRs in 13 Departments of Colombia. Participants identified a total of 141 healthcare access barriers affecting FARC ex-combatants, which affected healthcare needs, desires, seeking, initiation and continuation. Significant barriers were related to a lack of resources in rural areas, limited knowledge of the Colombian health system, the health insurance program, perceived stigma, and transition process from the FARC health system. CONCLUSIONS: FARC ex-combatants face significant healthcare access barriers, some of which are unique from other low-resource populations in Colombia. Potential solutions to these barriers included health insurance provider partnerships with health centers close to ETCRs, and training and contracting FARC health promoters to be primary healthcare providers in ETCRs. Future studies are needed to quantify the healthcare barriers affecting FARC ex-combatants, in order to implement targeted interventions to improve healthcare access.

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In Argentina, mortality from childhood cancer is higher than in more developed countries, with late diagnosis being one of the possible causes. Our objective was to determine the frequency of barriers to diagnosis faced by families assisted by a Non-Governmental Organization, and some associated demographic, institutional and medical factors. A retrospective observational and quantitative analysis of the diagnosis pathway of children with cancer assisted by the N.D. Flexer Foundation, Argentina, between 1/1/2011 and 12/31/2015 was carried out. The primary outcome was the presence of barriers to diagnosis. It was considered that there was a barrier when there were consultations without diagnostic suspicion, family delay, institutional delay, self-derivation and/or more than 30 days between the onset of symptoms and diagnosis. The frequency of barriers within each category was contrasted by the y2 test. A multivariate logistic regression was used to examine its association with relevant variables. Among the 1818 families included, 63.5% faced delays/ barriers to diagnosis. Negative modulators were diagnosis at age younger than 1-year, renal tumor and first attention at a public hospital of the City of Buenos Aires or a provincial capital hospital (all p < 0.0001). Positive modulators were the diagnosis of bone tumor (p = 0.009) and first attention at a primary healthcare center (p< 0.0001) or private doctor's office (p = 0.001). The main non-biological factor associated with the possibility of facing barriers to diagnosis was the type of first contact-health institution.

En Argentina, la mortalidad por cáncer infantil es mayor que en países más desarrollados, siendo el diagnóstico tardío una de las posibles causas. Nuestro objetivo fue determinar la frecuencia de obstáculos al diagnóstico enfrentados por las familias de niños con cáncer asistidas por un Organismo No Gubernamental, y algunos factores demográficos, institucionales y médicos asociados. Se realizó un análisis retrospectivo observacional y cuantitativo del recorrido diagnóstico de los niños con cáncer asistidos por la Fundación N.D. Flexer, Argentina, entre el 1/1/2011 y el 31/12/2015. El resultado primario fue la presencia de obstáculos para acceder al diagnóstico. Se consideró que existió un obstáculo cuando tuvieron lugar consultas no orientativas, demora familiar, demora institucional, autoderivación y/o más de 30 días entre la aparición de síntomas y el diagnóstico. La frecuencia dentro de cada categoría se contrastó mediante la prueba de y2. La influencia de distintas variables se evaluó mediante una regresión logística multivariada. De 1818 familias incluidas, 63.5% enfrentaron algún tipo de obstáculos. Resultaron moduladores negativos el diagnóstico antes del año, de tumor renal y la concurrencia a un hospital público de la Ciudad de Buenos Aires o de capital provincial como centro de primer contacto (todos p < 0.0001). Resultaron moduladores positivos el diagnóstico de tumor óseo (p = 0.009) y los centros de atención primaria (p < 0.0001) y consultorios particulares (p = 0.001) como centros de primer contacto. El principal factor no biológico asociado a la frecuencia de obstáculos al diagnóstico de cáncer infantil fue el tipo de centro de primer contacto.

