Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 16 nº 3 - Jul/Sep - 2019

Original Article Imprimir 

Páginas 7 a 16


Early deaths in the state of Bahia: adolescent mortality and the protagonism of external causes

Muertes tempranas en el estado de Bahía: mortalidad de adolescentes y protagonismo de causas externas

Mortes precoces no estado da Bahia: mortalidade de adolescentes e o protagonismo das causas externas

Autores: Alba Lúcia Santos Pinheiro1; Kerlly Taynara Santos Andrade2; Ellen da Anunciação3; Irene Maurício Cazorla4; Aretusa de Oliveira Martins Bitencourt5

1. Doctorate in Sciences from the University of São Paulo (USP). Master in Nursing from the Federal University of Bahia (UFBA). Teacher at the Department of Health Sciences at Santa Cruz State University (UESC). Ilhéus, BA, Brazil
2. Master's student from the Graduate Program in Nursing (PPGENF) at teh State University of Santa Cruz (UESC). Postgraduate student in Adult Hospital Health from the Venda Nova do Imigrante College (FAVENI). Degree in Nursing from Santa Cruz State University (UESC). Ilhéus, BA, Brazil
3. Resident of the Multiprofessional Residency Program in Hospital Attention with emphasis on Care Management by Dom Moura Regional Hospital (HRDM). Degree in Nursing from Santa Cruz State University (UESC). Ilhéus, BA, Brazil
4. Doctorate in Education from the State University of Campinas (UNICAMP). Master in Statistics from the State University of Campinas (UNICAMP). Lecturer at the Master Program in Mathematical Education of Santa Cruz State University (UESC). Ilhéus, BA, Brazil
5. Master in Nursing from the Federal University of Bahia (UFBA). Teacher at Health Sciences Department at Santa Cruz State University (UESC). Ilhéus, BA, Brazil

Kerlly Taynara Santos Andrade
(ktsandrade@hotmail.com)
Universidade Estadual de Santa Cruz (UESC), Departamento de Ciências da Saúde
Rodovia Jorge Amado, km 16, Salobrinho
Ilhéus, BA, Brasil. CEP: 45662-900

Submitted on 12/12/2018
Approved on 18/06/2019

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Keywords: Adolescent; Adolescent Health; Health Status Indicators; Mortality.
Palabra Clave: Adolescente Salud del adolescente; Indicadores básicos de salud; La mortalidad
Descritores: Adolescente; Saúde do Adolescente; Indicadores Básicos de Saúde; Mortalidade.

Abstract:
OBJECTIVE: Identify the pattern and tendencies of death in teenagers among the state of Bahia, from 1989 to 2016.
METHODS: Ecologic study with temporal tendency based on public domain data extracted from Department of Informatics of the Unified Health System and Directorate of Health Information of the Superintendence of Health Surveillance and Protection of the State of Bahia, with analysis based on Specific Mortality Coefficients (SMC) through linear regression, t-student test, F (ANOVA) and Bonferronis' test.
RESULTS: The Specific Mortality Coefficient of adolescents from 15 to 19 years was greater than the coefficient of 10 to 14 years. There is an over-mortality in the male sex, where the east, southern and south regions stand out. The external causes were the top position in both age groups cases during the period of survey, and aggressions were the main cause of death.
CONCLUSION: The aggressions and the high mortality of Bahia are a threatening indicator which reflects the needs to establish effective strategies aimed to avoid the untimely death of this population group.

Resumen:
OBJETIVO: identificar tendencias de comportamiento y mortalidad en el estado de Bahía de 1989 a 2016.
MÉTODOS: Estudio ecológico de la tendencia temporal con datos de dominio público extraídos del Departamento de Informática del Sistema Único de Salud y la Dirección de Información de Salud de la Superintendencia de Vigilancia y Protección de la Salud del Estado de Bahía, con análisis basado en coeficientes de mortalidad específicos utilizando regresión lineal, test t-student, F (ANOVA) y test de Bonferroni.
RESULTADOS: El coeficiente de mortalidad específico (CME) de adolescentes de 15 a 19 años fue mayor que el coeficiente de 10 a 14 años. Existe un exceso de mortalidad en los hombres, donde las regiones Este, Extremo Sur y Sur se destacaron por el número de casos. Las causas externas permanecieron en la primera posición en ambos grupos de edad durante todo el período de estudio y las agresiones fueron la principal causa de muerte.
CONCLUSIÓN: la agresión y la alta mortalidad en Bahía son un indicador alarmante que refleja la necesidad de establecer estrategias efectivas para prevenir las muertes prematuras de este grupo de población.

