Inequities in Healthcare utilization: results of the Brazilian National Health Survey, 2013

Deciphering Trends in Cancer Mortality: A Comprehensive Analysis of Brazilian Data From 1979 to 2021 With Emphasis on Breast and Prostate Cancers

Background

This study examined cancer mortality trends in Brazil from 1979 to 2021, emphasizing breast and prostate cancers.

Methods

Utilizing data from the Brazilian Mortality Information System and the Brazilian Institute of Geography and Statistics, it analyzed cancer deaths nationally and regionally, highlighting gender-specific and regional disparities.

Results

The research finds that cancer death rates have been growing at an average of 12% per year, contrasting with the population growth rate of 2.2%. This trend is more pronounced in the southern and southeastern regions of Brazil. A comparison of cancer mortality rates between Brazil, the USA, and China reveals that while the Brazilian and Chinese rates exhibit slower growth, the US rate shows a continuous decline since the 1990s.

Conclusions

The study adopts a novel approach by focusing on growth rates and employing polynomial interpolation, revealing a deceleration in cancer death growth over the last 15 years across all malignant neoplasms. The study also contextualizes these findings within Brazil's cancer control policies, tracing the evolution of preventive measures and treatment advancements. It highlights the significant role of the National Cancer Institute and the Unified Health System in implementing effective strategies. The decreasing trend in cancer mortality rates in Brazil, despite population growth, illustrates the effectiveness of comprehensive cancer control and prevention measures, underlining their importance in public health policy.

Burden of liver disease in Brazil, 1996-2022: a retrospective descriptive study of the epidemiology and impact on public healthcare

Background

Liver disease is a major cause of mortality and morbidity worldwide and its epidemiology depends on the genetic background, exposure to risk factors, access to healthcare and other sociodemographic characteristics. Brazil is a large country with diverse multicultural and ethnic heritages and important socioeconomic inequalities. The burden of liver disease in Brazil, its regions and population is unknown.

Methods

We retrieved data from the Unified Health System regarding liver diseases and analyzed the mortality and morbidity from 1996 to 2022 by gender, race/ethnicity, age, region and overall. We calculated the age-specific risk of deaths by liver disease, age-standardization of the data, mean hospitalization and liver transplant-associated costs.

Findings

Malignant neoplasm of the liver and intrahepatic bile ducts, alcohol-associated liver disease, fibrosis, and cirrhosis of the liver, other diseases of the liver, hepatic failure, chronic viral hepatitis were identified as the major causes of death and morbidity in Brazil in the period analyzed. The epidemiology of these diseases was diverse, with variations according to geographic regions, gender and race/ethnicity. The major economic burden of liver disease is related to liver transplants, a common outcome of the progression of these diseases.

Interpretation

Liver disease in Brazil is a serious issue for the public health system due to the high number of deaths and increasing mortality rate. Our study contributes as a necessary prerequisite for the development of tailored public health policies aimed at mitigating the increasing burden of liver diseases in specific populations and regions.

Funding

CNPq, INCT, CAPES, FAPEMIG.

Healthcare utilization and its association with socioeconomic status in China: Evidence from the 2011-2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Healthcare utilization often favors the higher-socioeconomic status (SES) and having chronic diseases may exacerbate this inequality. This study aims to examine the trends in health service use over time, the effect of SES on healthcare utilization, and the role of chronic diseases in this association.

METHODS

Data used in this study were from the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, 2015, and 2018, which is the first nationally representative survey of the middle-aged and older. The sample included people aged 45 years and older who responded to all the waves. A total of 10,922 adults were included in this study. Healthcare utilization was categorized into outpatient and inpatient service use and SES was measured by per-capita household expenditure. A multilevel zero-inflated negative binomial regression model was performed to analyze outpatient and inpatient service use, separately.

RESULTS

The rates of outpatient service use in 2011, 2013, 2015, and 2018 were 19.11%, 21.45%, 20.12%, and 16.32%, respectively, while the rates of inpatient service use were 8.40%, 13.04%, 14.17%, and 18.79%, respectively. Compared to individuals in the lowest quintile of per-capita household expenditure, those in higher quintiles had higher odds of outpatient service use (Q2: odds ratio = 1.233, p < 0.0001; Q3: 1.416, p < 0.0001; Q4: 1.408, p < 0.0001; or Q5: 1.439, p < 0.0001) and higher rates of inpatient service use (Q2: incidence rate ratio = 1.273, p < 0.0001; Q3: 1.773, p < 0.0001; Q4: 2.071, p < 0.0001; or Q5: 1.992, p < 0.0001). Additionally, having morbidity generally increased healthcare utilization, but did not play a significant role in moderating the relationship between SES and healthcare utilization.

CONCLUSIONS

Healthcare utilization rates were overall low in China, but relatively high for people in higher quintiles of per-capita household expenditure or those with morbidity, compared to their counterparts. Policy actions are required to provide more health education to the public, to further optimize health insurance schemes targeting outpatient services, especially for the low-SES, and to establish new health delivery models for NCD management in the primary health care setting.

Health insurance status, lifestyle choices and the presence of non-communicable diseases: a systematic review

BACKGROUND

Although health insurance (HI) has effectively mitigated healthcare financial burdens, its contribution to healthy lifestyle choices and the presence of non-communicable diseases (NCDs) is not well established. We aimed to systematically review the existing evidence on the effect of HI on healthy lifestyle choices and NCDs.

METHODS

A systematic review was conducted across PubMed, Medline, Embase, Cochrane Library and CINAHLComplet@EBSCOhost from inception until 30 September 2022, capturing studies that reported the effect of HI on healthy lifestyle and NCDs. A narrative synthesis of the studies was done. The review concluded both longitudinal and cross-sectional studies. A critical appraisal checklist for survey-based studies and the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies were used for the quality assessment.

RESULT

Twenty-four studies met the inclusion criteria. HI was associated with the propensity to engage in physical activities (6/11 studies), consume healthy diets (4/7 studies), not to smoke (5/11 studies) or take alcohol (5/10 studies). Six (of nine) studies showed that HI coverage was associated with a lowered prevalence of NCDs.

CONCLUSION

This evidence suggests that HI is beneficial. More reports showed that it propitiated a healthy lifestyle and was associated with a reduced prevalence of NCDs.

Twenty-first-century demographic and social inequalities of heat-related deaths in Brazilian urban areas

Population exposure to heat waves (HWs) is increasing worldwide due to climate change, significantly affecting society, including public health. Despite its significant vulnerabilities and limited adaptation resources to rising temperatures, South America, particularly Brazil, lacks research on the health impacts of temperature extremes, especially on the role played by socioeconomic factors in the risk of heat-related illness. Here, we present a comprehensive analysis of the effects of HWs on mortality rates in the 14 most populous urban areas, comprising approximately 35% of the country's population. Excess mortality during HWs was estimated through the observed-to-expected ratio (O/E) for total deaths during the events identified. Moreover, the interplay of intersectionality and vulnerability to heat considering demographics and socioeconomic heterogeneities, using gender, age, race, and educational level as proxies, as well as the leading causes of heat-related excess death, were assessed. A significant increase in the frequency was observed from the 1970s (0-3 HWs year-1) to the 2010s (3-11 HWs year-1), with higher tendencies in the northern, northeastern, and central-western regions. Over the 2000-2018 period, 48,075 (40,448-55,279) excessive deaths were attributed to the growing number of HWs (>20 times the number of landslides-related deaths for the same period). Nevertheless, our event-based surveillance analysis did not detect the HW-mortality nexus, reinforcing that extreme heat events are a neglected disaster in Brazil. Among the leading causes of death, diseases of the circulatory and respiratory systems and neoplasms were the most frequent. Critical regional differences were observed, which can be linked to the sharp North-South inequalities in terms of socioeconomic and health indicators, such as life expectancy. Higher heat-related excess mortality was observed for low-educational level people, blacks and browns, older adults, and females. Such findings highlight that the strengthening of primary health care combined with reducing socioeconomic, racial, and gender inequalities represents a crucial step to reducing heat-related deaths.

Socioeconomic inequalities in health and healthcare utilization among the elderly in Brazil: results from the 2019 National Health Survey

OBJECTIVES

To assess socioeconomic-related inequalities in health and healthcare utilization among the elderly in Brazil.

STUDY DESIGN

Cross-sectional nationally representative household-based survey.

METHODS

We evaluated the Brazilian National Health Survey data collected in 2019. We computed the prevalence of measures of health conditions and healthcare utilization by age-bracket and markers of socioeconomic status-income, educational attainment, and race/ethnicity-among individuals aged 60 or older. We further employed logistic regression models, adjusted for a wide set of covariates, to estimate the relationship between socioeconomic status and those outcomes.

RESULTS

Higher-income and more educated individuals exhibit better health conditions compared to their lower-income and less-educated counterparts within each age bracket. Results from regression models showed strong associations with income and educational attainment for most health conditions: health status, physical activity, difficulties with activities of daily living and instrumental activities of daily living, and depression. For most conditions, weaker or no associations with race/ethnicity were found. Individuals in the highest income quintile and that completed higher education also had higher odds of having consulted a physician, while high-income individuals had lower odds of having received emergency care at home.