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En Argentina, la mortalidad por cáncer infantil es mayor que en países más desarrollados, siendo el diagnóstico tardío una de las posibles causas. Nuestro objetivo fue determinar la frecuencia de obstáculos al diagnóstico enfrentados por las familias de niños con cáncer asistidas por un Organismo No Gubernamental, y algunos factores demográficos, institucionales y médicos asociados. Se realizó un análisis retrospectivo observacional y cuantitativo del recorrido diagnóstico de los niños con cáncer asistidos por la Fundación N.D. Flexer, Argentina, entre el 1/1/2011 y el 31/12/2015. El resultado primario fue la presencia de obstáculos para acceder al diagnóstico. Se consideró que existió un obstáculo cuando tuvieron lugar consultas no orientativas, demora familiar, demora institucional, autoderivación y/o más de 30 días entre la aparición de síntomas y el diagnóstico. La frecuencia dentro de cada categoría se contrastó mediante la prueba de χ2. La influencia de distintas variables se evaluó mediante una regresión logística multivariada. De 1818 familias incluidas, 63.5% enfrentaron algún tipo de obstáculos. Resultaron moduladores negativos el diagnóstico antes del año, de tumor renal y la concurrencia a un hospital público de la Ciudad de Buenos Aires o de capital provincial como centro de primer contacto (todos p < 0.0001). Resultaron moduladores positivos el diagnóstico de tumor óseo (p = 0.009) y los centros de atención primaria (p < 0.0001) y consultorios particulares (p = 0.001) como centros de primer contacto. El principal factor no biológico asociado a la frecuencia de obstáculos al diagnóstico de cáncer infantil fue el tipo de centro de primer contacto.

In Argentina, mortality from childhood cancer is higher than in more developed countries, with late diagnosis being one of the possible causes. Our objective was to determine the frequency of barriers to diagnosis faced by families assisted by a Non-Governmental Organization, and some associated demographic, institutional and medical factors. A retrospective observational and quantitative analysis of the diagnosis pathway of children with cancer assisted by the N.D. Flexer Foundation, Argentina, between 1/1/2011 and 12/31/2015 was carried out. The primary outcome was the presence of barriers to diagnosis. It was considered that there was a barrier when there were consultations without diagnostic suspicion, family delay, institutional delay, self-derivation and/ or more than 30 days between the onset of symptoms and diagnosis. The frequency of barriers within each category was contrasted by the χ2 test. A multivariate logistic regression was used to examine its association with relevant variables. Among the 1818 families included, 63.5% faced delays/ barriers to diagnosis. Negative modulators were diagnosis at age younger than 1-year, renal tumor and first attention at a public hospital of the City of Buenos Aires or a provincial capital hospital (all p < 0.0001). Positive modulators were the diagnosis of bone tumor (p = 0.009) and first attention at a primary healthcare center (p< 0.0001) or private doctor's office (p= 0.001). The main non-biological factor associated with the possibility of facing barriers to diagnosis was the type of first contact-health institution.

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BACKGROUND: On an absolute basis, Argentina is the country with the largest affected population with Chagas Disease (ChD). This constitutes a significant public health issue. As a consequence of Argentina's migratory patterns, there has been a significant increase of affected population in urban centers. An innovative project for early diagnosis and timely treatment of ChD was designed for Municipal Primary Care Facilities of La Plata City, a non- endemic area, in line with a proposal from the Pan-American Health Organization. The project was a public -private intervention. The objectives of this study were to demonstrate the feasibility of the primary healthcare level for early diagnosis and timely treatment of ChD; to design and implement a tailor made program and to innovate in a public-private association. METHODS: The healthcare barriers for early diagnosis and timely treatment for the population with ChD of La Plata were analyzed. The four dimensions described by Peters et al. (Ann N Y Acad Sci 1136:161-71, 2008) were used. The baseline was measured during a previous pilot project and the same items were evaluated at the end of 2017. The model from Damschroder et al. (Implement Sci 4:50, 2009) was used during the implementation process. RESULTS: With all the information gathered during this investigation, a "patient-centered" model was designed. During the program, 17,894 people were serologically tested for ChD, 1,394 were positive and 1,035 were treated. Additionally, 3,750 children from 46 public schools were evaluated for risk factors of ChD. CONCLUSIONS: This project showed the feasibility of the primary healthcare level for early diagnosis and timely treatment of ChD. Tailor made programs and public-private associations should be considered for vulnerable populations in emerging economies in order to enhance efforts and obtain better results. This program may be replicated in other countries of Latin America were Chagas is a main public health issue and, with the corresponding adaptations, for other neglected diseases as well.

