Inequalities in healthy life expectancy by Brazilian geographic regions: findings from the National Health Survey, 2013

Political struggles for a universal health system in Brazil: successes and limits in the reduction of inequalities

Background

Brazil is a populous high/middle-income country, characterized by deep economic and social inequalities. Like most other Latin American nations, Brazil constructed a health system that included, on the one hand, public health programs and, on the other, social insurance healthcare for those working in the formal sector. This study analyzes the political struggles surrounding the implementation of a universal health system from the mid-1980s to the present, and their effects on selected health indicators, focusing on the relevant international and national contexts, political agendas, government orientations and actors.

Main text

In the 1980s, against the backdrop of economic crisis and democratization, Brazil’s health reform movement proposed a Unified Health System (SUS), which was incorporated into the 1988 Constitution. The combination of a democratic system with opportunities for interaction between various developmental and social agendas and actors has played a key role in shaping health policy since then. However, the expansion of public services has been hampered by insufficient public funding and by the strengthening of the private sector, subsidized by the state. Private enterprises have expanded their markets and political influence, in a process that has accelerated in recent years. Despite these obstacles, SUS has produced significant health-status improvements and some (although incomplete) reductions in Brazil’s vast health inequalities.

Conclusions

We find that a combination of long-term structural and contingent factors, international agendas and interests, as well as domestic political struggles, explains the advances and obstacles to building a universal system in an economically important yet unequal peripheral country. Further consolidation of SUS and reduction of health inequalities hinge on the uncertain prospects for democracy and national development, on enlarging the political coalition to support a public and universal health system, and on strengthening the state’s ability to regulate the private sector.

Prevalence and co-occurrence of modifiable risk factors in adults and older people

OBJECTIVE

To estimate the co-occurrence of the major risk factors for chronic diseases in adults (18-59 years old) and older people (≥ 60 years old) living in Brazilian state capitals and the Federal District.

METHODS

Cross-sectional study with population-based data from 35,448 adults and 18,726 older people collected in the Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (System of Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey - Vigitel) in 2015. The prevalence of each of the five risk factors (smoking, overweight, physical inactivity, alcohol and unhealthy diet) was estimated, as well as their co-occurrence for the different possible combinations, according to socioeconomic and health self-assessment variables. The independent associations were verified via multinomial logistic regression to obtain the estimates of the odds ratio (OR) and corresponding 95% confidence intervals.

RESULTS

At least two risk factors were present in 38.5% of the adults and 37.0% of the older participants. The male adults and older participants who did not have private health insurance and classified their health as average or poor/very poor were more likely to have two or more concurrent risk behaviors. The greater chance of co-occurrence of smoking and alcohol abuse in adults (adjusted OR = 3.52) and older people (adjusted OR = 2.94) stands out.

CONCLUSIONS

The subgroups with increased risk of developing multiple unhealthy behaviors and the most prevalent behaviors were identified. These findings are expected to contribute to the better targeting of health promotion and preventive care. It is worth noting that, for the adoption of healthy lifestyle habits, macro-social and inter-sectoral policies are more effective.

Inequity in utilizing health services in the Brazilian Amazon: A population-based survey, 2015

BACKGROUND

Although Brazil has a public and universal healthcare system, utilization of health services is marked by social and regional discrepancies.

OBJECTIVE

To assess the prevalence and factors associated with underutilization of healthcare services in the Brazilian Amazon.

METHOD

Cross-sectional, population-based study. Adults aged over 18 years old were selected through probabilistic sampling. Underutilization of healthcare services was defined as never seeing a physician or a dentist. Poisson regression with robust variance was performed to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). A complex sample design was considered.

RESULTS

A total of 4001 individuals were included, of which 419 (10.4%; 95% CI, 9.5-11.4%) never visited a physician or a dentist. In the adjusted analysis, underutilization was higher among poorer people (PR = 3.32; 95% CI, 2.16-5.11), men (PR = 1.34; 95% CI, 1.10-1.65), people with brown skin color (Brazilian mixed race; PR = 1.34; 95% CI, 1.02-1.76), and people who are separated (PR = 1.40; 95% CI, 1.01-1.94) and widowed (PR = 1.55; 95% CI, 1.02-2.37), when compared with the reference categories. Individuals with informal jobs, those who are retired, students/housewives, and unemployed people were more vulnerable to underutilization than formal workers (P < .04).

