TEORIAS EPIDEMIOLÓGICAS EM DEBATE: UM ESTUDO SOBRE DETERMINAÇÃO SOCIAL, DETERMINANTES SOCIAIS E SINDEMIA
DOI:
https://doi.org/10.14393/Hygeia2279794Palavras-chave:
Epidemiologia, Geografia da saúde, Saúde coletiva, Teorias epidemiológicasResumo
O conceito de saúde é um problema complexo e multidimensional, cuja compreensão exige abordagens teóricas que considerem aspectos sociais e biológicos de forma complementar, sobretudo a partir de uma visão ontológica. Nesse sentido, a saúde pode ser compreendida a partir da relação sociedade/natureza, realizada pelas análises geográficas. Torna-se fundamental recorrer a teorias que, a partir de uma perspectiva ontológica da relação saúde-espaço, permitam compreender a complexidade da saúde e mensurar sua ocorrência e expressão na realidade concreta. O objetivo deste artigo é apresentar e analisar, destacando potencialidades e fragilidades de três abordagens epidemiológicas: 1) determinação social da saúde; 2) determinantes sociais da saúde; e 3) sindemia. Busca-se identificar qual delas oferece a melhor aptidão para uma análise ontológica da relação entre saúde e espaço por meio de um levantamento bibliométrico e revisão da literatura. Conclui-se que a teoria da sindemia, quando integrada à geografia, demonstra o maior potencial para analisar a complexa dialética entre o social, o biológico e o espacial na produção dos processos de saúde e doença.
Downloads
Referências
ABRAMS, E. M.; SZEFLER, S. J. COVID-19 and the impact of social determinants of health. The Lancet, v. 8, p. 659-661, 2020. https://doi.org/10.1016/S2213-2600(20)30234-4
ALMEIDA FILHO, N. O conceito de saúde: ponto-cego da epidemiologia?. Rev. Bras. Epidemiol., v. 3, n. 1-3, p. 4-20, 2000. https://doi.org/10.1590/S1415-790X2000000100002
ALMEIDA FILHO, N. O que é saúde. Rio de Janeiro: Editora Fiocruz, 2011, 160 p. https://doi.org/10.7476/9788575413432
ANUNCIAÇÃO, D. et al. (Des)caminhos na garantia da saúde da população negra e no enfrentamento ao racismo no Brasil. Ciência & Saúde Coletiva, v. 27, n. 10, p. 3861-3870, 2022. https://doi.org/10.1590/1413-812320222710.08212022en
ARENA, R. et al. Mapping one million COVID-19 deaths and unhealthy lifestyle behaviours in the United States: recognizing the syndemic pattern and taking action. The American Journal of Medicine, v. 135, n. 11, p. 1288-1295, 2022. https://doi.org/10.1016/j.amjmed.2022.06.006
BARRIOS, Y. H. et al. Using a syndemics perspective to (re) conceptualize vulnerability during covid-19 pandemic: a scope review. Tropical Medicine and Infectious Disease, Basel, n. 118, v. 9, 2024. https://doi.org/10.3390/tropicalmed9080189
BECASEN, J. S. et al. Estimating the prevalence of HIV and sexual behaviours among the US transgender population: a systematic review and meta-analysis, 2006-2017. AJPH, v. 109, n. 1, p.1-8, jan. 2019. https://doi.org/10.2105/AJPH.2018.304727
BLANKENSHIP, K. M. et al. Social determination of HIV: women’s relationship work in the context of mass incarceration and housing vulnerability. AIDS and Behaviour, v. 25, n. 2, p. 190-201, 2021. https://doi.org/10.1007/s10461-021-03238-4
BLANKENSHIP, K. M. et al. Structural racism, the social determination of health, and health inequities: the intersecting impacts of housing and mass incarceration. AJPH, v. 113, n. S1, p. 58-64, 2023. https://doi.org/10.2105/AJPH.2022.307116