CONCLUSIONS

The findings of this study highlight the significant socioeconomic inequalities in the health of the elderly population in Brazil. The substantial and pervasive nature of these inequalities stresses the need for action to address them.

The Role of Socioeconomic and Health Services Organizational Factors on Infection Control Structure Score, Brazil

This study aimed to analyze possible associations between the Infection Control Structure Score (ICSS), health services, and social characteristics of the municipalities in Brazil. Secondary data from the third cycle 2017-2018 of the Brazilian National Program for Improving Primary Care Access and Quality (PMAQ) was analyzed. Six independent variables - FIRJAN Index of Municipal Development, number of inhabitants, number of family health teams receiving a financial incentive from the federal government, healthcare expenditure per capita, and number of Oral Health Teams modalities 1 and 2 - were included to assess their influence on ICSS, measured for each Brazilian town. Data analysis used the Classification and Regression Tree model performed with IBM SPSS 25. A total of 4,900 municipalities were included, and the mean ICSS was 0.905 (±0.092). A positive relationship was observed between healthcare expenditure per capita, municipal development, and the outcome. Conversely, towns with a higher number of family health teams receiving a financial incentive from the federal government showed lower mean ICSS. The findings suggest that inequalities in the infection control structures exist within the country, and they were related to the health services and social characteristics of the municipalities.

Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010-2016

INTRODUCTION

Mental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low-income and middle-income countries such as Brazil. This study investigates racial and socioeconomic inequalities in primary healthcare usage, hospitalisation and mortality for mental health disorders in Rio de Janeiro, Brazil.

METHODS

A cohort of 1.2 million low-income adults from Rio de Janeiro, Brazil with linked socioeconomic, demographic, healthcare use and mortality records was cross-sectionally analysed. Poisson regression models were used to investigate associations between self-defined race/colour and primary healthcare (PHC) usage, hospitalisation and mortality due to mental disorders, adjusting for socioeconomic factors. Interactions between race/colour and socioeconomic characteristics (sex, education level, income) explored if black and pardo (mixed race) individuals faced compounded risk of adverse mental health outcomes.

RESULTS

There were 272 532 PHC consultations, 10 970 hospitalisations and 259 deaths due to mental disorders between 2010 and 2016. After adjusting for a wide range of socioeconomic factors, the lowest PHC usage rates were observed in black (adjusted rate ratio (ARR): 0.64; 95% CI 0.60 to 0.68; compared with white) and pardo individuals (ARR: 0.87; 95% CI 0.83 to 0.92). Black individuals were more likely to die from mental disorders (ARR: 1.68; 95% CI 1.19 to 2.37; compared with white), as were those with lower educational attainment and household income. In interaction models, being black or pardo conferred additional disadvantage across mental health outcomes. The highest educated black (ARR: 0.56; 95% CI 0.47 to 0.66) and pardo (ARR: 0.75; 95% CI 0.66 to 0.87) individuals had lower rates of PHC usage for mental disorders compared with the least educated white individuals. Black individuals were 3.7 times (ARR: 3.67; 95% CI 1.29 to 10.42) more likely to die from mental disorders compared with white individuals with the same education level.

CONCLUSION

In low-income individuals in Rio de Janeiro, racial/colour inequalities in mental health outcomes were large and not fully explainable by socioeconomic status. Black and pardo Brazilians were consistently negatively affected, with lower PHC usage and worse mental health outcomes.

The Prevalence and Severity of Dental Caries Among Pregnant Women in the State of Rio de Janeiro, Brazil

AIM

To assess in a pilot study the prevalence and severity of dental caries among pregnant women compared to non-pregnant women in the state of Rio de Janeiro, Brazil.

MATERIALS AND METHODS

A cross-sectional, observational study was conducted. Data collection consisted of clinical examinations and general questionnaires concerning oral hygiene habits and recent dental visits of pregnant and non-pregnant women. Prevalence and severity of caries was determined by the CAST index and the CAST severity score. Permission for this study was granted by the National Research Ethics Commission of Brazil. Written informed consent was obtained from all participants.

RESULTS

In total, 67 pregnant women were included (mean age (SD) 25.5 ± 5.4 years) and 79 non-pregnant women (26.0 ± 5.3 years). Mean number of teeth with untreated caries (CAST 4-7) among pregnant women was significantly lower (1.2 ± 1.8) compared to non-pregnant women (2.7 ± 4.0; Mann-Whitney test, p = 0.027). In both groups, 40-60% were in need of curative treatment. There was no significant difference between the two groups in frequency of dental visits (p > 0.05), but pregnant women brushed their teeth more often (Mann-Whitney test, p < 0.001).

CONCLUSION

Pregnant women in the state of Rio de Janeiro have fewer untreated caries and less severe dental caries compared to non-pregnant women. Still, half of all women in this study are in need of curative treatment for at least one tooth. Effective preventive programs should therefore be developed to stimulate preventive oral care among all women.

A Closer Look Into Brazil's Healthcare System: What Can We Learn?

Brazil's healthcare system has made significant progress in recent years but still faces major challenges. In this editorial, we examine the greatest flaws and achievements of Brazil's healthcare system, focusing on population coverage, quality metrics, spending over the last ten years, and estimates of per capita spending over the next decade. We discuss the role of the government, private sector, and civil society in shaping Brazil's healthcare landscape and provide recommendations for improvement. Despite the challenges, Brazil has made impressive strides in healthcare, such as the implementation of the family health program, which has improved primary care access and reduced infant mortality rates. However, much work remains to be done, and Brazil must prioritize investment in healthcare infrastructure, workforce development, and the integration of digital technologies to ensure universal access to quality care for all.

[The use of dental services in the past year in the brazilian population: a systematic review with meta-analysis]

The scope of this study was to analyze the factors associated with the use of dental services in Brazil. The review strategy included PubMed, SciELO, LILACS, BBO, EMBASE, Scopus, WOS and Google Scholar databases, in addition to repositories and databases of dissertations and theses. Studies were selected using the PEO (Population/Exposure/Outcomes) strategy. The outcome of this study was the use of dental services in the last year by the Brazilian population, treated as dichotomous variables for the following analyses: ≤ 1 year and > 1 year. Mantel-Haenszel random effect meta-analysis was performed, estimating Prevalence Ratios (PR) and 95% confidence intervals (95%CI). A total of 94 studies were selected. The majority (98%) had a cross-sectional design, with 63% derived from primary data. For the meta-analysis, 25 studies were included. The use of oral health services in the last year was associated with higher education (≥ 8 years of schooling) (PR = 0.49, (95%CI: 0.39-0.60)); higher family income (≥ 2 minimum wages) (RP = 0.79, (95%CI: 0.74-0.84)); and living in urban areas (RP = 0.79, (95%CI: 0.64-0.97)). The availability of dental services in the Unified Health System needs to be made readily accessible to people with lower income, less education and those living in rural areas.

Prevalence of complementary and alternative medicine use in Brazil: results of the National Health Survey, 2019

Background

In recent decades, it has been possible to observe an increase in Complementary and Alternative Medicine (CAM) usage globally for both disease prevention and health promotion purposes. we aim to estimate the prevalence of CAM use and analyze associated factors in Brazil.

Methods

Observational study with data from the 2019 National Health Survey that evaluated a sample of Brazilian adults. The outcome was CAM use, such as acupuncture, homeopathy, medicinal plants and herbal medicines, meditation, and yoga in the last 12 months. A logistic regression model with a 99% confidence interval was used to assess factors associated with CAM use.

Results

The prevalence of CAM use in 2019 was 5.2% (CI99% = 4.8–5.6%), the most used modalities: medicinal plants and herbal medicines, with a prevalence of 3.0% (CI99% = 2.7–3.33) followed by: acupuncture 1.4% (CI99% = 1.3–1.6) homeopathy 0.9% (CI99% = 0.7–1.0), meditation 0.7% (CI99% = 0.6–0.8) and yoga 0.4% (CI99% = 0.4–0.5). We observed important geographical differences in CAM use in Brazil, with a higher prevalence in the North Region, 3.7% (CI99% = 2.81–4.75), where herbal medicines were more frequent the in the other regions. After estimating an adjusted model, women, older people, and people with a higher level of education and per capita income were the ones who used all types of CAM the most. The practice of yoga stands out among women 3.6% (CI99% = 2.49–5.28) and among individuals with higher per capita income 7.5% (CI99% = 2.97–18.93); meditation among individuals with higher educational level 13.4% (CI99% = 6.41–28.33) and acupuncture for those who declared regular or poor health 1.9% (CI99% = 1.51–2.39).

Conclusions

We recommend that the Ministry of Health expand CAM access to Unified Health System users and promote health professionals’ conscious and guided use for the Brazilian population.