CONCLUSION

Underutilization of healthcare services occurs in one-tenth of adults in Manaus Metropolitan Region and is associated with social and economic inequities.

Inequalities in Life Expectancy With Frailty Among Brazilian Older Adults: A Multistate Approach

Background and Objectives

Frailty is considered one of the major conditions faced by aging societies. Little has been reported about the effect of becoming frail on life expectancy among older adults in developing countries. The aim was to estimate total life expectancy and life expectancy with or without frailty by age, sex, and education among older adults in Brazil.

Data and Methods:  The study was developed based on information provided by the Health, Well-being, and Aging (SABE) Study. The sample included 1,399 older adults (≥60 years old) followed up from 2006 to 2010. Frailty status was classified according to the Fried criteria. Additional variables include age (in years), gender, and years of education. Estimates of total life expectancy, frailty-free life expectancy, and frailty life expectancy were obtained using the multistate life table method.

Results

At the baseline, the proportion of individuals with frailty was 13.7% and participants had, on average, 4.0 years of education. Men had more years of education than women (4.6 vs. 3.7, p < .001). Older adults with higher education live fewer years with frailty. Compared with older adults with no education, those with 6 years of education have higher frailty-free life expectancy. At age 70, men with no education expect to live 9.1 years (95% confidence interval [CI] = 7.8, 10.4) without frailty compared with 10.6 years (95% CI = 9.4, 11.8) among those with 6 years of education. Among women age 70, frailty-free life expectancy reaches 11.7 years (95% CI = 10.6, 12.8) among those with no education, but 13.9 years (95% CI = 12.5, 15.3) among those with 6 years.

Implications

Given the recent changes in educational achievement in Brazil, we believe that educational policies are powerful ways in addressing inequalities in healthy life expectancy. Public health policies aimed at avoiding the development of frailty among elderly at risk should be encouraged.

Stomatological disorders in older people: An epidemiological study in the Brazil southern

BACKGROUND

The aim of this retrospective, cross-sectional and observational study was to perform a survey of the stomatological conditions of elderly patients seen in a period of 40 years at a Stomatology Service in Southern Brazil.

MATERIAL AND METHODS

A total of 24,347 medical records were reviewed, of which 5,063 belonged to elderly patients aged 60 to 97 years. The stomatological conditions, systemic conditions, and smoking and alcohol drinking habits as well were recorded.

RESULTS

The mean age of the patients was 69.29 years, 67.1% were female and 32.9% were male. Variations of normality accounted for 44.5% of the cases. The most prevalent disorders were fungal infections (26.1%), reactive inflammatory lesions (24.6%), burning mouth syndrome (14.9%), benign neoplasms (12.4%), autoimmune disorders (12.3%), premalignant lesions (10.2%) and malignant epithelial neoplasms (7.2%). Regarding biopsied lesions, squamous cell carcinoma was the most prevalent at 30.2%, followed by hyperplasic lesions (28.2%).

CONCLUSIONS

Knowledge of these physiological and pathological conditions in the oral cavity of the older people is essential for early diagnosis and preventive and therapeutic measures when necessary.

Use of health services by adults in Manaus, 2019: Protocol of a population-based survey

INTRODUCTION

Health services utilization is an indirect measure of the rights and equity of a health system. A 2015 survey conducted in the Manaus metropolitan region showed that in the previous year, over 70% of adults visited the doctor and 1 in 3 had visited a dentist. Socioeconomic factors and inequality played a central role in the usage of healthcare services and health situation in this population. Since then, political and economic crisis are evolving in Brazil. This project aims to estimate the prevalence of use of health services and the health status of the adults residing in Manaus in 2019.

METHODS AND ANALYSIS

This is a population-based survey of adults (≥18 years old) residing in Manaus. This survey will be conducted in the first half of 2019 with 2300 participants who will be interviewed at home, selected from a probabilistic sampling in 3 stages (census tracts, household, and dweller), and stratified by sex and age quotas based on official estimates. The participants will be interviewed using previously validated tools and questions employed in Brazilian official surveys, which will cover use of health services and supplies, health status, and lifestyle. Primary outcome will be any healthcare usage in the last 15 days. Associations between health services usage and socioeconomic data and health outcomes will be assessed using a Poisson regression with a complex sampling design correction. Results will be reported according to the strengthening the reporting of observational studies in epidemiology statement.

