Use of health services by Brazilian older adults with and without functional limitation

Healthcare system navigation difficulties among informal caregivers of older adults: a logistic regression analysis of social capital, caregiving support and utilization factors

BACKGROUND

Informal caregivers of older adults play a vital role in improving the degree to which older adults access community and healthcare services in a seamless and timely manner. They are fulfilling important navigation and support roles for their older care recipients. However, there is still little knowledge of the most significant facilitators and barriers to effective and efficient system navigation among caregivers. This paper aims to fill these knowledge gaps through investigation of the key factors (i.e., social capital/cohesion, caregiving supports, and utilization factors) affecting navigation difficulties faced by informal caregivers of older adults.

METHODS

The Behavioural-Ecological Framework of Healthcare Access and Navigation (BEAN) model is used to frame the study. Using the General Social Survey on Caregiving and Care Receiving 2018, we analyzed 2,733 informal caregivers whose primary care recipients were aged 65 or older. Hierarchical logistic regression was conducted to identify the relationship between system navigation difficulties among informal caregivers and four sequentially ordered blocks of predictors: (1) sociodemographic (2), social capital/cohesion (3), caregiving supports, and (4) healthcare demand.

RESULTS

The fully adjusted model showed that the probability of reporting navigation difficulties was lower for caregivers with social capital/cohesion compared to those without social capital/cohesion. In comparison, the probability of reporting navigation difficulties was higher among caregivers with caregiving support and among caregivers whose care receivers use a higher amount of health service use. Several sociodemographic covariates were also identified.

CONCLUSION

Our findings support certain aspects of the BEAN model. This study extends our understanding of potential facilitators and barriers that informal caregivers of older adults face while navigating complex community and health systems. There is a need to implement coordinated schemes and health policies especially for older adults with mental/neurological issues to address the challenges of their caregivers given the specific vulnerability identified in this study. The need for further research using different approaches to examine the disproportionate impact of COVID-19 on caregivers' system navigation experience is crucial.

Discontinuation of Health Interventions Among Brazilian Older Adults During the Covid-19 Pandemic: REMOBILIZE Study

The objective of this study was to analyze changes in access to health interventions during the pandemic among Brazilian older adults and to investigate the factors associated with social and health inequalities. We conducted an online survey with Brazilian adults aged 60  +  years between May and June 2020. A multidimensional questionnaire was used to investigate access to health interventions during the pandemic and associated factors. Of 1482 participants, 56.5% reported health care before the pandemic, and 36.4% discontinued it during the pandemic. The discontinuation rate was 64.4% (95% CI 61.1-67.6). Participants with higher educational level (nine or more years of education: OR 0.34; 95% CI 0.17-0.70) and higher income (eight or more times the minimum wage: OR 0.54; 95% CI 0.36-0.81) were associated with less probability of discontinuation. Presenting multimorbidity (OR: 1.42; 95% CI 1.06-1.90) and polypharmacy (OR: 0.61; 95% CI 0.46-0.81) were associated with discontinuity in health interventions. Our study showed that structural health inequities in access to health care shaped the rates of discontinuation in health care interventions during the COVID-19 pandemic. Strategic actions should be set up to actively monitor socially vulnerable older adults and strengthen community-based services to mitigate the discontinuation of health care interventions.

The effects of an innovative integrated care intervention in Brazil on local health service use by dependent older people

BACKGROUND

Since 2011, the Brazilian city of Belo Horizonte has been operating an innovative scheme to support care-dependent older people in disadvantaged communities: Programa Maior Cuidado (PMC - Older Person's Care Program). This paper examines two potential associations between inclusion in PMC on types of outpatient health service utilization by dependent older people. The first is that being in PMC is associated with a higher frequency of outpatient visits for physical rehabilitation. The second is that being in PMC is associated with a higher frequency of planned versus unplanned outpatient visits.

METHODS

We apply a quasi-experimental design to a unique set of health administrative data recording visits to outpatient health services. We focus on comparisons of the universe of visits, transformed to ratios of planned/unplanned visits and rehabilitation/other reasons for visiting the outpatient service. First, we preprocess our sample through different matching techniques such as 'coarsened exact matching' (CEM), 'nearest neighbor' based on logit scores (NN), 'optimal pair' (OP) and 'optimal full' (OF) methods. Second, we estimate marginal effects of being in PMC on our outcomes of interest. We use Poisson regressions controlling for individual and community factors and use robust standard errors. Our results are presented as the comparative incidence ratio of PMC on rehabilitation and planned visits.