Expansion of primary healthcare and emergency hospital admissions among the urban poor in Rio de Janeiro Brazil: A cohort analysis

Background

Robust evidence on the relationship between primary care and emergency admissions is lacking in low- and middle-income countries. This study evaluates how the phased roll out of the family health strategy (FHS) to the urban poor in Rio de Janeiro Brazil affected emergency hospital admissions and readmissions from ambulatory-care sensitives conditions (ACSCs).

Methods

A cohort of 1.2 million adults in Rio de Janeiro city were followed for five years (Jan 2012 to Dec 2016). The association between FHS use and the likelihood of emergency hospital admissions and 30-day readmissions were evaluated using multi-level Poisson regression models with inverse probability treatment weighting and regression adjustment (IPTW-RA) for socioeconomic and household characteristics. Inequalities in associations were examined across groups of causes and by key socioeconomic groups.

Results

Records from 2,551,934 primary care consultations and 15,627 admissions were analysed. In IPTW-RA analyses, each additional FHS consultation was associated with a 3% lower rate of ACSC admission (RR: 0.97; 95%CI: 0.95, 0.98), a 63% lower rate of 30-day readmissions from any non-birth cause (RR: 0.37; 95%CI: 0.30, 0.46), and an 57% lower rate of 30-day readmissions from ACSCs (RR: 0.43; 95%CI: 0.33, 0.55). Individuals who were older, had the lowest educational attainment, were unemployed, and had higher incomes had larger reductions in ACSC admissions associated with FHS use.

Interpretation

Investment in primary care is important for reducing emergency hospital admissions and their associated costs in LMICs.

Funding

DFID/MRC/Wellcome Trust/ESRC.

da Paixão Melo M, Ferreira da Silva M, de Jesus Gonçalves dos Santos N, de Souza Pessoa N, Silva de Araujo R, de Macedo Godim T, Fraga de Oliveira Tosta S, Brandão Nardy V, Cristina Faria E, Frederico de Carvalho Dominguez Souza B, Laís Almeida dos Santos J, Wikramaratna P, Giovanetti M, Alcântara LCJ, Lourenço J, Leal e Silva de Mello A. Dynamics and Determinants of SARS-CoV-2 RT-PCR Testing on Symptomatic Individuals Attending Healthcare Centers during 2020 in Bahia, Brazil

RT-PCR testing data provides opportunities to explore regional and individual determinants of test positivity and surveillance infrastructure. Using Generalized Additive Models, we explored 222,515 tests of a random sample of individuals with COVID-19 compatible symptoms in the Brazilian state of Bahia during 2020. We found that age and male gender were the most significant determinants of test positivity. There was evidence of an unequal impact among socio-demographic strata, with higher positivity among those living in areas with low education levels during the first epidemic wave, followed by those living in areas with higher education levels in the second wave. Our estimated probability of testing positive after symptom onset corroborates previous reports that the probability decreases with time, more than halving by about two weeks and converging to zero by three weeks. Test positivity rates generally followed state-level reported cases, and while a single laboratory performed ~90% of tests covering ~99% of the state's area, test turn-around time generally remained below four days. This testing effort is a testimony to the Bahian surveillance capacity during public health emergencies, as previously witnessed during the recent Zika and Yellow Fever outbreaks.

Health services utilization in the Brazilian Amazon: panel of two cross-sectional studies

OBJECTIVE

To investigate the use of health services among adults living in Manaus, Amazonas.

METHODS

This was a panel of two cross-sectional studies conducted in Manaus in 2015 and 2019. Individuals aged ≥ 18 years were selected by probabilistic sampling and interviewed at home. The study outcomes were doctor visits and hospitalizations in the previous 12 months, and unmet surgical needs. Variations between 2015 and 2019 were tested using chi-squared goodness-of-fit test. Poisson regression with robust variance was employed to calculate the prevalence ratios (PR) of the outcomes with 95% confidence intervals (95%CI).

RESULTS

The surveys included 5,800 participants in total. Visits to the doctor decreased from 2015 (78.7%) to 2019 (76.3%; p < 0.001), hospital admissions increased from 2015 (7.9%) to 2019 (11.5%; p < 0.001), and unmet surgical needs decreased in the period (15.9% to 12.1%; p < 0.001). These variations were particularly observed in vulnerable individuals – sicker; poorer; non-whites; and those belonging to lower social classes, with less access to education, formal jobs, and health insurance (p < 0.05). Doctor visits were higher in people with fair health status (PR = 1.09; 95%CI 1.06–1.12), health insurance (PR = 1.13; 95%CI 1.09–1.17), and chronic diseases (p < 0.001) but lower in men (PR = 0.87; 95%CI 0.84–0.90) and informal workers (PR = 0.89; 95%CI 0.84–0.94). Hospitalizations were higher in people with worse health statuses (p < 0.001), without partners (PR = 1.27; 95%CI 1.05–1.53), and with multimorbidity (PR = 1.68; 95%CI 1.33–2.12) but lower in men (PR = 0.55; 95%CI 0.44–0.68), older adults (p < 0.001), informal workers (PR = 0.67; 95%CI 0.51–0.89), and unemployed (PR = 0.72; 95%CI 0.53–0.97). Unmet surgical needs were higher in older adults (p < 0.001), middle-class people (PR = 1.24; 95%CI 1.01–1.55), worse health statuses (p < 0.001), and chronic diseases (p < 0.001) but lower in men (PR = 0.76; 95%CI 0.65–0.86).

CONCLUSIONS

From 2015 to 2019, less people visited the doctor, more were admitted to hospitals, and less were in need of surgery or aware of that need, potentially indicating poorer access to health services.

"A lack of information keeps us from medicine, well-being, harmony…": a mixed method study with plaintiffs requesting medicines in administrative cases

The need to request public health managers to ensure the right of access to medicines characterizes an administrative case and the method to do so is called the administrative route. This mixed method study aimed to analyze the perceptions of plaintiffs requesting medications by the administrative route about barriers to access medicines in the Brazilian public health sector. Data were gathered through focus groups and questionnaires. The results point to the interdependence of pharmaceutical services with the interfacing areas to ensure access. The barriers related to individuals reflect the commitment to develop citizenship, justifying the cost of the medicine to motivate the demand. Barriers to service provision include irregular availability of medicines, insufficient resources, and unsatisfactory quality of services. The difficulty in obtaining medical consultations and prescriptions originating in the public sector are barriers to the health sector. The barriers above the health sector are compliance with administrative procedures, corruption, and clientelism. The administrative route intensifies inequities in access to healthcare in Brazil.

Dual Use of Public and Private Health Care Services in Brazil

(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose–response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use.

Atenção ao câncer de mama a partir da suspeita na atenção primária à saúde nos municípios de São Paulo e Campinas, Brasil

Resumo Buscou-se identificar fatores que interferem na suspeita do câncer de mama (CM) pela atenção primária à saúde (APS) que impulsionam o encaminhamento para a atenção especializada (AE) nos municípios de São Paulo e Campinas. Foram entrevistadas 664 mulheres (353 paulistanas e 311 campineiras) diagnosticadas com CM, encaminhadas para AE pela APS. Utilizou-se a análise de regressão logística multinível para a identificação das associações entre a suspeita do CM pela APS, variáveis socioeconômicas e atenção ao câncer. Mostraram associação significativa: nível superior de escolaridade (RC = 0,59; IC 95% = 0,35-0,98); pagamento de consulta médica para atendimento relacionado ao câncer (RC = 0,59; IC 95% = 0,36-0,96), continuou atendimento na APS após início do tratamento na AE (RC = 0,62; IC 95% = 0,41-0,95); mama examinada na APS (ECM) antes do encaminhamento para a AE (RC = 1,61; IC 95% = 1,10-2,34) e primeira mamografia solicitada na APS (RC = 2,81; IC 95% = 1,95-4,00). A solicitação da mamografia e o ECM são ações que têm sido incorporadas na APS para a detecção precoce do CM nos municípios. Continuar o atendimento na APS e melhores condições socioeconômicas, como ter nível superior de escolaridade e capacidade de pagar por atendimento, reduzem a chance da suspeita.

Socioeconomic inequalities in the access to health services: a population-based study in Southern Brazil

Abstract This article aims to measure socioeconomic inequalities regarding access to health services, contact with health professionals, and specific health interventions. This was a cross-sectional population-based study with individuals aged 18 years or older, living in the city of Rio Grande. The outcomes were the following: Family Health Strategy (FHS) coverage; having a health insurance plan; receiving a visit of a community health worker; medical consultation; dental consultation; dietary counseling; having a class with a physical education professional; flu vaccination; mammography, cytopathological and prostate exams. Relative and absolute measures were used to assess inequalities in the distribution of the outcomes. There was a response rate of 91% (1,300 adults were interviewed). Coverage indicators ranged from 16.1%, for having a class with a physical education professional, to 80.0% for medical consultation. FHS coverage and visit of a community health agent presented higher proportions among the poorest while outcomes regarding contact with health professionals, screening exams and flu vaccine were more prevalent among richest group. We observed low coverage levels of access to health services and professionals in addition to marked socioeconomic inequalities.