BORDE, E.; HERNÁNDEZ-ÁLVAREZ, M.; PORTO, M. F. de S. Uma análise crítica da abordagem dos Determinantes Sociais da Saúde a partir da medicina social e saúde coletiva latino-americana. Saúde Debate, Rio de Janeiro, v. 39, n. 106, p. 841-854, 2015. https://doi.org/10.1590/0103-1104201510600030023
BRAVEMAN, P.; EGERTER, S.; WILLIAMS, D. R. The social determinants of health: comingo of age. Annu. Rev. Public Health, v. 32, p. 381-398, 2011. https://doi.org/10.1146/annurev-publhealth-031210-101218
BREILH, J. Epidemiology of the 21st century and cyberspace: rethinking power and the social determination of health. Rev. Bras. Epidemiol., v. 18, n. 4, p. 972-982, 2015. https://doi.org/10.1590/1980-5497201500040025
BREILH, J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev. Fac. Nac. Salud Pública, v. 31, p. 13-27, 2013. https://doi.org/10.17533/udea.rfnsp.16637
BREILH, J. Una perspectiva emancipadora de la investigación e incidencia basada en la determinación social de la salud. In: HARTMAN, Catalina Eibenschutz (Org.); GONZÁLEZ, Silvia Tamez (Org.); GUZMÁN, Rafael González (Org.). ¿Determinación social o determinantes sociales de la salud?: memoria del Taller Latinoamericano sobre determinantes sociales de la salud. 1.ed. México: Universidad Autónoma Metropolitana, 2011, p. 45-69.
BURSTRÖM, B.; TAO, Wenjing. Social determinants of health and inequalities in COVID-19. The European Journal of Public Health, v. 30, n. 4, p. 617-618, 2020. https://doi.org/10.1093/eurpub/ckaa095
BULLED, N.; SINGER, Merrill. Conceptualizing COVID-19 syndemics: a scoping review. Journal of Multimorbidity and Comorbidity, v. 14, p. 1-13, 2024. https://doi.org/10.1177/26335565241249835
BUSS, P. M.; FILHO, A. P. A saúde e seus determinantes sociais. PHYSIS: Rev. Saúde Coletiva, Rio de Janeiro, v. 17, n. 1, p. 77-93, 2007. https://doi.org/10.1590/S0103-73312007000100006
CARDONA-ARIAS, J. A.; SALAS-ZAPATA, W. A.; CARMONA-FONSECA, J. Determinación y determinantes sociales de la malaria: revisión sistemática, 1980-2018. Rev. Panam. Salud Publica, v. 43, p. 1-9, 2019. https://doi.org/10.26633/RPSP.2019.39
CHAKRAPANI, V. et al. The syndemic of violence victimisation, drug use, frequent alcohol use, and HIV transmission risk behaviour among men who have sex with men: cross-sectional, population-based study in India. SSM - Population Health, v. 7, p. 1-11, 2019. https://doi.org/10.1016/j.ssmph.2018.100348
CHUNG, G. Ka-Ki et al. Differential impacts of multimorbidity on COVID-19 severity across the socioeconomic ladder in Hong Kong: a syndemic perspective. Int. J. Environ. Res. Public Health, v. 18, p. 1-13, 2021. https://doi.org/10.3390/ijerph18158168
COSTELLO, A. et al. Lancet and University College London Institute for Global Health Commission. Managing the health effects of climate change. The Lancet, v. 373, p. 1693-1733, 2009.
CRAFT-BLACKSHEARE, M.; KAHN, P. Midwives and other perinatal health workers’ perceptions of the black maternal mortality crisis in the United States. Journal of Midwifery & Women’s Health, v. 68, n. 1, p. 62-70, 2023. https://doi.org/10.1111/jmwh.13433
DARSIE, C. et al. A COVID-19, os determinantes sociais da saúde e as iniquidades dos territórios de saúde brasileiros. Sanare, v. 21, n. 2, p. 06-14, 2022. https://doi.org/10.36925/sanare.v21i2.1659
DAVID, H. M. S. L. et al. Pandemia, conjunturas de crise e prática profissional: qual o papel da enfermagem diante da Covid-19?. Revista Gaúcha de Enfermagem, v. 42, p. 1-7, 2021.