RESULTS

We find significant positive incidence rates for belonging to PMC for both outcomes of interest under all matching specifications. Poisson models using CEM shows a higher incidence rate for planned visits in comparison to unplanned visits, 1.3 (95% CI 1.1-1.4), by PMC patients compared to the non-PMC controls, and a higher proportion of visits for rehabilitation, 3.4 (95% CI 1.7-6.8). Similar positive results are found across other matching methods and models.

CONCLUSIONS

Our analysis reveals significant positive associations between older people included in PMC and a matched set of controls for a greater ratio of making outpatient visits that were planned, rather than unplanned. We find similar associations for the proportion of visits made for rehabilitation, as opposed to other reasons. These findings indicate that PMC influences some elements of outpatient health service utilization by dependent older people.

Building the capacity of community health workers to support health and social care for dependent older people in Latin America: a pilot study in Fortaleza, Brazil

Background

Brazil is seeing rapid population ageing, which is leading to new demands on primary health care services. There is a need to develop and assess the effectiveness of new interventions to build the capacity of staff, including community health workers, to meet the needs of groups such as care-dependent older people and their care-givers. This study examines the feasibility of a small training intervention piloted in the Brazilian city of Fortaleza.

Methods

The study evaluated participants’ own assessments of key knowledge and skills related to the needs of care-dependent older people, both before and after the training intervention. It also assessed their capacity to implement a simple screening tool of geriatric risk factors.

Results

The participant self-assessments indicate significant improvements in their perceived knowledge and capacity in responding to the health needs of care-dependent older people. Additionally, participants were able to successfully conduct the home visits and screening for risk factors.

Conclusions

The study demonstrates the feasibility of developing interventions to enhance the capacity of community health workers to meet the needs of dependent older people in countries like Brazil. The evidence of effectiveness, though limited and subjective, provides justification for a larger, formally evaluated intervention. The experience of Fortaleza provides valuable lessons for other cities and countries in the region which are facing similar challenges.

Integrated Care in the Community: The Case of the Programa Maior Cuidado (Older Adult Care Programme) in Belo Horizonte-Minas Gerais, BRA

Internationally, there is a large body of scientific evidence concerning the benefits of integrating health and social care to ensure that frail older people living in the community receive the assistance they need to maintain independence. In the Brazilian city of Belo Horizonte, located in the state of Minas Gerais, an integrated care intervention has been developed: the Programa Maior Cuidado – Older Adult Care Programme (PMC). This programme represents a pioneering example in Brazil of the provision of carers for highly vulnerable older people, through integrated action between public health and social service agencies. This paper draws on the first phase of a mixed method evaluation of PMC, including data from documentary sources, focus groups, empirical observation and expert workshops, to examine the processes that led to the establishment of programme. The origins of the PMC are discussed and its operational processes, with a particular emphasis on integrated activities and the roles of different actors. The paper situates PMC within comparable international experiences of integrated provision for older people and considers how it has been affected by unique context and challenging of a middle-income country.

Caracterização clínica de idosos com estomia atendidos em consulta de enfermagem em um centro de referência

Objetivo: caracterizar o perfil clínico de idosos com estomia atendidos em consultas de enfermagem em um centro de referência.Método: estudo descritivo de abordagem quantitativa com amostra intencional composta por 171 idosos. A pesquisa foi realizada em um centro de referência para estomias durante o atendimento de consultas de enfermagem. Os dados foram coletados no período de abril de 2018 a abril de 2019, e analisados conforme estatística descritiva simples.Resultados: do total de pacientes idosos atendidos no período analisado, observou-se que a média de idade entre eles foi de 71,6 anos, e não houve diferença significativa em relação ao sexo. A estomia mais frequentemente apresentada foi a colostomia (63,15%) e a neoplasia predominante nos pacientes foi a neoplasia maligna do reto (31,58%). Apenas 6 (3,51%) dos idosos apresentam estomia em virtude da doençadiverticular do intestino grosso com perfuração e abscesso. O principal motivo para consulta foi para realizar a troca da bolsa com 570 (62,10%), seguido por solicitação de avaliação 102 (11,11%). O quantitativo de consultas por gênero, revelam que as idosas buscam menos atendimento de enfermagem quando comparados aos homens.Conclusão: o conhecimento referente à caracterização dos idosos com estomia possibilitará a adequação do planejamento da assistência aos idosos estomizados dispondo de melhor qualidade e efetividade pela enfermeira estomaterapeuta no centro de referência.