Difficulty in taking medication and stroke among older adults with systemic arterial hypertension: the Fibra Study

This article aims to investigate whether difficulty in taking medication is associated with stroke among older adults with Systemic Arterial Hypertension (SAH) and to explore their association with living arrangements. Cross-sectional study was based on 3,502 older adults with SAH from the four universities pole of Frailty in Brazilian Older People (Fibra) Study, Brazil, including 14 municipalities of the five Brazilian regions. We used the medical diagnosis of stroke and difficulty in taking medications (self-reported difficulty and financial difficulty affording prescribed medications). Multivariate analysis was performed using logistic regression. Differently from women, older men with SAH, which report difficulty in taking medication (unintentional non-adherence), have higher odds of stroke. When stratified by living arrangements, those living with a partner have even higher odds of stroke compared to those without difficulty in taking medication and living alone. None association was found for difficulty affording prescribed medication for both men and women. Unintentional difficulty in taking medication plays a role in SAH treatment among men. Primary care strategies for controlling blood pressure should not be focus only on patients but targeting spouses as well.

Inequalities in the prevalence of major depressive disorder in Brazilian slum populations: a cross-sectional analysis

AIMS

The mental health of slum residents is under-researched globally, and depression is a significant source of worldwide morbidity. Brazil's large slum-dwelling population is often considered part of a general urban-poor demographic. This study aims to identify the prevalence and distribution of depression in Brazil and compare mental health inequalities between slum and non-slum populations.

METHODS

Data were obtained from Brazil's 2019 National Health Survey. Slum residence was defined based on the UN-Habitat definition for slums and estimated from survey responses. Doctor-diagnosed depression, Patient Health Questionnaire (PHQ-9)-screened depression and presence of undiagnosed depression (PHQ-9-screened depression in the absence of a doctor's diagnosis) were analysed as primary outcomes, alongside depressive symptom severity as a secondary outcome. Prevalence estimates for all outcomes were calculated. Multivariable logistic regression models were used to investigate the association of socioeconomic characteristics, including slum residence, with primary outcomes. Depressive symptom severity was analysed using generalised ordinal logistic regression.

RESULTS

Nationally, the prevalence of doctor diagnosed, PHQ-9 screened and undiagnosed depression were 9.9% (95% confidence interval (CI): 9.5-10.3), 10.8% (95% CI: 10.4-11.2) and 6.9% (95% CI: 6.6-7.2), respectively. Slum residents exhibited lower levels of doctor-diagnosed depression than non-slum urban residents (8.6%; 95% CI: 7.9-9.3 v. 10.7%; 95% CI: 10.2-11.2), while reporting similar levels of PHQ-9-screened depression (11.3%; 95% CI: 10.4-12.1 v. 11.3%; 95% CI: 10.8-11.8). In adjusted regression models, slum residence was associated with a lower likelihood of doctor diagnosed (adjusted odds ratio (adjusted OR): 0.87; 95% CI: 0.77-0.97) and PHQ-9-screened depression (adjusted OR: 0.87; 95% CI: 0.78-0.97). Slum residents showed a greater likelihood of reporting less severe depressive symptoms. There were significant ethnic/racial disparities in the likelihood of reporting doctor-diagnosed depression. Black individuals were less likely to report doctor-diagnosed depression (adjusted OR: 0.66; 95% CI: 0.57-0.75) than white individuals. A similar pattern was observed in Mixed Black (adjusted OR: 0.72; 95% CI: 0.66-0.79) and other (adjusted OR: 0.63; 95% CI: 0.45-0.88) ethnic/racial groups. Slum residents self-reporting a diagnosis of one or more chronic non-communicable diseases had greater odds of exhibiting all three primary depression outcomes.

CONCLUSIONS

Substantial inequalities characterise the distribution of depression in Brazil including in slum settings. People living in slums may have lower diagnosed rates of depression than non-slum urban residents. Understanding the mechanisms behind the discrepancy in depression diagnosis between slum and non-slum populations is important to inform health policy in Brazil, including in addressing potential gaps in access to mental healthcare.

The door is open, but not everyone may enter: racial inequities in healthcare access across three Brazilian surveys

Health policies in Brazil have sought to expand healthcare access and mitigate inequities, but recent revisions of their content have weakened the Brazilian Unified Health System. This study estimates three healthcare indicators across three national surveys conducted in 2008, 2013, and 2019 to assess the impact of changes to the National Primary Care Policy on racial inequities in healthcare. Considering the survey design and sampling weights, we estimated the prevalence of each outcome among both whites and Blacks for the whole country, and according to the Brazilian regions. We test the following hypotheses: compared to whites, Blacks showed higher frequency of coverage by the Family Health Strategy, lower frequency of health insurance coverage, and higher frequency of perceived difficulty accessing health services (H1); Racial inequities decreased in the ten-year period but remained constant between 2013-2019 (H2); Racial gaps have widened among regions with lower proportions of Blacks (H3). Our findings fully support H1, but not H2 and H3. Racial inequities either remained constant or decreased in the 2013-2019 period. By downplaying the importance of the universality and equity principles, the latest revision of the National Primary Care Policy has contributed to the persistence of racial inequities in healthcare.

Translation, Cultural Adaptation, and Reproducibility of the Physical Activity Readiness Questionnaire for Everyone (PAR-Q+): The Brazilian Portuguese Version

Background: The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) is the international standard for pre-participation risk stratification and screening. In order to provide a practical and valid screening tool to facilitate safe engagement in physical activity and fitness assessments for the Brazilian population, this study aimed to translate, culturally adapt, and verify the reproducibility of the evidence-based PAR-Q+ to the Brazilian Portuguese language.

Method: Initially, the document was translated by two independent translators, before Brazilian experts in health and physical activity evaluated the translations and produced a common initial version. Next, two English native speakers, fluent in Brazilian Portuguese and accustomed to the local culture, back-translated the questionnaire. These back translations were assessed by the organization in charge of the PAR-Q+, then a final Brazilian version was approved. A total of 493 Brazilians between 5 and 93 yr (39.9 ± 25.4 yr), 59% female, with varying levels of health and physical activity, completed the questionnaire twice, in person or online, 1–2 weeks apart. Cronbach's alpha was used to calculate the internal consistency of all items of the questionnaire, and the Kappa statistic was used to assess the individual reproducibility of each item of the document. Additionally, the intraclass correlation coefficient and its 95% confidence interval (CI) were used to verify the general reproducibility (reliability) of the translated version.

Results: The Brazilian version had an excellent internal consistency (0.993), with an almost perfect agreement in 93.8% of the questions, and a substantial agreement in the other 6.2%. The translated version also had a good to excellent total reproducibility (0.901, 95% CI: 0.887–0.914).

Conclusion: The results show this translation is a valid and reliable screening tool, which may facilitate a larger number of Brazilians to start or increase physical activity participation in a safe manner.

Higher mortality during the COVID-19 pandemic in socially vulnerable areas in Belo Horizonte: implications for vaccine prioritization

OBJECTIVE

To assess mortality during the COVID-19 pandemic according to social vulnerability by areas of Belo Horizonte (BH), aiming at strategies for vaccination.

METHODS

Ecological study with mortality analysis according to census tracts classified by the Health Vulnerability Index, a composite indicator that includes socioeconomic and sanitation variables. Deaths by natural causes and by COVID-19 were obtained from the "Mortality Information System", between the 10th and 43rd epidemiological weeks (EW) of 2020. Excess mortality was calculated in a time series model, considering observed and expected deaths per EW, between 2015 and 2019, per census tracts. Mortality rates (MR) were calculated and age-standardized using population estimates from the 2010 census, by the Brazilian Institute of Geography and Statistics (IBGE).

RESULTS

Excess mortality in BH was 16.1% (n = 1,524): 11, 18.8 and 17.3% in low, intermediate and high vulnerability areas, respectively. The differences between observed and expected age-standardized MR by natural causes were equal to 59/100,000 inhabitants in BH, increasing from 31 to 77 and 95/100,000 inhabitants in the areas of low, intermediate and high vulnerability, respectively. There was an aging gradient in MR by COVID-19, ranging from 4 to 611/100,000 inhabitants among individuals aged 20-39 years and 75+ years. The COVID-19 MR per 100,000 older adults (60+ years) was 292 in BH, increasing from 179 to 354 and 476, in low, intermediate and high vulnerability areas, respectively.

CONCLUSION

Inequalities in mortality, particularly among older adults, combined with the limited supply of doses, demonstrate the importance of prioritizing socially vulnerable areas during vaccination against COVID-19.