ETHICS AND DISSEMINATION

This project was approved by the Ethics Committee of the Federal University of Amazonas, Manaus, Amazonas, Brazil. All participants will sign an informed consent before the interview. The results will be disseminated in peer-reviewed manuscripts, reports, conference presentations, and through the media.

Late Onset of Antiretroviral Therapy in Adults Living with HIV in an Urban Area in Brazil: Prevalence and Risk Factors

Introduction

Highly active antiretroviral therapy has been available since 1996. Early initiation of antiretroviral therapy (ART) leads to improved therapeutic response and reduced HIV transmission. However, a significant number of people living with HIV (PLHIV) still start treatment late.

Objective

This study aimed to analyze characteristics and factors associated with late initiation of ART among HIV-infected treatment-naïve patients.

Methods

This cross-sectional study included PLHIV older than 17 years who initiated ART at two public health facilities from 2009 to 2012, in a city located in Midwestern Brazil. Pregnant women were excluded. Data were collected from medical records, antiviral dispensing forms, and the Logistics Control of Medications System (SICLOM) of the Brazilian Ministry of Health. Late initiation of ART was defined as CD4+ cell count < 200 cells/mm³ or presence of AIDS-defining illness. Uni- and multivariate analysis were performed to evaluate associated factors for late ARV using SPSS®, version 21. The significance level was set at p<0.05.

Results

1,141 individuals were included, with a median age of 41 years, and 69.1% were male. The prevalence of late initiation of ART was 55.8% (95%CI: 52.9-58.7). The more common opportunistic infections at ART initiation were pneumocystosis, cerebral toxoplasmosis, tuberculosis, and histoplasmosis. Overall, 38.8% of patients had HIV viral load equal to or greater than 100,000 copies/mL. Late onset of ART was associated with higher mortality. After logistic regression, factors shown to be associated with late initiation of ARV were low education level, sexual orientation, high baseline viral load, place of residence outside metropolitan area, and concomitant infection with hepatitis B virus.

Conclusion

These results revealed the need to increase early treatment of HIV infection, focusing especially on groups of people who are more socially vulnerable or have lower self-perceived risk.

Participation frequency in physical education classes and physical activity and sitting time in Brazilian adolescents

Introduction

To examine the association between participation frequency per week in physical education (PE) classes and physical activity (PA) and sitting time levels in adolescents according to the economic development level of the region of residence.

Methods

A cross-sectional study with a sample representative of Brazil was carried out with 12,220 students aged 11–19 years. Participation frequency per week in PE classes, moderate-to-vigorous PA (MVPA), PA during PE classes, active commuting, PA outside of school hours, total accumulated PA, time sitting in front of the TV and total sitting time were assessed by using a self-administered questionnaire.

Results

Adolescents who reported having PE classes were more likely to meet MVPA recommendations (1–2 PE class/week–OR: 1.3, 95%CI: 1.1–1.5; ≥3 PE class/week–OR: 2.0, 95%CI: 1.7–2.5), spent more time in PA outside of school hours (1–2 PE class/week–OR: 1.6, 95%CI: 1.4–1.9; ≥3 PE class/week–OR: 2.0, 95%CI: 1.5–2.6), and accumulated more PA (1–2 PE class/week–OR: 1.9, 95%CI: 1.6–2.2; ≥3 PE class/week–OR: 6.0, 95%CI: 4.0–8.9) than students who reported not taking PE classes. Boys from regions with higher Human Development Index (HDI) who took ≥3 PE classes/week were more likely to have higher levels of active commuting (OR: 1.4, 95%CI: 1.1–1.9) and less likely of getting in front of TV (OR: 0.7, 95%CI: 0.5–0.9). Adolescents from regions with higher HDI were more likely to have more time spent in PA during PE classes (Male–OR: 2.7, 95%CI: 2.4–3.1; Female–OR = 3.2, 95%CI: 2.8–3.7).

Conclusions

Having PE classes is associated with a higher level of PA in both sexes and in both regions and lower level of sitting time in boys from regions with higher HDI.

Epidemiological profile of Brazilian oncological patients seen by a reference oncology center of the public health system and who migrate in search of adequate health care

INTRODUCTION

Structural disparities between different Brazilian regions in public health system cause patients to migrate in search of better conditions to treat their diseases. Besides patient's discomfort, there is a concentration of care in large centres, causing overload to current capacity.

OBJECTIVE

To evaluate migratory flow and associated factors in a reference service in oncology.