Hospitalization of the aged due to stroke: An ecological perspective

Contextual variables have been associated with the incidence of stroke, but their association with hospitalization of older persons remains unclear. This study evaluated the association between social context variables and hospitalization of 60 years old and older patients due to stroke in Rio de Janeiro, Brazil. An ecological cross-sectional study was conducted, with secondary data from the Brazilian Hospital Information System from 2006 to 2014. Hospitalization rates were calculated and categorized by tertiles. For subsequent analyzes, the polar extremes method was used to select the groups with extremes values. After that, Student t or Mann-Whitney tests were used to compare the contextual variables and the hospitalization rates clusters. Then, a Binary Logistic Regression analysis was used to assess the association between hospitalization rates clusters and the contextual variables. The total number of hospitalizations was 82 796; the hospitalization rate varied in extremes groups from the lowest (3.49) to the highest (11.95) (p<0.001). The highest rates group was positively associated with the proportion of elderly (p<0.001), the illiteracy rate of the aged (p = 0.01), primary care coverage (p<0.001) and ambulatory care for hypertension and diabetes, while the income ratio showed negative association with the highest rates of hospitalization (p = 0.01). In the multivariate analysis, only the proportion of elderly (OR = 1.55; 95%CI 1.07–2.25), primary care coverage (OR = 1.05; 95%CI 1.01–1.11) and income ratio (OR = 0.82; 95%CI 0.67–0.99) maintained the association. In conclusion, contextual variables in the three dimensions studied were associated with the rate of hospitalization of aged due to stroke in the municipalities in Rio de Janeiro State. Transitional care and other improvements in both the health care and social services are demanded.

Care and functional disabilities in daily activities - ELSI-Brazil

OBJECTIVE

To investigate the prevalence of demand and provision of care for the Brazilian population with functional disabilities in activities of daily living.

METHODS

This is a quantitative and descriptive study using baseline data from ELSI-Brazil (Brazilian Longitudinal Study of Aging), a cohort study with a representative sample of the Brazilian population aged 50 years or older (n = 9,412). We considered the demand for care from the self-report of having some difficulty to perform at least one activity of daily life (eating, bathing, going to the toilet, dressing, moving in a room [ambulation], and transferring from chair [transfer]). Care supply was measured by having some help to perform the activity of daily living.

RESULTS

Approximately a quarter of the individuals evaluated (23.2%) reported difficulty in at least one activity of daily living, especially regarding transfer and dressing. Age, schooling, and number of chronic diseases were significantly associated with the difficulty in activities of daily living. Among those who reported difficulty, 35.1% received help of others and 11.8% did not receive (lack of care). The activities with greater lack of care were bathing (13.3%) and transfer (11.7%), which reveals an undignified survival condition. Care remains a family (94.1%) and female (72.1%) issue; despite the important changes that have taken place in society, there is still a lack of care policies. Of the total caregivers, 25.8% reported stopping working or studying to perform this role and only 9.2% were paid (hired ones or family members).

CONCLUSIONS

The ELSI-Brazil results reveal the expressive care demand of the Brazilian population aged 50 years or older with functional disabilities on activities of daily living and the lack of care policies aimed at this public.

Hospitalizations among older adults: results from ELSI-Brazil

OBJECTIVE

To examine the factors associated with hospital use and their frequency in a nationally representative sample of the Brazilian population aged 50 years or older.

METHODS

Data from the baseline of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), conducted in 2015-2016, were used. Predisposing, enabling and need factors for the use of health services were considered. The analyzes were based on the Hurdle regression model and on estimates of population attributable risks.

RESULTS

Among 9,389 participants, 10.2% had been hospitalized in the previous 12 months. After adjusting for potential confounding variables, statistically significant associations (p < 0.05) were observed for need factors (previous medical diagnosis for chronic diseases and limitation to perform basic activities of daily living) and for enabling factors (living in a rural area and in the North and Midwest regions of the country). The analysis of population attributable risks (PAR) showed a hierarchy of the need factors for the occurrence of hospitalizations, with higher contributions by stroke (PAR = 10.7%) and cardiovascular disease (PAR = 10.0%), followed by cancer (PAR = 8.9%), difficulty to perform basic activities of daily living (PAR = 6.8%), depression (PAR = 5.5%), diabetes (PAR = 4.4% ) and hypertension (PAR = 2.2%).

CONCLUSIONS

Four of the major diseases associated with hospitalizations (stroke, cardiovascular disease, diabetes and hypertension) are part of the Brazilian list of primary care-sensitive hospitalizations. These results show that there is a window of opportunity to reduce unnecessary hospitalizations among older Brazilian adults through effective primary care actions.