Racial disparity in excess mortality in Brazil during COVID-19 times

We evaluated the impact of the COVID-19 pandemic on excess mortality by race/skin color in Brazil, between epidemiological weeks 12 and 50 of 2020. We compared the 2020-point estimate and the expected point-estimate applying 2019 mortality rates to the 2020 population. There was an excess of 187,002 deaths (+20.2%) compared to the expected. Excess mortality was 26.3% (23.3%-29.3%) among blacks/browns compared to 15.1% (14.1%-16.1%) among whites (58.9% of excess among black/browns). Age-standardized rates increased from 377 to 419/100,000 among blacks/browns compared to 328 to 398/100,000 in whites, resulting in 9% relative risk. Excess mortality in Brazil depicts a considerable gap, with increased mortality in all age-groups in the black/brown population.

Perceptions of dementia amongst the general public across Latin America: a systematic review

Introduction: Perceptions of dementia are important determinants of support, treatment and care received in the dementia community. Understanding these perceptions are vital for regions such as Latin America, where there is a rapid increase in people living with dementia. The aim of this study is to review and synthesise the general public's perceptions of dementia in Latin America, what factors are associated with these perceptions, and how they differ between countries in the region.Methods: Searches were completed across five databases (Medline, SCOPUS, PsychINFO, SciELO, and WoS). Studies were required to capture attitudes or knowledge of dementia in the general public residing within Latin America. English, Spanish and Portuguese search terms were used. Results were synthesised narratively.Results: About 1574 unique records were identified. Following lateral searches, de-duplication and screening, six articles (four studies) met the inclusion criteria for this review. All the studies were quantitative research from Brazil (median, n = 722). There was evidence of a limited to moderate knowledge of dementia, though a significant minority had negative or stigmatising attitudes. Only higher levels of education were consistently associated with better attitudes and knowledge of dementia in the region.Conclusion: There is a need for more in-depth research about attitudes of the general public across Latin America, particularly outside of São Paulo state, Brazil. There appears to be a greater need to raise awareness of dementia amongst less educated Latin American groups.

Who are the people with Alzheimer's disease in Brazil? Findings from the Brazilian Longitudinal Study of Aging

OBJECTIVE

To describe the socioeconomic, behavioral, clinical, and health-related characteristics of Brazilian older adults with Alzheimer's disease (AD).

METHODS

Baseline data from the Brazilian Longitudinal Study of Aging were analyzed. This nationwide survey interviewed 9,412 adults aged at least 50 years. Self-reported medical diagnosis of AD and exposure variables (sociodemographic, clinical, behavioral, and health-related) were assessed by face-to-face questionnaire-based interview. Multivariate analyses accounted for possible confounding factors, and values were reported in prevalence ratio (PR) and 95% confidence interval (95%CI).

RESULTS

Participants with AD have important demographic differences compared with older non-AD participants such as low education level and retirement. Clinically, these patients reported more medical appointments, falls, and higher frequency and duration of hospitalizations compared with non-AD participants. These characteristics may be related to worse physical and mental health observed in this population. Indeed, two out of five older adults with AD in Brazil reported always feeling lonely, while two out of three said they felt depressed or sad much of the time. Adjusted analyses showed that patients with AD were 95% (95%CI 1.08 - 3.50) more likely to be hospitalized in a year compared with non-AD older adults. People with AD in Brazil were more likely to be diagnosed with diabetes (PR = 1.83 [95%CI 1.08 - 3.12]), depression (PR = 3.07% [95%CI 1.63 - 5.79]), Parkinson's disease (PR = 17.63 [95%CI 6.99 - 44.51]), and stroke (PR = 3.55 [95%CI 1.90 - 6.67]) compared with non-AD participants.

CONCLUSION

Older adults with AD in Brazil reported impaired physical and mental health compared with the non-AD population.

Contextual determinants for use of dental services according to different healthcare financing systems: Andersen's model

OBJECTIVES

To explore contextual factors associated with overall dental service use, and investigate whether these factors influenced choice of the type of service according to the healthcare financing alternatives (public services; out-of-pocket services; and private health insurance), by adults and older individuals, based on the most recent Andersen's behavioural model.

METHODS

Cross-sectional study with individual data on 17,305 adults from 177 Brazilian municipalities in the National Oral Health Survey (SBBrasil 2010). Municipal-level information was obtained from health information systems and census data. Multilevel multinomial logistic regression was carried out for multivariable analysis.

RESULTS

In the previous year, 38.2% of the individuals visited the dentist; of which 21.4% used out-of-pocket spending, 11.6% used public services and 5.2% private dental insurance. Municipalities with population coverage of public primary dental care >80% had higher chances of using public services (OR = 1.28, 95%CI:1.00-1.64) than those with ≤60%, but lower chances of using private insurance (OR = 0.56, 95%CI:0.38-0.83). Municipalities with population coverage of private dental insurance > 5% had lower chances of using public services (OR = 0.62, 95%CI:0.47-0.81) than those with <1% coverage, and greater chances of using private insurance (OR = 4.33, CI:95% 2.02-9.29). These factors were not associated with out-of-pocket dental services.

CONCLUSIONS

Municipal coverage of dental services is associated with dental care use, and this is different according to the type of financing system (public or private), as they may change the individual's choice of service. A large public healthcare system may increase public service use for those with reduced access and decrease private service use.

Socioeconomic inequalities in the quality of primary care under Brazil's national pay-for-performance programme: a longitudinal study of family health teams

Background

Many governments have introduced pay-for-performance programmes to incentivise health providers to improve quality of care. Evidence on whether these programmes reduce or exacerbate disparities in health care is scarce. In this study, we aimed to assess socioeconomic inequalities in the performance of family health teams under Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ).

Methods

For this longitudinal study, we analysed data on the quality of care delivered by family health teams participating in PMAQ over three rounds of implementation: round 1 (November, 2011, to March, 2013), round 2 (April, 2013, to September, 2015), and round 3 (October, 2015, to December, 2019). The primary outcome was the percentage of the maximum performance score obtainable by family health teams (the PMAQ score), based on several hundred (ranging from 598 to 914) indicators of health-care delivery. Using census data on household income of local areas, we examined the PMAQ score by income ventile. We used ordinary least squares regressions to examine the association between PMAQ scores and the income of each local area across implementation rounds, and we did an analysis of variance to assess geographical variation in PMAQ score.

Findings

Of the 40 361 family health teams that were registered as ever participating in PMAQ, we included 13 934 teams that participated in the three rounds of PMAQ in our analysis. These teams were located in 11 472 census areas and served approximately 48 million people. The mean PMAQ score was 61·0% (median 61·8, IQR 55·3–67·9) in round 1, 55·3% (median 56·0, IQR 47·6–63·4) in round 2, and 61·6% (median 62·7, IQR 54·4–69·9) in round 3. In round 1, we observed a positive socioeconomic gradient, with the mean PMAQ score ranging from 56·6% in the poorest group to 64·1% in the richest group. Between rounds 1 and 3, mean PMAQ performance increased by 7·1 percentage points for the poorest group and decreased by 0·8 percentage points for the richest group (p<0·0001), with the gap between richest and poorest narrowing from 7·5 percentage points (95% CI 6·5 to 8·5) to –0·4 percentage points over the same period (–1·6 to 0·8).

Interpretation

Existing income inequalities in the delivery of primary health care were eliminated during the three rounds of PMAQ, plausibly due to a design feature of PMAQ that adjusted financial payments for socioeconomic inequalities. However, there remains an important policy agenda in Brazil to address the large inequities in health.

Funding

UK Medical Research Council, Newton Fund, and CONFAP (Conselho Nacional das Fundações Estaduais de Amparo à Pesquisa).

Socio-demographic characteristics affect health information seeking on the Internet in Turkey

OBJECTIVE

The objective of this paper was to determine the effects of certain socio-demographic characteristics of Turkish individuals who seek health information on the Internet.

METHODS

This study was granted permission to use data obtained by the Turkish Statistical Institute (TSI) in 2018 under their Household Information Technology Use (HITU) study. The original sample for this research comprised 19,389 participants.

RESULTS

Age, gender, educational level, place of residence and frequency of Internet use were all found to impact the participants' health information seeking behaviour on the Internet. Health information was sought more frequently by women than men, by younger than older people and by those with higher levels of education. Also, health information searches were conducted more often in developed regions than in less-developed regions. In addition, it was also found that the habit of seeking health information was more common among those who use the Internet more frequently.

CONCLUSION

Several socio-demographic characteristics of individuals affect their health information seeking behaviour on the Internet. All individuals should be granted equivalent access to reliable health information by taking sociodemographic characteristics and discrepancies into consideration.

Impact of age in health-related quality of life in older adults with cancer

OBJECTIVE: To evaluate the impact of age in health-related quality of life (HRQoL) in older adults with cancer. METHODS: This was a cross-sectional study of 608 older adults diagnosed with cancer. Age groups were considered an independent variable. For the analysis of HRQoL, the mean scores of age groups were compared by analysis of variance and the Scheffé comparison test. For measuring the association between age and HRQoL, we used simple and multiple linear regression analyses. RESULTS: Cognitive function showed the highest scores (average 87.94 ± 26.87), while physical function showed the lowest ones (68.04 ± 28.63). The highest symptom score was observed for financial difficulties (34.21 ± 39.06), followed by pain (29.47 ± 33.92) and insomnia (28.51 ± 37.03). After adjustment, we observed a decrease in physical function (p = 0.028) and an improvement in emotional function (p = 0.003) with increasing age. Conclusions: In older patients with cancer, age negatively impacted physical function and positively impacted emotional function.