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Historicamente, no Brasil e no mundo, o setor saúde tem se relacionado de forma ambivalente com travestis e transexuais (TT) promovendo acesso ao processo transexualizador, por um lado, mas condicionando-o ao diagnóstico de Tanstorno de Identidade de Gênero (TIG), patologizando assim a experiência da diversidade de gênero. As medidas preventivas adotadas na década de 80 com a epidemia do HIV, também acentuaram o estigma sofrido por este grupo, segregando o acesso aos serviços de saúde especializados. Pesquisas revelam, no entanto, necessidades de saúde relacionadas, não apenas ao acesso às tecnologias mais especializadas, mas de forma integral, associadas às marcas de opressão sofridas por essa população, à necessidade de vínculo aos serviços de saúde e à possibilidade de desenvolver autonomia. No que diz respeito, especificamente, aos dados epidemiológicos, essa população apresenta altos índices de transtornos mentais, uso de substâncias, violência e uso indiscriminado de hormônio. Apontam, ainda, a invisibilidade no que se refere à Atenção Primária à Saúde (APS) e a população TT. --------|a A Política Nacional de Atenção à Saúde Integral da População Lésbicas, Gays, Bisexuais, Travestis e Transexuais (LGBTT) vem como resposta a estas necessidades de cuidado integral, indo além do estigma patologização. Em consonância com esta política, o presente estudo teve como objetivo geral: elaborar um manual de acolhimento à população travesti e transexual para a APS e objetivos específicos: caracterizar o perfil da população TT; identificar os motivos pelos quais o usuário usa ou deixa de usar a APS; identificar barreiras que dificultam o acesso da população à APS; propor estratégias de superação das barreiras de acesso da população TT à APS. O projeto de pesquisa foi submetido ao Comitê de Ética da Escola de Enfermagem da Universidade de São Paulo (EEUSP) e da Secretaria Municipal de Saúde de São Paulo (SMSSP), bem como à gestão do Centro de Cidadania LGBT (CCLGBT) Luiz Carlos Ruas. Método: trata-se de um estudo qualitativo exploratório que realizou entrevistas semiestruturadas na Unidade Básica de Saúde-Sé (UBS-Sé) e no CCLGBT-Luiz Carlos Ruas, ambos na região central de São Paulo. O conteúdo das entrevistas foi registrado e, posteriormente submetido à diversas leituras para análise temática de conteúdo segundo a proposta de Bardin (2006). Análise dos dados: foram identificadas categorias empíricas a partir do referencial teórico relativo ao acesso enquanto dispositivo transformador da realidade, segundo Abreu de Jesus (2006) e às barreiras no acesso aos serviços de saúde à população LGBTT (Albuquerque et. al, 2016).Com relação aos dados quantitativos estes foram organizados em uma planilha para a análise dos dados. Resultados: Foram entrevistadas vinte pessoas trans, entre elas, treze se identificaram como mulheres trans, uma como travesti e seis como homens trans. Com idade média de 33 anos, em sua maioria solteiros (80%), com baixo grau de escolaridade (40% da amostra, referiram ter ensino médio incompleto ou menor grau de escolaridade) e apenas 30% inseridos no mercado de trabalho formal, evidenciando o panorama de vulnerabilidades da população trans. Com relação às barreiras no acesso à APS foram identificadas barreiras tecnoassistenciais relacionadas: 1) ao paradigma heteronormativo e de gênero como equivalência de sexo na APS; 2) pouca oferta do cartão do SUS com nome social e não uso do nome social; 3) falta de uma escuta qualificada; além de barreiras relacionadas às: 4) implicações da transfobia no acesso do serviço de saúde; 5) educação permanente: desconhecimento dos fluxos e conceitos da rede da pessoa trans; e 6) Transfobia nos serviços da APS. A partir das barreiras identificadas foram elaboradas proposições de superação das mesmas que integraram o Manual de acolhimento de Transexuais e Travestis à Atenção Primária à Saúde. Dentre as propostas de superação com relação às barreiras tecnoassitencias: estratégias de uso correto do nome social, a superação de paradigmas biologizantes e a valorização da dimensão relacional do trabalho em saúde, como o uso de uma comunicação responsiva e do acolhimento. Com relação às barreiras associadas à educação permanente, destaca-se a necessidade de ampliar o conhecimento dos trabalhadores com relação às informações a respeito das características da população TT, tais como: conceitos básicos envolvidos na temática, suas principais demandas e fluxos de apoio na rede. Investindo em metodologias ativas de ensino que se pautem em um modelo de saúde ampliado, evidenciando a visão política transformadora do trabalho no SUS. A superação da transfobia nos serviços de saúde está relacionada à promoção de educação permanente neste contexto. Outros estudos poderão avaliar a compreensão e utilização do Manual pelos profissionais da APS e a satisfação das necessidades da população TT.