DEATON, A. The great escape: health, wealth, and the origins of inequality. Princeton University Press, 2013. https://doi.org/10.1515/9781400847969
DIEGUEZ, E. Y. H. et al. Determinación social de la vigilancia en salud pública en un municipio cubano. Universidad y Sociedad: Revista Científica de la Universidad de Cienfuegos, v. 16, n. 3, p. 61-70, 2024.
DONTHU, N. et al. How to conduct a bibliometric analysis: an overview and guidelines. Journal of Business Research, v. 133, p. 285-296, 2021. https://doi.org/10.1016/j.jbusres.2021.04.070
DUAYER, M.; MEDEIROS, J. L. A ontologia de Lukács: para uma ética objetivamente fundada. In: MIRANDA, Flávio Ferreira de; MONFARDINI, Rodrigo Delpupo. Marx: ontologia e estética. 1. ed. Rio de Janeiro: Consequência, 2015, p.17-44.
EVANS, T. et al. Introduction. In: EVANS, T. et al. (Ed.). Challenging inequities in health: from ethics to action. 2. ed. Nova Iorque: Oxford University Press, 2001, p. 3-11. Disponível em: <https://archive.org/details/challenginginequ0000unse/page/12/mode/2up?view=theater> Acesso em: 16 de nov. 2024. https://doi.org/10.1093/acprof:oso/9780195137408.003.0001
FIGUEIREDO, A. M. de et al. Determinantes sociais da saúde e infecção por COVID-19 no Brasil: uma análise da epidemia. Revista Brasileira de Enfermagem, v. 73, p. 1-7, 2020. https://doi.org/10.1590/0034-7167-2020-0673
FRONTEIRA, I. et al. The SARS-CoV-2 pandemic: a syndemic perspective. One Health, v. 12, p. 1-7, 2021. https://doi.org/10.1016/j.onehlt.2021.100228
GARBOIS, J. A.; SODRÉ, F.; DALBELLO-ARAUJO, M. Da noção de determinação social à de determinantes sociais da saúde. Saúde Debate, Rio de Janeiro, v. 41, n. 112, p. 63-76, 2017. https://doi.org/10.1590/0103-1104201711206
GOMES, E. C. S. Conceitos e ferramentas da epidemiologia. Recife: Ed. Universitária da UFPE, 2015.
GOOGLE LLC. Google Planilhas. [S.l.], 2024. Disponível em: https://www.google.com/sheets/about/. Acesso em: 19 maio 2025.
GRAVLEE, C. C. Systemic racism, chronic health inequities, and COVID-19: a syndemic in the making?. American Journal of Human Biology, v. 32, p. 1-8, 2020. https://doi.org/10.1002/ajhb.23482
GUIMARÃES, R. B. Saúde coletiva e o fazer geográfico. Caderno Prudentino de Geografia, Presidente Prudente, n. 41, v. 1, p. 119-132, jan-jun. 2019.
GUIMARÃES, R. B.; PICKENHAYN, J. A.; LIMA, S. do C. Geografia e saúde sem fronteiras. Uberlândia: Assis, 2014.