Mapping the Margins in Health Services Research: How Does Race Intersect With Gender and Socioeconomic Status to Shape Difficulty Accessing HealthCare Among Unequal Brazilian States?

Research on healthcare inequities has centralized whether marginalized racial, gender, or socioeconomic (SES) groups are afforded equitable access to care, yet scant investigations have focused on how race intersects with other social statuses to shape difficulty accessing health services. Contextual specificity has also been under-researched in this field of knowledge. Data from 59,249 respondents 18 years of age and over from the 2013 Brazilian National Health Survey were analyzed using multilevel regressions models. We test 3 hypotheses: racial, gender, and socioeconomically oppressed groups are each more likely to report difficulty accessing health services (H1); compared to high-SES white men, low-SES Black women report expressively higher frequencies of the outcome (H2); and intersectional healthcare inequities are larger among low-SES Brazilian states (H3). Partially supporting H1 and H2, results suggest that race and SES, but not gender, are each strong predictors of difficulty accessing healthcare, with low-SES Black respondents facing the highest odds of reporting this outcome. Although H3 was not supported, intersectional groups residing in low-SES Brazilian states were more likely to report difficulty accessing healthcare. This study demonstrated that, together with contextual specificity, the intersections of race with other axes of marginalization should be at the forefront of research and policy addressing healthcare inequities.

Notes for the study on health systems: multifaceted analysis and tracer indicators

OBJECTIVE

To present the methodological approach used in a research that analyzed the use and performance of specialized health care, from primary care access, in four major Brazilian cities: Fortaleza (CE), Campinas (SP), São Paulo (SP) and Porto Alegre (RS).

METHODS

Presentation and discussion of the quantitative-qualitative components of the proposed research strategy.

RESULTS

Four tracing conditions were studied: systemic arterial hypertension, high-risk pregnancy, breast cancer and severe mental disorder. For each health condition, indicators were constructed based on health information systems data, pointing out frequencies, temporal trends and local differences. This initial contextualization was enriched with a descriptive-qualitative study of the performance of each municipal health service network. Next, a cross-sectional study was conducted through a survey of 7,053 users of specialized services for each health condition. Finally, in-depth interviews were conducted with key actors to complement selected operational aspects of each municipality’s network. The results of all these data sources were triangulated, allowing us to explore the variability of SUS implementations in different regional scenarios.

CONCLUSIONS

The multifaceted analytical model presented allows us to understand relevant aspects of the Unified Health System performance, paying attention to the singularities, heterogeneities and inequalities that characterize its implementation in Brazil and emphasizing the performance of local networks for the addressed health conditions.

Inequality in healthcare use among older people in Colombia

BACKGROUND

Since the early 1990s, Colombia has made great strides in extending healthcare coverage to its population. In order to measure the impact of these efforts, it is important to assess whether the introduction of universal health coverage has translated into equitable access to healthcare in the country, particularly for the elderly. Thus, in this study we assessed the inequality in utilization of health services among elderly patients in Colombia. In addition, we identified the determinants of healthcare utilization.

METHODS

We analyzed the 2015 Colombian health, well-being and aging study (SABE). To classify determinants of healthcare use into predisposing, enabling and need factors, we employed the Anderson framework of healthcare utilization. Use of outpatient, inpatient and preventive health services constituted the dependent variables. We performed multivariate logistic regressions, estimated concentration indexes (CI) and performed decomposition analyses of the CIs to determine the contribution of various determinants to inequality of healthcare utilization.

RESULTS

The study sample included 23,694 adults over 60-years-old. Wealth quintile, urban dwelling, health insurance type and multimorbidity predicted the utilization of all types of healthcare services except for hospitalization. Aside from inpatient care, pro-rich inequality in utilization of healthcare services was present. Wealth quintile and type of health insurance were the largest contributors to pro-rich inequality in use of preventive services.

CONCLUSIONS

While there has been progress in health insurance coverage for the elderly in Colombia, there are still equality challenges in the delivery of healthcare, especially for preventive and outpatient care. These inequalities are driven by individual characteristics such as wealth, urban residence, type of health insurance carried, and presence of multimorbidity. To address this issue, the Colombian health system should extend health insurance coverage to uninsured populations, as well as reduce barriers of access to healthcare services among poorest and the rural population receiving subsidized insurance.

Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults

BACKGROUND

Expanding delivery of primary healthcare to urban poor populations is a priority in many low- and middle-income countries. This remains a key challenge in Brazil despite expansion of the country's internationally recognized Family Health Strategy (FHS) over the past two decades. This study evaluates the impact of an ambitious program to rapidly expand FHS coverage in the city of Rio de Janeiro, Brazil, since 2008.

METHODS AND FINDINGS

A cohort of 1,241,351 low-income adults (observed January 2010-December 2016; total person-years 6,498,607) with linked FHS utilization and mortality records was analyzed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and nonusers. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA). The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education, whereas 102,899 (8%) had no formal education. Two thirds of individuals (827,250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analyzed, of which 8,765 (26%) were due to cardiovascular disease; 5,777 (17%) were due to neoplasms; 5,683 (17%) were due to external causes; 3,152 (9%) were due to respiratory diseases; and 3,115 (9%) were due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54-0.59, p < 0.001) and a 5-year risk reduction of 8.3 per 1,000 (95% CI 7.8-8.9, p < 0.001) compared with a non-FHS user. There were greater reductions in the risk of death for FHS users who were black (HR 0.50, 95% CI 0.46-0.54, p < 0.001) or pardo (HR 0.57, 95% CI 0.54-0.60, p < 0.001) compared with white (HR 0.59, 95% CI 0.56-0.63, p < 0.001); had lower educational attainment (HR 0.50, 95% CI 0.46-0.55, p < 0.001) for those with no education compared to no significant association for those with higher education (p = 0.758); or were in receipt of conditional cash transfers (Bolsa Família) (HR 0.51, 95% CI 0.49-0.54, p < 0.001) compared with nonrecipients (HR 0.63, 95% CI 0.60-0.67, p < 0.001). Key limitations in this study are potential unobserved confounding through selection into the program and linkage errors, although analytical approaches have minimized the potential for bias.

CONCLUSIONS

FHS utilization in urban poor populations in Brazil was associated with a lower risk of death, with greater reductions among more deprived race/ethnic and socioeconomic groups. Increased investment in primary healthcare is likely to improve health and reduce health inequalities in urban poor populations globally.

Intersectional equity in health care: assessing complex inequities in primary and secondary care utilization by gender and education in northern Sweden

BACKGROUND

Knowledge remains scarce about inequities in health care utilization between groups defined, not only by single, but by multiple and intersecting social categories. This study aims to estimate intersectional horizontal inequities in health care utilization by gender and educational level in Northern Sweden, applying a novel methodological approach.

METHODS

Data on participants (N = 22,997) aged 16-84 years from Northern Sweden came from the 2014 Health on Equal Terms cross sectional survey. Primary (general practitioner) and secondary (specialist doctor) health care utilization and health care needs indicators were self-reported, and sociodemographic information came from registers. Four intersectional categories representing high and low educated men, and high and low educated women, were created, to estimate intersectional (joint, referent, and excess) inequalities, and needs-adjusted horizontal inequities in utilization.

RESULTS

Joint inequalities in primary care were large; 8.20 percentage points difference (95%CI: 6.40-9.99) higher utilization among low-educated women than high-educated men. Only the gender referent inequity remained after needs adjustment, with high- (but not low-) educated women utilizing care more frequently than high-educated men (3.66 percentage points difference (95%CI: 2.67-5.25)). In contrast, inequalities in specialist visits were dominated by referent educational inequalities, (5.69 percentage points difference (95%CI: 2.56-6.19), but with no significant horizontal inequity - by gender, education, or their combination - remaining after needs adjustment.

CONCLUSION

This study suggests a complex interaction of gender and educational inequities in access to care in Northern Sweden, with horizontal equity observable for secondary but not primary care. The study thereby illustrates the unique knowledge gained from an intersectional perspective to equity in health care.

Equality and poverty: views from managers and professionals from public services and household heads in the Belo Horizonte Metropolitan Area, Brazil

BACKGROUND

Tackling poverty requires reconsideration of quantitative factors related to "who" is poor and by "how much" and qualitative factors addressing "what poverty means in these individuals' lives". Greater understanding is required concerning the types of access actually used by families in poverty in attempts to meet their basic needs. Poverty must be addressed based on the question: "Inequality of what?" It is in reflecting on the realities of such groups when their basic needs are not met that public policies can be improved and implemented with legitimate priorities.

OBJECTIVE

Describe coverage and access to public health, education and social assistance services and the related effects on the quality of life of families in extreme poverty.