METHODS

Cross-sectional study conducted at a referral oncology service in Great ABC region of São Paulo. Patients were interviewed, and clinical and demographic data collected.

RESULTS

Between March-July 2016, 217 patients were included. Analysis showed a divergence between the postal code registered in the medical record and that recorded during the interview in approximately 10% of cases. Of these, 42.9% were residents of other states. Search for treatment motivated most patients to seek service outside their city.

CONCLUSION

Results reflect the informal search for medical care outside the home area. Besides the direct impact on patients' quality of life, migratory flow has an economic-social impact because these patients place a burden and impose costs on services of cities where they do not perform their responsibilities as citizens. Confirmation of the existence of a significant migratory flow demonstrates the need to discuss restructuring public health policies.

Epidemiology of HIV, syphilis, and hepatitis B and C among manual cane cutters in low-income regions of Brazil

Background

In recent decades the epidemic of asymptomatic sexually transmitted infections has extended deep into Brazil, including small towns and rural areas. The purpose of this study was to investigate the epidemiology of HIV, syphilis, and hepatitis B (HBV) and hepatitis C viruses (HCV), and to evaluate immunization coverage against hepatitis B in a group of rural workers in Brazil.

Methods

In 2016, a cross-sectional study was conducted with 937 manual sugarcane cutters of the Midwest and Northeast Regions of Brazil. All individuals were interviewed and screened for HIV, syphilis, HBV and HCV. Correlating factors with lifetime HBV infection were investigated using logistic regression. Positive Predictive Values, Negative Predictive Values, sensitivity and specificity were also calculated relative to vaccination against Hepatitis B, comparing anti-HBs titers to vaccination reports.

Results

Most reported previous hospitalization (55%), occupational injuries (54%), sharing of personal items (45.8%), alcohol consumption (77.2%), multiple sexual partners in previous 12 months (39.8%), and no condom use during sexual intercourse in last 12 months (46.5%). Only 0.2% reported using injection drugs. Anti-HIV-1 was detected in three individuals (0.3%). Serological markers of lifetime syphilis (treponemal test) were detected in 2.5% (95% CI: 1.6–3.6) of participants, and active syphilis (treponemal test and VDRL) present in 1.2%. No samples were positive for anti-HCV. The prevalence of lifetime HBV infection (current or past infection) was 15.9%, and 0.7% (95% CI 0.4 to 1.5) were HBsAg-positive. Previous hospitalization (OR 1.53, CI 1.05–2.24, p < 0.01) and multiple sexual partners in the last 12 months (OR 1.80, CI 1.25–2.60, p < 0.01) were predictors for lifetime HBV infection. Although 46.7% (95% CI 43.4–49.9) of individuals reported having been vaccinated against hepatitis B, only 20.6% (95% CI 18.1–23.3) showed serological evidence of previous hepatitis B vaccination (positive for anti-HBs alone).

Conclusions

The high prevalence of syphilis and HBV compared to the general population and the high frequency of risk behaviors show the potential for sexual and parenteral dissemination of these agents in this rural population. In addition, the low frequency of hepatitis B vaccinated individuals suggests a need for improved vaccination services.

The implantation of the Surveillance System for Non-communicable Diseases in Brazil, 2003 to 2015: successes and challenges

OBJECTIVE

To describe the implantation of the Surveillance System for Noncommunicable Diseases (NCDs) in the Unified Health System (Sistema Único de Saúde) and the challenges in maintaining it.

METHODS

A literature review was carried out the information contained in federal government directives between 2003 and 2015 was consulted.

RESULTS

A comprehensive risk and protection factor surveillance system was implemented. It is capable of producing information and providing evidence to monitor changes in the health behavior of the population. Among the advances cited are the organization of epidemiological surveys, such as the Surveillance System for Risk Factors and Protection for NCD (Sistema de Vigilância de Fatores de Risco e Proteção para DCNT - Vigitel), the National School Health Survey (Pesquisa Nacional de Saúde do Escolar - PeNSE), and the National Health Survey (Pesquisa Nacional de Saude) from 2013, which enabled the most extensive health diagnosis of the Brazilian population. In 2011, the NCD National Plan 2011-2022 established targets for reducing risk factors and NCD mortality.

CONCLUSION

The information gathered from the NCD surveillance system can support the implementation of sectoral and intersectorial strategies, which will result in the implementation of the Brazilian Strategic Action Plan for the prevention and control of NCDs, as well as the monitoring and evaluation of their results periodically. Finally, it can be a very important tool to help Brazil achieve the goals proposed by the 2030 Agenda for Sustainable Development and the Global Plan to Tackling NCDs.