Resumo:
OBJETIVO: Identificar o comportamento e as tendências de mortalidade do adolescente no Estado da Bahia, de 1989 até 2016.
MÉTODOS: Estudo ecológico de tendência temporal com dados de domínio público extraídos do Departamento de Informática do Sistema Único de Saúde e da Diretoria de Informação em Saúde da Superintendência de Vigilância e Proteção da Saúde do Estado da Bahia, com análise baseada em Coeficientes de Mortalidade Específica através de regressão linear, teste t-student, F (ANOVA) e teste de Bonferroni.
RESULTADOS: O Coeficiente de Mortalidade Específica (CME) de adolescentes de 15 a 19 anos mostrou-se maior do que o coeficiente de 10 a 14 anos. Há sobremortalidade no sexo masculino, onde as regiões Leste, Extremo Sul e Sul se destacaram pelo número de casos. As causas externas mantiveramse na primeira posição em ambos os grupos etários em todo o período de estudo, sendo as agressões a principal causa de morte.
CONCLUSÃO: As agressões e a elevada mortalidade na Bahia são um indicador alarmante que reflete a necessidade de estabelecimento de estratégias efetivas voltadas para evitar as mortes precoces desse grupo populacional.

INTRODUCTION

Adolescence is understood as a transition period from childhood to adulthood, representing a phase of intense growth and human development that involves multiple and simultaneous transformations of physical, psychic and social aspects1,2.This can be understood both as a subjective response to the onset of puberty and as a cultural and social construction linked to age3,4,5.

The Ministry of Health (MS) chronologically defines adolescents as individuals aged 10-19 years and can be classified as "precocious adolescent" (10 and 14 years) and "young adolescent" (15-19 years) 2,5.

According to the Department of Informatics of the Unified Health System (DATASUS) 6, in 2016, Bahia had 2,598,291 adolescents.Of these, about 51% are male and 49% female, 50.2% are between 10 and 14 years old and 49.8% are between 15 and 19 years old.Despite the demographic importance associated with their vulnerability to health problems, adolescents present themselves as a group excluded from health care and care that considers the specificities of their demands.

Adolescents have their health influenced by factors that are associated with both causes of illness and death in children and young adults.In this sense, prevention and control measures initially depend on the identification of the central determinants of diseases and illnesses in this group, made possible through the "establishment of disease and disease distribution patterns"7. These patterns can be generated from the use of collective health measures that describe the health situation, among which are the mortality indicators7,8. Statistics enable a situational diagnosis that provides support for planning and evaluation actions for health promotion and disease prevention7.

The objective of this paper is to identify the pattern and trends of adolescent mortality in the state of Bahia from 1989 to 2016, according to age group, gender, regional health centers and groups of causes.


METHODOLOGY

This is an ecological study of the temporal trend of adolescent mortality in Bahia from 1989 to 2016.The State of Bahia consists of 417 municipalities distributed in nine Regional Health Centers (NRS) and has an estimated population of 15,339,922 inhabitants, and 16.77% correspond to the adolescent population6,9.

The chosen period was 1989, based on the year of promulgation of the Adolescent Health Program (PROSAD) 10, until 2016.The data used are public domain and correspond to recorded deaths of adolescents, extracted from the Mortality Information System (SIM) of the State of Bahia from November to December 2016, from the DATASUS and DIS/SUVISA websites. (Health Information Direction of the Bahia State Health Surveillance and Protection Superintendence). From this system, which is currently being replaced by e-SUS, variables such as age, sex, macroregions of health, coincident with NRS, and causes of death were extracted.