METHODS

An exploratory mixed methods study was conducted applying Amartya Sen's "Basic Capability Equality" framework, with: 1) 27 interviews with managers and professionals from public services serving territories with extreme poverty; 2) Survey with a systematic proportionate stratified sample of 336 heads of households in extreme poverty from a total 2605 families. The resulting data was analyzed with thematic content analysis and descriptive statistics, respectively.

RESULTS

The managers and professionals described the lives of families in extreme poverty with phrases such as, "These people suffer. Sadness weighs on their lives!" and "Depression is the most common illness". Their precarious circumstances and inadequate access were cited as causes. Quality of life was considered bad or very bad by 41.4% of heads of households. A total income of less than one-third of the minimum wage was received by 56.9% of the sample. One or more people were unemployed in the family in 55.8% of cases. For 53.3% of heads of households, public services "did not meet any or few of their needs". The main social determinants of health were described as: alcohol and drugs (68.8%); lack of good health care (60.7%); and absence of income/work (37.5%). The following were identified as solutions to improve their quality of life: (1) health (40.5%); (2) education (37.8%); and (3) employment (44.6%).

CONCLUSIONS

The social determinants of poverty and health must be addressed jointly through intersectoral public policies and egalitarian mechanisms that promote investment in social protection.

Care seeking behavior of people with common mental disorders in São Paulo-Brazil

Background

Mental health in developing countries is a keen area for improvements. Epidemiological research in this field helps to reinforce information, generate hypothesis and guide police makers. This study intends to analyze patterns of care seeking among cases of common mental disorders (CMD) in São Paulo city in 2015.

Methods

The data is from the population-based survey ISA-Capital 2015 and the screening for common mental disorders follows the Self-reporting questionnaire (SRQ-20). The study analyses care seeking according to sociodemographic and health conditions.

Results

The prevalence of CMD was 19.7% (95% CI 18.2–21.4%). There was a higher prevalence of CMD among who sought care in last 30 days (25.4%). Among CMD cases, care seeking presented significant different prevalence ratio (PR) for: women (PR 1.13; 95% CI 1.05–1.2); age 60 years or more (PR 1.13; 95% CI 1.05–1.22) and 30–44 years (PR 1.10; 95% CI 1.01–1.2); brown skin (PR 0.92; 95% CI 0.86–0.97); single or divorced (PR 0.93; 95% CI 0.89–0.99); unemployed (PR 1.06; 95% CI 1.01–1.12); last 15 days referred morbidity (PR 1.3; 95% CI 1.2–1.34); physical disability (PR 1.11; 95% CI 1.06–1.18); and chronic disease (PR 1.15; 95% CI 1.07–1.24).

Conclusion

Identifying vulnerable groups and developing proper public health actions is important to promote equity accessibility. Analysing care seeking behavior among people with CMD is a strong contribution.

Condição de saúde bucal e utilização de serviços odontológicos entre idosos em área rural no sul do Brasil

Resumo Este artigo objetiva avaliar a saúde bucal, a utilização de serviços odontológicos e os fatores associados entre indivíduos com 60 anos, ou mais, residentes em área rural. Estudo transversal, de base populacional, realizado na zona rural de um município de porte médio do extremo sul do Brasil. O desfecho foi ter utilizado serviços odontológicos nos 12 meses anteriores à data da entrevista. A análise abrangeu descrição da amostra, prevalência da utilização de serviços odontológicos para cada categoria das variáveis independentes e análise multivariada através da Regressão de Poisson. Foram entrevistados 1.030 idosos, sendo 49,9% edêntulos totais e tendo 13,9% consultado com dentista no último ano. A probabilidade de consultar foi maior em idosos do sexo feminino, com companheiros(as), com maior escolaridade, pertencentes aos melhores níveis econômicos e que referiram ter algum problema de saúde bucal. Por sua vez, idosos que relataram ser ex-fumantes ou fumantes consultaram menos. Planejamentos em saúde devem ser reorganizados com o intuito de priorizar grupos populacionais com maiores dificuldades na utilização dos serviços odontológicos.

Emotional problems and the use of psychotropic drugs: investigating racial inequality

The aim of the present study was to investigate the existence of racial inequalities in the prevalence of emotional problems, the search for healthcare services and the use of psychotropic drugs. A population-based, cross-sectional study was conducted with data from the 2014/15 Campinas Health Survey. Sample of 1953 individuals aged 20 years or older was analyzed. We estimated the prevalence of common mental disorders (CMDs), the reporting of emotional problems, insomnia, the search for and the use of healthcare services and the use of psychotropic drugs according to self-reported skin color (white and black/brown). Prevalence ratios were estimated using "Poisson" multiple regression. The prevalence of CMDs was higher among blacks/brown compared to whites but no difference was found regarding the reporting of emotional problems and insomnia. Whites sought healthcare services more due to emotional problems. The use of psychotropic drugs was also higher among whites. The results revealed racial inequalities in the presence of CMDs, the search for healthcare services and the use of psychotropics drugs, highlighting the need for actions to identify and overcome barriers that hinder access to mental health care by different racial segments of the population.

Perceptions and experiences regarding the impact of race on the quality of healthcare in Southeast Brazil: a qualitative study

Objective: To explore the impact of race on the quality of healthcare received by patients attending a primary care centre in Brazil.Design: This was a qualitative study consisting of 19 semi-structured interviews conducted on patients from six racial groups (as defined in Brazil as white, yellow, brown, black and indigenous and one self-identified 'other' group). The interviews were analysed using thematic analysis.Results: Four main themes were identified during analysis; factors affecting the access to healthcare, experiences regarding quality of healthcare, discrimination in healthcare and deep-rooted societal discrimination, which were categorised into a number of sub-themes. Within these themes, interviewees reported (1) experiences of racism in society towards the black racial group, (2) one personal perception and two observations of racial discrimination in healthcare, (3) perceived racial discrimination due to healthcare professional behaviour and (4) other factors, such as delays in appointments and long waiting times in health facilities were felt to impact access to care.Conclusion: The findings suggest that racial discrimination exists in Brazilian society but its direct impact on healthcare access was felt to be less obvious. Instead, organisational level factors were felt to contribute to difficulty accessing care. Interviewees perceived that racial discrimination may affect the quality of care, particularly for those designated as 'black'. Socio-economic factors were felt to influence discrimination in healthcare. The findings can help inform further studies and educational initiatives to help address discrimination and access to healthcare in Brazil.

Prioritizing the perceived equity of the residents to construct an equitable health care system: evidence from a national cross-sectional study in China

BACKGROUND

Building an equitable health care system involves both the promotion of social justice in health and people's subjective perception of the promotion. This study aimed to analyze the overall status and associated factors of the perceived equity of the Chinese health care system, and then to offer policy recommendations for health care reform.

METHODS

Information on the perceived equity score (scale 0 to 10) of 10,243 valid cases in total were derived from the data set of Chinese Social Survey 2015. Univariate analysis methods were applied to present respondents' overall perceived equity of the Chinese health care system. Multivariate linear regression method was used to explore the associated factors of the perceived equity and examine their independent effect.

RESULTS

The respondents gave positive but relatively low marks (6.7 ± 2.6, 95% CI: = 6.64~6.74) of the equity of the Chinese health care system. Younger respondents reported a higher score of perceived equity than their elder counterparts (β = - 0.132, 95% CI: - 0.203~ - 0.062, P < 0.001). Respondents with lower education level were significantly more likely to consider the Chinese health care system equitable (β = - 0.104, 95% CI: - 0.153~ - 0.056, P < 0.001). Respondents satisfied with the Social Health Insurance reimbursement ratio tended to score the system higher in the survey (β = 0.044, 95% CI: 0.024~0.063, P < 0.001). Respondents residing in eastern China and rural areas were significantly more likely to consider the Chinese health care system equitable (β = - 0.268, 95% CI: - 0.338~ - 0.199, P < 0.001). Meanwhile, rural respondents reported higher scores of the perceived equity than urban respondents did (β = 0.348, 95% CI: 0.237~0.458, P < 0.001). Respondents from regions with adequate GPs scored the system higher in this survey (β = 0.087, 95% CI: 0.008~0.165, P < 0.001). The present study found no influence of gender, economic status, Social Health Insurance coverage, or satisfaction with the latest treatment on perceived equity.

CONCLUSIONS

Eliminating the sense of inequity among a range of populations should be prioritized in health care reform. A national-level investigation system to rate residents' perceived equity was necessary for global health care reform.

Association of the Level Healthcare Resource Consumption and Frequency of Temporary Disability Cases with Cardiovascular Risk Factors Based on Data of Population Study in Russian Federation

Aim. To analyze the associations of health care system resources utilization and temporary disability (TD) with the main cardiovascular risk factors (RF) at the population and individual level in working age population based on ESSE-RF study data.

Material and methods. The analysis was based on ESSE-RF study data. Standard epidemiological survey methods and evaluation criteria were used. Analysis of probability and number of outpatient visits, hospitalizations, ambulance calls and TD was conducted by using hurdle model. Hypertension, obesity, hypercholesterolemia, hyperglycemia and tobacco consumption were independent variables.