HORTON, R. Offline: COVID-19 is not a pandemic. The Lancet, v. 396, n. 10255, p.874, set. 2020. https://doi.org/10.1016/S0140-6736(20)32000-6
ILLANGASEKARE, S. et al. The syndemic effects of intimate partner violence, HIV/AIDS, and substance abuse on depression among Low-Income urban women. Journal of Urban Health: Bulletin of the New York Academy of Medicine, v. 90, n. 5, p. 934-947, 2013. https://doi.org/10.1007/s11524-013-9797-8
JÚNIOR, J. P. B.; SANTOS, Djanilson B. COVID-19 como sindemia: modelo teórico e fundamentos para a abordagem abrangente em saúde. Cad. Saúde Pública, v. 37, n. 10, p. 1-14, 2021. https://doi.org/10.1590/0102-311x00119021
KRIEGER, N. Theories for social epidemiology in the 21st century: an ecosocial perspective. International Epidemiological Association, v. 30, p.668-677, 2001. https://doi.org/10.1093/ije/30.4.668
KWAN, C. K.; ERNST, J. D. HIV and Tuberculosis: a deadly human syndemic. Clinical Microbiology Reviews, v. 24, n. 2, p. 351-376, abr. 2011. https://doi.org/10.1128/CMR.00042-10
LEAL, L. M.; CASTRO E CASTRO M. M. de. Determinação social da saúde e Covid-19: fundamentos para o trabalho em saúde na crise sanitária. Emancipação, v. 21, p. 1-14, 2021. https://doi.org/10.5212/Emancipacao.v.21.2118178.036
MACDONALD, N. E. The SAGE working group on vaccine hesitancy. Vaccine Hesitancy: definition, scope and determinants. Vaccine, v. 33, p. 4161-4164, 2015. https://doi.org/10.1016/j.vaccine.2015.04.036
MACKENZIE, M.; SKIVINGTON, K.; FERGIE, G. “The state they’re in”: unpicking fantasy paradigms of health improvement interventions as tools for addressing health inequalities. Social Science & Medicine, v. 256, p. 1-8, 2020. https://doi.org/10.1016/j.socscimed.2020.113047
MEARA, J. G. et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet, v. 386, p. 569-624, 2015. https://doi.org/10.1016/j.surg.2015.02.009
MENDENHALL, E. Beyond co-morbidity: a critical anthropological perspective of syndemic depression and diabetes in cross-cultural contexts. Med Anthropol Q., v. 30, n. 4, p. 462-478, dez. 2016. https://doi.org/10.1111/maq.12215
MENDENHALL, E. Syndemics: a new path for global health research. The Lancet, v. 389, p. 889-891. 2017a. https://doi.org/10.1016/S0140-6736(17)30602-5
MENDENHALL, E. The COVID-19 syndemic is not global: context matters. The Lancet, v. 396, p. 1731, nov. 2020. https://doi.org/10.1016/S0140-6736(20)32218-2
MENDENHALL, Emily et al. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet, v. 389, n. 10072, p. 951-963, mar. 2017b. https://doi.org/10.1016/S0140-6736(17)30402-6
MENDENHALL, E.; NEWFIELD, T.; TSAI, A. C. Syndemic theory, methods and data. Social Science and Medicine, v. 295, p. 1-5, 2022. https://doi.org/10.1016/j.socscimed.2021.114656
MENDENHALL, E.; SINGER, M. The global syndemic of obesity, undernutrition, and climate change. The Lancet, v. 393, p. 741, fev. 2019. https://doi.org/10.1016/S0140-6736(19)30310-1
MEYER, J. P.; SPRINGER, Sandra A.; ALTICE, Frederick L. Substance abuse, violence, and HIV in women: a literature review of the syndemic. Journal of Women’s Health, v. 20, n. 7, p. 991-1006, 2011. https://doi.org/10.1089/jwh.2010.2328
MUTANSKI, B. et al. Psychosocial health problems increase risk for HIV among urban young men who have sex with men: preliminary evidence of a syndemic in need of attention. Ann Behav Med., v. 34, n. 1, p. 37-45, 2007. https://doi.org/10.1007/BF02879919