Historically, in Brazil and in the world, health has related itself in an ambivalent way with transsexuals and transvestites (TT). Understood as pathology and not as diversity and freedom of gender by international disease manuals, this diagnosis allows access to medical procedures for changes in sexual characteristics. In Brazil, health places attention on the TT population beginning at the HIV/AIDS epidemic in the 80's, increasing this group's stigma and segregation, limiting access to specialized services, marking the ambivalence of the health system. Research describe, however, health care needs that go beyond HIV and physical transformations desired by trans people: high rates of mental disorders, substance use, violence, and indiscriminate use of hormones. Research also point out the invisibility in relation to Primary Health Care (PHC). The National Policy for Attention to Comprehensive Health Care for the Lesbian, Gay, Bi-sexual, Transvestite, and Transsexual (LGBTT) Population comes as a response to these needs for comprehensive care, going beyond the stigma and pathologization of gender identity. In line with this policy, the present study had as general objective: develop a manual for embracing the transvestite and transsexual population in the PHC; and specific objectives: characterize the TT population's profile, identify the reasons why users use or not the PHC, identify barriers that hinder the population's access to the PHC, and propose strategies for overcoming the TT population's access barriers to the PHC. Method: this is a qualitative and exploratory study in which 20 semi-structured interviews were carried out in Sé's Basic Health Unit -(BHU) and in Center for LGBT Citizenship (CLGBTC), both in the downtown area of Sao Paulo. The empirical material was analyzed through thematic analysis. Results: Twenty trans people were interviewed, among them thirteen identified themselves as trans women, one as transvestite and six as trans men. With a mean age of 33 years, mostly unmarried (80%), with a low level of schooling (40% of the sample, reported having incomplete high school or lower education) and only 30% inserted in the formal job market, evidencing the panorama of vulnerabilities of the trans population. Technical-care barriers were identified related to: 1) the paradigm of hetero-normative and gender as sex equivalence in the PHC; 2) offer little of the SUS (Brazilian Public Health Care System) card with social name social printed and the non-use of the social name; 3) lack of qualified listening. In addition to the related barriers: 4) implications of transphobia in access to the health service; 5) permanent education: lack of knowledge of flows and concepts of the trans person's network; 6) Transphobia in the PHC services. Based on the barriers identified, proposals were made to overcome them, which integrated the "Handbook on the reception of Transsexuals and Transvestites for Primary Health Care". Among the proposals for overcoming in relation to the tecnoassitencias barriers: strategies of correct use of the social name, the overcoming of biologizing paradigms and the valorization of the relational dimension of health work, such as the use of a responsive and welcoming communication. Regarding the barriers associated with lifelong education, the need to broaden workers' knowledge regarding information about the characteristics of the TT population, such as: basic concepts involved in the theme, its main demands and support flows in the public health system. Investing in active teaching methodologies that are based on an expanded health model, evidencing the transformative political vision of the SUS work. The overcoming of transphobia in the health services is related to the promotion of permanent education in this context. Other studies may assess the understanding and use of the Manual by PHC professionals and the satisfaction of the needs of the TT population. From the identified barriers, propositions for improvement of these were built, as well as the "Embracing Transvestites and Transsexuals (TT) in Primary Health Care (PHC) Manual".