Results. A total of 21923 individuals aged 25-64 years were included: men – 8373 (38%) and women – 13550 (62%). The probability of outpatient visits significantly determined in group with tobacco consumption and with hypercholesterolemia for men, and for women – in the smoking group, with obesity and with hyperglycemia. Numbers of outpatient visits has doubled for patient with hyperglycemia. The numbers of outpatient visits were higher among women smokers compared to non-smokers. Chance to be hospitalized significantly associate with smoking, obesity, hypercholesterolemia for men and with obesity, hyperglycemia – for women. Hypercholesterolemia was associated with a smaller number of inpatient treatment cases among men. The probability of ambulance calls increased for smoking men, for male group with hypertension, hypercholesterolemia, obesity and with hyperglycemia, at the same time, the likelihood increased in female group with hypertension, hyperglycemia, smoking and with obesity. In addition, numbers of ambulance calls were higher in 1.55 times for women with obesity (p<0.05).

Conclusion. So, there is a significant association of probability of using and consumption level of healthcare recourse with the RF depending on the type of medical care, sex and RF.

Prevalence of complementary and alternative medicine (CAM) use in Brazil

Background

The use of medicinal plants or other alternative practices can be the only therapeutic resources for many communities and ethnic groups, especially in developing countries. In Brazil, the Ministry of Health incorporated Complementary and Alternative Medicine (CAM) as a public health policy since 2006. The aim of this study was to evaluate the prevalence of CAM use in Brazil.

Methods

This was a cross-sectional study performed as an epidemiological survey, with data from the National Health Survey, 2013 that evaluated a sample of adult Brazilians (18+ years old). The outcome was the use of CAM therapies, such as acupuncture, homeopathy, medicinal plants and herbal medicines in the last 12 months. We employed a logistic regression model (CI 95%) to evaluate the chances of CAM use.

Results

The prevalence of CAM use in Brazil was 4.5%. The subjects with higher chances to use CAM were: women (AOR = 1.42), aged > 40 years (AOR = 1.64), with higher educational levels (AOR = 2.35), and residents at North (AOR = 2.02) and South (AOR = 1.67) regions of Brazil, all with p-value < 0.001. According to the socioeconomic status, subjects from upper classes had higher chances to use acupuncture and homeopathy when compared to the other classes, and individuals from lower classes had higher chances to use medicinal plants and herbal medicines. Almost half of all individuals reporting CAM use did so outside the health care system. The Brazilian Unified Health System (SUS) was the least used funding for CAM when compared to other types of funding.

Conclusions

We recommend that the Ministry of Health invests in capacity building for health professionals who work with CAM, providing structure for those practices in health services, increasing the access of CAM therapies for SUS users, and improving the registering of information about those therapies, encouraging the use of CAM by the Brazilian population.

Challenges for implementing a global mental health agenda in Brazil: The "silencing" of culture

Since its emergence in 2007, Global Mental Health has been a growing and polemic area of study, research and practice in mental health worldwide. Despite having a significant endogenous academic production and innovative policy experiences, the Brazilian mental health field and its actors make few references to, and scarcely dialogue with, the Global Mental Health agenda. This article explores an aspect of this divergence between Global Mental Health initiatives and public mental health care in Brazil regarding the role of culture within mental health policies and practices. Our hypothesis is that part of this difficulty can be attributed to the low relevance of the cultural dimension for the Brazilian mental health field, here referred to as the "silencing of culture." We examine the possible historical roots of this process with reference to theories of "anthropophagy" and "cultural uniformity" in the context of Brazilian cultural matrices. We then describe two recent experiences in public mental health care that incorporate cultural competence through the work of community health workers and the example of community therapy. We argue that the development of cultural competence can be decisive in enabling an improved dialogue between research and practice in Brazilian mental health and global mental health initiatives.

Malnutrition in all its forms and social inequalities in Brazil

Objective:

To describe malnutrition (undernutrition and excess weight) by income, education and race/ethnicity in the Brazilian population.

Design:

Cross-sectional study.

Setting:

Brazil.

Participants:

Children aged <5 years (n 14 580), adolescents aged 11–19 years (n 31 892) and adults aged 20–49 years (n 84 660).

Results:

Among children, prevalence of excess weight, wasting and stunting was 16·9, 2·8 and 6·0 %, respectively. Differences related to income, education and race/ethnicity were verified, except for prevalence of wasting by education level. Girls and boys presented 18·4 and 20·5 % of excess weight, 2·8 and 3·7 % of underweight and 5·5 and 7·3 % of stunting, respectively. Prevalence of excess weight was lower among poorer, lower-educated (only for boys) and white adolescents, while stunting was lower among higher-income, higher-educated and white adolescents. Over three-quarters of women and almost half of men presented excess weight. Among adults, 3·9 % of women and 1·7 % of men were underweight, and 5·7 % of women and 0·2 % of men presented short stature. Prevalence of excess weight for women was higher among lower education and black, while for men it was higher among higher income and education and white. Short stature was more prevalent among black and mixed-race, low-educated and low-income women. Underweight prevalence was higher among low-educated, black and mixed-race women.

Conclusions:

In Brazil, the prevalence of excess weight was at least threefold higher than that of undernutrition for children and adolescents and at least sevenfold higher for adults. Social inequalities were observed in the distribution of malnutrition across the lifespan and by gender.

Factors Associated With Early Virological Response in HIV-Infected Individuals Starting Antiretroviral Therapy in Brazil (2014-2015): Results From a Large HIV Surveillance Cohort

Objective:

To identify clinical, sociodemographic, and treatment-related factors associated with early virological response in HIV-infected adults starting antiretroviral treatment (ART) in Brazil in 2014–2015.

Methods:

Data from 4 information systems from the Brazilian AIDS Program were combined to create a historical cohort. Unconditional logistic regression models were used to assess the likelihood of not achieving viral load suppression (VLS), defined as having either a viral load (VL) count >200 copies per milliliter or an aids-related death recorded within 180 ± 90 days after treatment initiation.

Results:

Among 76,950 individuals, 64.8% were men; median age, CD4⁺, and VL counts were 34 years, 378 cells per micro liter, and 38,131 copies per milliliter, respectively, and 85.2% achieved VLS. In the multivariate analysis, some factors which increased the odds of non-VLS were as follows: lower CD4⁺ and higher VL counts, younger age, heterosexual or injection drug use groups (relative to men who have sex with men), lower educational level, black/brown race, higher pill burden, and higher dosing frequency. Regimens containing boosted protease inhibitors were similar to those containing nonnucleoside reverse transcriptase inhibitors and superior to those containing unboosted protease inhibitors (all P values <0.001). No difference was observed between patients with CD4⁺ counts 350–499 and 500+ cells per micro liter.

Conclusions:

Our findings support the decision made in Brazil in 2013 to recommend immediate initiation of ART regardless of clinical stage or CD4⁺. Several factors were found to be associated with poorer virologic outcomes and should be addressed to maximize ART adherence and success rates.

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.

Socioeconomic determinants of leprosy new case detection in the 100 Million Brazilian Cohort: a population-based linkage study

BACKGROUND

Although leprosy is recognised as a disease of poverty, there is little evidence on the specific socioeconomic factors associated with disease risk. To inform targeted strategies for disease elimination, we investigated socioeconomic markers of leprosy risk in Brazil.

METHODS

Socioeconomic data from the 100 Million Brazilian Cohort were linked to the Brazilian national disease registry (Sistema de Informação de Agravos de Notificação) for leprosy from Jan 1, 2007, to Dec 31, 2014. Using Poisson regression, we assessed the association of socioeconomic factors with risk of incident leprosy in the full cohort and in children (aged 0-15 years), by leprosy subtype and region of residence.

FINDINGS

In an analysis of 23 899 942 individuals including 18 518 patients with leprosy, increased levels of deprivation were associated with an increased risk of leprosy in Brazil. Directions of effect were consistent in children younger than 15 years and across disease subtypes. Individuals residing in regions with the highest poverty in the country (central-west, north, and northeast regions) had a risk of leprosy incidence five-to-eight times greater than did other individuals. Decreased levels of income and education and factors reflecting unfavourable living conditions were associated with an up to two-times increase in leprosy incidence (incidence rate ratio 1·46, 95% CI 1·32-1·62, for lowest vs highest quartile of income per capita; 2·09, 95% CI 1·62-2·72, for lowest vs highest level of education).

INTERPRETATION

Within the poorest half of the Brazilian population, the most deprived individuals have the greatest risk of leprosy. Strategies focusing on early detection and treatment in the poorest populations could contribute substantially to global disease control.

FUNDING

Medical Research Council, Wellcome Trust, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Brazil), the Conselho Nacional das Fundações Estaduais de Amparo à Pesquisa, Economic and Social Research Council, Biotechnology and Biological Sciences Research Council, Conselho Nacional de Desenvolvimento Científico e Tecnológico, and Fundação de Apoio à Pesquisa do Distrito Federal.