OLIVEIRA, R. G. Práticas de saúde em contextos de vulnerabilização e negligência de doenças, sujeitos e territórios: potencialidades e contradições na atenção à saúde de pessoas em situação de rua. Saúde Soc., São Paulo, v. 27, n. 1p. 37-50, 2018. https://doi.org/10.1590/s0104-12902018170915
PARSONS, J. T.; GROV, Christian; GOLUB, Sarit A. Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic. American Journal of Public Health, v. 102, n. 1, p. 156-162, jan. 2012. https://doi.org/10.2105/AJPH.2011.300284
PATEL, V. et al. The Lancet Commission on global mental health and sustainable development. The Lancet, v. 392, p. 1553-1598, 2018. https://doi.org/10.1016/S0140-6736(18)31612-X
PERES, M. A. et al. Oral diseases: a global public health challenge. The Lancet, v. 394, p. 249-260, 2019. https://doi.org/10.1016/S0140-6736(19)31146-8
POTEAT, T. et al. Global epidemiology of HIV infection and related syndemics affecting transgender people. J Acquir Immune Defic Syndr, v. 72, p.210-219, ago. 2016. https://doi.org/10.1097/QAI.0000000000001087
RAINE, S. et al. Racial and ethnic disparities in COVID-19 outcomes: social determination of health. Int. J. Environ. Res. Public Health, v. 17, p. 1-16, 2020. https://doi.org/10.3390/ijerph17218115
RAMÍREZ, I. J.; LEE, J. COVID-19 emergence and social and health determinants in colorado: a rapid spatial analysis. Int. J. Environ. Res. Public Health, v. 17, p. 1-15, 2020. https://doi.org/10.3390/ijerph17113856
SAFREN, S. et al. Mental health and HIV risk in men who have sex with men. J Acquir Immune Defic Syndr, v. 55, p. 74-77, dez. 2010. https://doi.org/10.1097/QAI.0b013e3181fbc939
SANTOS, M. A natureza do espaço: técnica e tempo, razão e emoção. 4. ed. 9. reimpr. São Paulo: Editora da Universidade de São Paulo, 2017.
SANTOS, M. Metamorfoses do espaço habitado: fundamentos teóricos e metodológicos da geografia. 6 ed. 3 reimp. São Paulo: Editora da Universidade de São Paulo, 2021.
SANTOS, M. Saúde e ambiente no processo de desenvolvimento. Ciência e Saúde Coletiva, v. 8, n. 1, p. 309-314, 2003. https://doi.org/10.1590/S1413-81232003000100024
SCHIMIDT-SANE, M. et al. Local covid-19 syndemics and the need for a integrated response. IDS Bulletin, v. 52, n. 1, 2021. https://doi.org/10.19088/1968-2021.103
SHIAU, S. et al. The burden of COVID-19 in people living with HIV: a syndemic perspective. AIDS and Behaviour, v. 24, p. 2244-2249, 2020. https://doi.org/10.1007/s10461-020-02871-9
SHRESTHA, S. et al. Spatial epidemiology: an empirical framework for syndemics research. Soc Sci Med, v. 295, p. 1-22, 2022. https://doi.org/10.1016/j.socscimed.2020.113352
SINGER, M. A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic. Free Inquiry, v. 24, n. 2, p. 99-110, 1996.
SINGER, M. C. et al. Syndemics, sex and the city: understanding sexually transmitted diseases in social and cultural context. Social Science and Medicine, v. 63, p. 2010-2021, 2006. https://doi.org/10.1016/j.socscimed.2006.05.012
SINGER, M.; CLAIR, S. Syndemics and public health: reconceptualizing disease in bio-social context. Medical Anthropology Quarterly, v. 17, n. 4, p. 423-441. 2003. https://doi.org/10.1525/maq.2003.17.4.423
SINGER, M. et al. Syndemics and the biosocial conception of health. The Lancet, v. 389, p. 941-950, mar. 2017. https://doi.org/10.1016/S0140-6736(17)30003-X
SOLAR, O.; IRWIN, A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva: World Health Organization, 2010. Disponível em: https://www.afro.who.int/sites/default/files/2017-06/SDH_conceptual_framework_for_action.pdf. Acesso em: 17 de nov. 2024.