Causes are named according to the International Statistical Classification of Diseases and Related Health Problems (SCD) and the study period comprises the ninth and tenth revisions.Thus, in order to avoid bias in the collection and analysis of information, a grouping of the major cause groups was performed between ICD-BR-9 and ICD-BR-10.

Information regarding the resident population in each year of the study period was collected based on estimates from the Brazilian Institute of Geography and Statistics (IBGE).It is noteworthy that until the submission of this study there were no data available on the resident population by macroregions in 2016.

Data analysis was based on Specific Mortality Coefficients (SMC), which is defined by the number of deaths by sex, age or cause, divided by the population of this same group, considering the area and year, multiplied by one hundred thousand inhabitants.The race/color variable was excluded due to the large amount of information ignored.

To analyze the SMC trajectory, the linear regression method was used.In order to analyze the difference in mean EBF by gender and age over time, the t-studenttest for paired data was used. A análise do SMC por região e por causas foi feita utilizando o Teste F - Análise de Variância (ANOVA) para medidas repetidas e para a comparação de médias em pares o teste de Bonferroni.O nível de significância utilizado foi de 5%.

We used the line chart and the trend adjustment by the least squares method, we also used the cash diagram to visualize the behavior of the mean level of the SMC in the various categories.Data were compiled in the spreadsheet EXCEL © and statistical analyzes were performed using the Statistical Package for the Social Sciences (SPSS), version 22.

This research is part of the Project "Attention to Adolescent Health in the State of Bahia: Unveiling Public Policies and Indicators" approved by the Research Ethics Committee of the Santa Cruz State University (CEP-UESC) with Certificate of Presentation for Ethical Appraisal number 60045716.2.0000.5526, approved in November 2016 and funded by the Bahia State Research Support Foundation (FAPESB).


RESULTS

During the study period, 52,915 deaths of adolescents in the State of Bahia were recorded, of which 73.7% (39,021 deaths) corresponded to deaths of adolescents aged 15-19 years.In this group, 2016 stood out with the highest mortality rate: 174.9 per 100,000 inhabitants. The SMC of adolescents aged 15-19 years old was always higher than the SMC of adolescents aged 10 to 14 years old, almost constant around their averages until 2006. From 2007 onwards, the SMC of 15-19 year olds began an increasing linear trajectory justifying the establishment of a cutoff point between these years to facilitate statistical analysis (Figure 1).


Figure 1. Evolution of Specific Mortality Coefficients by age of Adolescents in the State of Bahia, with trend lines, from 1989 to 2016.
Source: Research Data.



The means and statistics of the t-student test for paired samples showed that these differences were statistically significant. From 1989 to 2006, the 15 to 19 years old SMC was more than double than the 10- to 14 years old SMC and quadrupled from 2007 to 2016. Already the age group of 10 to 14 years maintained a behavior of stability throughout the period of analysis.

The linear adjustment of the trends showed that the 10 to 14 year-old BMCs are not related to time, since the angular coefficient could be considered zero (p = 0.483).That is, the SMC tended to a constant around a SMC of 33.5, very close to the average value of the whole period, which was 32.8.The same occurred with the trend for the 15-19 year old group until 2006, with time-independent SMC, considering zero the angular coefficient (p = 0.174).That is, the SMC tended to 72.3, which was very close to the average of 74 corresponding to the period.

However, from 2007 onwards, the 15- to 19-year-old SMC started a linear upward trend at a rate of 6.72 per year (p = 0.001), which dramatically described the status of this age group ( Figure 1).

Regarding the distribution of mortality by sex, it was found that male mortality was always statistically higher than female mortality, according to the result of the t-student test (10 to 14 years - 17,366; 15 to 19 years - 8,801). In the 10 to 14 year old group, male mortality was 60% higher than female mortality.Already in the range of 15 to 19, in the period from 1989 to 2006, male mortality was 2.6 times higher than female and this doubled in the period from 2007 to 2016.The 15- to 19-year-old male SMC was found to be the only one that escaped the standards of the other categories (Figure 2).


Figure 2 - Evolution of Specific Mortality Coefficients by sex and age of adolescents, in the State of Bahia, from 1989 to 2016.
Source: Research Data.