The interplay of contextual layers: A multilevel analysis of income distribution, neighborhood infrastructure, socioeconomic position and self-rated health in Brazil

Our hypothesis is that neighborhood infrastructure modifies the association between state-level income distribution and self-rated health. In our findings neighborhood infrastructure amplifies the association between income equality and self-rated health, yet with a differential impact on health according to sex, race and education level favoring individuals at higher socioeconomic positions. Most of the individual health variation attributed to context happens at neighborhood level, based on random effects analyses. Our findings contribute to a further understanding of health inequalities in Brazil. The demonstrated synergism between state, neighborhood and individual level determinants of health supports inter-sectoral policies and interventions in a clearly multileveled way.

Increasing educational inequalities in self-rated health in Brazil, 1998-2013

The objectives of this study are to analyze the associations between educational levels and poor self-rated health (SRH) among adults in Brazil and to assess trends in the prevalence of poor self-rated health across educational groups between 1998 and 2013. Individual-level data came from the 1998, 2003 and 2008 Brazilian National Household Survey and the 2013 National Health Survey. We estimate prevalence rates of poor SRH by education. Using multivariable regressions, we assess the associations between educational levels and poor self-rated health. We use these regressions to predict the estimated ratios between the prevalence rates of those in low vs. high education in order to assess if relative changes in poor SRH have narrowed over time. Finally, we tested for statistically significant time trends in adult chronic disease inequalities by education. Results indicate a clear educational gradient in poor SRH. Prevalence ratios show that Brazilian adults with no education have levels of poor SRH that are 7 to 9 times higher than those with some college or more. The difference between those with lowest and highest education increased from 1998 to 2013. Compared to those with no education, there were increases in the prevalence of poor SRH among those with primary and secondary incomplete as well as among those with secondary complete in 2008 and 2013. In conclusion, there is a positive association between poor SRH and low education. Brazil has many social and geographic inequalities in health. Even though educational levels are increasing, there is no improvement in the general subjective health of Brazilians. Health inequalities by race and region highlight the need to improve the health of socially disadvantaged groups in Brazil. Addressing chronic conditions and mental health is needed to improve self-perceptions of health in Brazil as well.

Contribution of chronic conditions to functional limitations using a multinomial outcome: results for the older population in Belgium and Brazil

Background

The global phenomenon of population ageing is creating new challenges in both high and middle income countries, as functional limitations are expected to increase with age. The attribution method has been proposed to identify which conditions contribute most to disability using cross-sectional data. Although the original method was based on binary outcomes, we recently proposed an extension to multinomial responses, since different disability levels are often investigated in surveys. This is the first application of the extended method to evaluate differences in the contribution of chronic conditions to functional limitations in the older population of Brazil and Belgium.

Methods

Representative data from individuals aged ≥65 years who participated in the 2008 or 2013 Health Interview Surveys in Belgium (N = 4521) or in the 2008 National Household Sample Survey in Brazil (N = 28,437) were analysed. Individuals were classified as without, moderate or severe functional limitations, based on three activities of daily living: eating, showering, and toileting. Six chronic conditions common to the surveys – diabetes, heart diseases, musculoskeletal conditions, depression, chronic respiratory diseases, and cancer – were included in the analysis. Separate multinomial additive hazards models by gender for each country were fitted.

Results

The prevalence of moderate functional limitations was larger in men in Brazil (8.4%) compared to Belgium (6.0%) and similar in women (approximately 12.0%). Conversely, the severe prevalence in men was similar in the two countries (around 8.0%) and higher in women from Belgium (16.6%) than from Brazil (9.1%). Musculoskeletal conditions were the main contributors to the prevalence of functional limitations in men and women in Belgium but only in men and women with moderate functional limitations in Brazil. Depression and heart diseases contributed most to the severe prevalence of functional limitations in men and women in Brazil, respectively.

Conclusions

Our findings provide a better understanding of differences in the prevalence of different levels of functional limitations in Brazil and Belgium. These differences can be related to differences in socioeconomic conditions, health care access and quality, disease diagnosis, stage of epidemiology transition, life expectancy, and the prevalence of lifestyle risk factors in the two countries.

Electronic supplementary material

The online version of this article (10.1186/s13690-017-0235-3) contains supplementary material, which is available to authorized users.