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Resumo A Constituição Federal de 1988 aprovou o Benefício de Prestação (BPC) para idosos e pessoas com deficiência com renda familiar até 1/4 do salário mínimo, que alcançou em 2015 cerca de 4 milhões de pessoas. Para pessoas com deficiência, a implementação do BPC envolve organizações da previdência social, assistência social e saúde. O trabalho discute como algumas lacunas nos mecanismos de coordenação intersetorial entre essas áreas produzem barreiras de acesso aos potenciais beneficiários. Os resultados são de pesquisa qualitativa realizada com médicos, técnicos administrativos e assistentes sociais do Instituto Nacional do Seguro Social (INSS) e dos Centro de Referência da Assistência Social (CRAS) em três municípios de diferentes regiões do país. A coordenação e a cooperação intersetoriais mais estruturadas ocorrem no nível federal. No nível local, dependem de iniciativas informais e horizontais, o que produz soluções imediatas, mas descontínuas. O papel dos CRAS permanece contingente na implementação. Ficou patente a necessidade de estabelecimento de mecanismos institucionalizados de coordenação e cooperação entre os setores da assistência social, saúde e previdência para melhorar a implementação e diminuir as barreiras de acesso ao BPC.

Abstract The 1988 Constitution approved the Continuous Cash Benefit (BCP) directed to elders and disabled persons with a household per capita income of 25% of the minimum wage, and around 4 million people received this benefit in 2015. The design of BPC for disabled persons involves organizations of social security, social welfare and health. This paper discusses how some intersectoral coordination mechanisms gaps between these areas produce access barriers to potential beneficiaries. Results stem from a qualitative study performed with physicians, administrative staff and social workers from the National Institute of Social Security (INSS) and of the Social Welfare Reference Center (CRAS) in three municipalities of different Brazilian regions. Intersectoral coordination and cooperation are more structured at the Federal level. At the local level, they rely on informal and horizontal initiatives, which produce immediate but discontinuous solutions. The role of the CRAS remains contingent on the implementation. The need to establish institutionalized mechanisms for coordination and cooperation between social welfare, health and social insurance to improve the implementation and reduce barriers to access to the BCP is apparent.

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Contexto: el acceso a servicios de salud es un tema de creciente preocupación, en el caso colombiano ha ganado importancia frente al aseguramiento. Objetivo: construir un concepto de acceso e identificar barreras y estrategias, desde la perspectiva de actores en Medellín. Material y métodos: investigación cualitativa con énfasis en tres zonas de Medellín. Resultados: se identificaron similitudes y diferencias en la visión del acceso, las cuales permitieron construir el concepto. Las barreras y los facilitadores se atribuyen a factores de oferta y de demanda. La mayoría de las barreras se dan en el acceso real, durante la búsqueda y continuidad del tratamiento. Algunas características sociales de la población también son factores determinantes. Discusión y conclusiones: los actores recurren a estrategias para solventar las barreras de acceso. El análisis cualitativo del concepto de acceso, de las barreras y las facilidades permite identificar alternativas que pueden servir de insumo para políticas en salud.