The SMC of the 10 to 14 year old male and female groups and the 15 to 19 year old female group showed a tendency that over time could be considered constant.For males aged 15-19 years, the linear trend was increasing, and in the period up to 2006, the angular coefficient was not more than one unit per year (y = 0.7326), becoming 13.098 each year (p = 0.000) from 2007 (Figure 2).

Regarding the distribution of SMC in the age group of 10 to 14 years by NRS, it was observed that there was a significant difference between the regions (F (1,26)= 1796.71; p = 0.000). and South stood out in relation to the others, according to the Bonferroni test.

In the age group 15-19 years, there was also a significant difference between the NRS (F(1,26) = 385,79; p = 0,000), keeping these same regions in the first three positions, but in this case, the NRS East occupied the first position, followed by the far south and south, according to the Bonferroni test.It is important to mention that the North Central Region showed a reversal in the trend from 2007 and such variability that compromises the comparison between the averages.It is important to mention that the North Central Region showed a reversal in the trend from 2007 and such variability that compromises the comparison between the averages.

Figure 3 shows the mean SMC of each NRS by age group, and in the range 15-19 the mean was calculated in the two separate periods (1989 to 2006 and 2007-2015).When comparing the age groups, it was observed that in all NRS the death rates were higher for adolescents from 15 to 19 years old, especially the Far South, East and South.It was also verified that there was a high correlation between the SMC of the range 10 to 14 and the SMC of the range of 15 to 19 years.That is, regions with a higher rate in one band tend to reproduce this high rate in the other band, except for the North Central region, which was the only one that changed the trend of falling sharply in the second study period, becoming an outpoint. of the trend.


Figure 3 - Specific Mortality Average Coefficient by age group and period, by Regional Health Center, in the State of Bahia, from 1989 to 2015.
Source: Research Data.



When analyzing the EBF by causes in the State of Bahia, deaths from "external causes of morbidity and mortality" remained in the first position throughout the study period, in both age groups.In the case of the range 10 to 14, the mean level by causes differed significantly (F(1,27) = 2561,08; p = 0,000).The external causes reached a SMC of 14.7, against 4.53 of the second cause, and the other three are below 2.5 and did not differ statistically, according to the Bonferroni test pair comparison.

In this age group, the second cause of death corresponded to "symptoms, signs and abnormal findings from clinical and laboratory examinations not elsewhere classified".That is, ill-defined causes, followed by "neoplasms", "circulatory diseases" and "infectious and parasitic diseases" (Figure 4).


Figure 4. Main causes of death by age group analyzed in the present study.
Source: Research Data.



In the case of the age group of 15-19 years, the differences were also significant (F(1,27) = 156,21; p = 0,000); mean external causes were 67.12 against 7.78 of the second cause, which were the ill-defined causes.The third leading cause of death in this group were "circulatory system diseases", followed by "neoplasms", and "endocrine, nutritional, metabolic, blood and hematopoietic diseases and some immune disorders" (Figure 4).

Regarding deaths from external causes, it was observed that in both age groups the main cause of death was identified as aggressions with a considerable increase from the year 2007; however, in the age group of 15-19 years this increase became even more expressive (Figure 5).


Figure 5. Main deaths from external causes in the group of 15-19 years in the present study analyzed by year.
Source: Research Data.



DISCUSSION

Regarding the age group, it is noteworthy that in Bahia, the deaths of young adolescents were always higher than the deaths of early adolescents, especially when the coefficients began to rise dramatically.

According to Horta and Sena11, public policies for adolescents nationwide increased between 1999 and 2002, but they constitute isolated projects that do not contribute to the change in the conformation of adolescent health. In Bahia, this reality is reaffirmed by viewing the trajectory of the SMC over time, which categorically demonstrates the poor effectiveness of the social rights and public health protection network, which should be guaranteed by the State4.

The data also show that there was a male over-mortality, especially in adolescents aged 15-19 years, which expressed increasing rates from 2007, corroborating with other studies12,13.The State of Bahia is known to have the second largest difference in life expectancy between men and women (9.1 in favor of women) in the Federative Units13.

Male over-mortality is considered as a result of the biological difference between the sexes that gives women a naturally longer life expectancy than men.In addition, testosterone drives them to violence and more frequent risk exposure14.