SOUZA, D. de O. A pandemia de COVID-19 para além das Ciências da Saúde: reflexões sobre sua determinação social. Ciência & Saúde Coletiva, v. 25, p. 2469-2477, 2020. https://doi.org/10.1590/1413-81232020256.1.11532020
SOUZA, .C D.; MACHADO, M. F.; CARMO, R. F. Human development, social vulnerability and COVID-19 in Brazil: a study of the social determinants of health. Infectious Diseases of Poverty, v. 9, n. 124, p. 1-10, 2020. https://doi.org/10.1186/s40249-020-00743-x
SPIEGEL, J. M.; BREILH, Jaime; YASSI, Annalee. Why language matters: insights and challenges in applying a social determination of health approach in a North-South collaborative research program. Globalization and Health, v. 11, n. 9, p. 1-17, 2015. https://doi.org/10.1186/s12992-015-0091-2
STALL, R. et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. American Journal of Public Health, v. 93, n. 6, p. 939-942, jun. 2003. https://doi.org/10.2105/AJPH.93.6.939
STALL, R. et al. Commentary on “Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept” by A. Tsai and B. Burns. Social Science and Medicine, v. 145, p. 129-131, 2015.http://doi.org/10.1016/j.socscimed.2015.07.016
SWINBURN, B. et al. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. The Lancet, v. 393, p. 791-846, fev. 2019. https://doi.org/10.1016/S0140-6736(19)30310-1
TAMIN, J. et al. Vulnerable workers and COVID-19: insights from a survey of members of the international commission for occupational health. Int. J. Environ. Res. Public Health, v. 18, n. 346, p. 1-15, 2021. https://doi.org/10.3390/ijerph18010346
THE PGADMIN DEVELOPMENT TEAM. pgAdmin 4. [S.l.]: PostgreSQL Global Development Group, 2024. Disponível em: <https://www.pgadmin.org/>. Acesso em: 19 maio 2025.
TOMORI, C. et al. Is there synergy in syndemics? Psychosocial conditions and sexual risk among men who have sex with men in India. Soc Sci Med., v. 206, p. 110-116, 2018. https://doi.org/10.1016/j.socscimed.2018.03.032
TSAI, A. C. Syndemics: a theory in search of data or data in search of a theory?. Social science and Medicine, v. 206, p. 117-122, 2018. https://doi.org/10.1016/j.socscimed.2018.03.040
TSAI, A. C.; BURNS, B. F. O. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med., v. 139, p. 26-35, 2015. https://doi.org/10.1016/j.socscimed.2015.06.024
TSAI, A.C. et al. Co-occurring epidemics, syndemics, and population health. The Lancet, v. 389, p. 978-982, mar. 2017. https://doi.org/10.1016/S0140-6736(17)30403-8
TSAI, A. C.; VENKATARAMANI, A. S. Syndemics and health disparities: a methodological note. AIDS Behav. v. 20, n. 2, p. 423-430, 2016. https://doi.org/10.1007/s10461-015-1260-2
VAN ECK, N. J.; WALTMMAN, L. VOSviewer. Version 1.6.20, Leiden: Centre for Science and Technology Studies, 2020. Disponível em: https://www.vosviewer.com/. Acesso em: 19 maio 2025.
VIRANI, S.S. et al. Hearth disease and stroke statistics - 2020 update: a report from the american heart association. Circulation, v. 141, n. 9, p. 139-596, 2020. https://doi.org/10.1161/CIR.0000000000000757
WHITEHEAD, M.; DAHLGREN, G. What can be done about inequalities in health?. The Lancet, v. 338, p. 1059-1063, 1991. https://doi.org/10.1016/0140-6736(91)91911-D
WHO. World Health Organization. Basic documents: forty-ninth edition. 2020. Disponível em: https://apps.who.int/gb/bd/pdf_files/BD_49th-en.pdf. Acesso em: 23 jun. 2025.
WHO. World Health Organization. Determinants of health. 2024. Disponível em: https://www.who.int/news-room/questions-and-answers/item/determinants-of-health. Acesso em: 11 jun. 2025.
WILLEN, S. S. et al. Syndemic vulnerability and the right to health. The Lancet, v. 389, p. 964-977, mar. 2017. https://doi.org/10.1016/S0140-6736(17)30261-1