Context: The access to health services is an increasingly worrying topic in the research and public policies agendas. In the case of Colombia, this topic becomes more important and attains supremacy opposite to assurance. Objective: Building a concept of access and identifying barriers, as well as strategies and alternatives to overcome them from the perspective of the actors of the health system in Medellin. Materials and Methods: qualitative research, focused on three areas of Medellin. We used techniques such as semi-structured interviews; social cartography workshops; observation and result questionnaires of the services. Results: The vision on the access is heterogeneous between actors, although some similarities and differences were identified, that allowed us to build a proposal of the concept of access. The barriers and factors that facilitate access can be attributed to factors on the offer side as well as on the demand side. Most of the barriers happen during real access, during the search and continuity of the treatment. The social characteristics of the population, such as knowledge of the system and social and community support are also determinant factors of access. Discussion and Conclusions: All actors use strategies to solve the access barriers and are affected by them on different levels. The qualitative analysis of the concept of access, of barriers and facilities, allow the identification of alternatives that may serve as components for health policies.

Contexto: O acesso aos serviços de saúde é tema de preocupação crescente nas agendas de pesquisa e as políticas públicas. No caso colombiano, a questão ganha importància e encontra uma supremacia frente à asseguração. Objetivo: construir um conceito de acesso e identificar barreiras, estratégias e alternativas para superá-las, desde a perspectiva dos atores do sistema de saúde na cidade de Medellín. Material e métodos: pesquisa qualitativa, com ènfase em très zonas de Medellín. Utilizaram-se técnicas como entrevistas semiestruturadas, oficinas de cartografia social, observação e questionários de saída dos serviços. Resultados: a visáo sobre o acesso é heterogénea entre atores, embora foram identificadas similitudes e diferencas que permitiram construir uma proposta de conceito de acesso. As barreiras e fatores que facilitam o acesso sáo atribuíveis a fatores tanto do lado da oferta quanto do lado da demanda. A maioria das barreiras ocorrem no acesso real, durante a procura e continuidade do tratamento. Características sociais da populacáo, como conhecimento do sistema e apoio social e comunitàrio, sáo também fatores determinantes do acesso. Discussao e conclusoes: todos os atores recorrem a estratégias para superar as barreiras de acesso e sáo afetados por estas em níveis diferentes. A análise qualitativa do conceito de acesso, das barreiras e as facilidades permite identificar alternativas que podem servir de insumo para políticas em saúde.

RESUMO

There are few comprehensive studies available on barriers encountered from the initial seeking of healthcare through to the resolution of the health problem; in other words, on access in its broad domain. For Colombia and Brazil, countries with different healthcare systems but common stated principles, there have been no such analyses to date. This paper compares factors that influence access in its broad domain in two municipalities of each country, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had had at least one health problem within the last three months (2163 in Colombia and 2155 in Brazil). The results reveal important barriers to healthcare access in both samples, with notable differences between and within countries, once differences in sociodemographic characteristics and health needs are accounted for. In the Colombian study areas, the greatest barriers were encountered in initial access to healthcare and in resolving the problem, and similarly when entering the health service in the Brazilian study areas. Differences can also be detected in the use of services: in Colombia greater geographical and economic barriers and the need for authorization from insurers are more relevant, whereas in Brazil, it is the limited availability of health centres, doctors and drugs that leads to longer waiting times. There are also differences according to enrolment status and insurance scheme in Colombia, and between areas in Brazil. The barriers appear to be related to the Colombian system's segmented, non-universal nature, and to the involvement of insurance companies, and to chronic underfunding of the public system in Brazil. Further research is required, but the results obtained reveal critical points to be tackled by health policies in both countries.

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Gaucher disease (GD) is an autosomal recessive disorder characterized by the absence of glucosylceramidase. The accumulation of substrates of this enzyme in the cytoplasm of cells of the phagocytary system causes skeletal and hematologic disorders, and has oral repercussions. This report describes the findings of the oral cavity of an 8-year-old diagnosed with subtype I GD who has been receiving enzyme replacement therapy for the past 6 years without interruption. The report highlights that the child had none of the most common oral disease signs and symptoms, which demonstrates the importance of early diagnosis and continuous treatment. The article also emphasizes that it is important for dentists to recognize oral manifestations of GD (in order to assist in early diagnosis) and understand how to treat the likely oral health conditions of GD patients.

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