The IBGE13, in the document "Complete Mortality Table for Brazil - 2015", states that male over-mortality occurred through a rapid process of urbanization and metropolization from the 1940s, when the population ceased to be essentially rural with conditions poor sanitary conditions. Currently, this phenomenon is concentrated in the group of young adolescents and young adults (15 to 29 years old) due to a higher incidence of preventable deaths that intensely affect this population13.

The adolescent mortality profile by NRS reveals a concern for the Far South, which has the highest coefficients. Differences between health regions of the State show the variability of risks to which adolescents are exposed, with exposure to vulnerabilities related to the territory15.

It is noted that the three regions of health (Far South, East and South) that stood out in relation to the others regarding the SMC coincide with the three regions that presented the highest Homicide Mortality Rates (HMR) in all age groups. , in another study in Bahia15.Although it can be said that there is no uniform distribution of diseases in the regions15, it is emphasized that the determinants of the specific mortality profile for each region are not easily identified.

Looking at the causes of death, we find a worrying highlight with regard to external causes.This, as the leading cause of death, has been highlighted since the publication of the PROSAD text10.Bustamante-Teixeira et al.12 state that among adolescents, Brazil showed an increase in mortality rates due to external causes, and similar results were identified in Bahia from 2007.

Some studies reinforce this result by stating that preventable causes are the major causes of the increase in adolescent deaths in Brazil4,12,16, reaching more significant proportions when compared to the rest of the population and being related to marginality, drug trafficking and drug use alcohol abuse16,17.

Within external causes, aggressions stand out, similarly to other studies4,15,18. For young adolescents, these SMC were always significantly higher compared to early ones.However, in the last 10 years, it has been observed that the SMC has been growing among early adolescents, revealing a necessary and urgent intervention.

It is emphasized that in 2007, the beginning of the rise in mortality rates in Bahia, the Lethal Violence Reduction Program was created, which through the Adolescent Homicide Index aims to "contribute to the monitoring of the phenomenon of lethal violence in adolescence. and for the evaluation of prevention-oriented public policies "19.It was noted that there was no positive influence on the change in mortality rates in Bahia, which presented itself as the state with the most municipalities that lead the national ranking of the incidence of adolescent homicides19.

Other causes that deserve attention are ill-defined, neoplasms and diseases of the circulatory system that occupy the second, third and fourth causes of death among adolescents, respectively.Results similar to the causes of death of adolescents nationwide10.

We highlight the initiative of the Ministry of Health to implement, since 2005, the program "Reduction of the percentage of deaths from ill-defined causes" to reduce this proportion that remains persistently high. Thus, monitoring and evaluation of the SIM information generation process must be present in the set of attributions of those responsible for health surveillance20.

Thus, the analysis of adolescent mortality indicators in the State of Bahia reveals that the field of citizenship production for this age group needs to be deepened in order to promote public policies that take into account universality, access, equity and the completeness of attention.It is necessary to incorporate the political dimension, as well as the technical dimension, from the construction of meanings for the decision making and operationalization in order to transform this reality. Therefore, it is expected that this study enables the creation, implementation and/or improvement of policies in order to offer improvements in care, subsidize managers, professionals and others involved in the qualification of comprehensive care for adolescent health in the state.


CONCLUSION

Adolescent mortality in Bahia is an alarming health indicator that reflects the importance of turning our eyes to the health needs of this public.The significant increase in SMC from 2007 deserves to be investigated to identify whether these indicators correspond to the introduction of new determinants of health and safety, or is due to other factors such as the reduction of public policies and the intensification of SIM feeding in the State.

This study helps to elucidate the issue of adolescent mortality in Bahia, but leaves open other research possibilities such as the deepening of the determinants and the perspective of the documents on the policies implemented/implemented in the state so that they can more assertively support the management in the state facing this multifaceted and transdisciplinary problem.

This study makes it possible to establish the diagnostic situation that seeks to support new perspectives of health care.It is notorious that government interventions must permeate the elements that make up the broader concept of health, ranging from health care at the links of primary care to public safety.


NOTE

Funded by the Bahia State Research Support Foundation (FAPESB).


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