Giseli Nogueira Damacena

Socio-demographic determinants of self-rated health in Brazil

Self-rated health has been used extensively in epidemiologic studies, not only due to its importance per se but also due to the validity established by its association with clinical conditions and with greater risk of subsequent morbidity and mortality. In this study, the socio-demographic determinants of good self-rated health are analyzed using data from the World Health Survey, adapted and carried out in Brazil in 2003. Logistic regression models were used, with age and sex as covariables, and educational level, a household assets index, and work-related indicators as measures of socioeconomic status. Besides the effects of sex and age, with consistently worst health perception among females and among the eldest, the results showed pronounced socioeconomic inequalities. After adjusting for age, among females the factors that contributed most to deterioration of health perception were incomplete education and material hardship; among males, besides material hardship, work related indicators (manual work, unemployment, work retirement or incapable to work) were also important determining factors. Among individuals with long-term illness or disability, the socioeconomic gradient persisted, although of smaller magnitude.

Amostras complexas em inquéritos populacionais: planejamento e implicações na análise estatística dos dados

A avaliacao do desempenho dos sistemas de saude das nacoes vem ganhando importância crescente entre os gestores do setor saude. Entre os instrumentais de avaliacao do desempenho de saude, destacam-se os inqueritos nacionais de saude, cada vez mais utilizados para avaliar o estado de saude da populacao e a assistencia de saude prestada do ponto de vista do usuario. A maioria dos inqueritos nacionais de saude nao usa amostragem aleatoria simples, em parte por restricoes orcamentarias, em parte por limites de tempo associado a coleta de dados. Em geral, utiliza-se combinacao de varios metodos probabilisticos de amostragem para selecao de uma amostra representativa da populacao, chamada de desenho complexo de amostragem. Entre os metodos de amostragem mais utilizados conjuntamente, destacam-se a amostra aleatoria simples, a amostragem estratificada, e a amostragem por conglomerados. Resultante desse processo, a preocupacao subsequente e a analise de dados provenientes de amostras complexas. Este artigo trata de questoes relacionadas a analise estatistica de dados obtidos atraves de pesquisas com desenhos complexos de amostragem. Apresentam-se os problemas que ocorrem quando a analise estatistica nao incorpora a estrutura do plano amostral. Ao ignorar o desenho de amostragem, a analise estatistica tradicional, sob a suposicao de amostragem aleatoria simples, pode produzir incorrecoes tanto para as estimativas medias como para as respectivas variâncias, comprometendo os resultados, os testes de hipoteses e as conclusoes da pesquisa. Para a exemplificacao dos metodos, e utilizada a Pesquisa Mundial de Saude (PMS), realizada no Brasil em 2003.

Pesquisa Nacional de Saude no Brasil: concepcao e metodologia de aplicacao

The National Health Survey is a household-based nationwide survey carried out by the Ministry of Health in partnership with the Brazilian Institute of Geography and Statistics. The scope of the survey is to establish the health status and lifestyles of the population - as well as how they look after their health - with regard to access and use of services, preventive actions, continuity of care, and health care financing. The sample size is 80,000 households and enables the calculation of some indicators at different geographic levels, namely states, capitals, metropolitan and rural areas. The questionnaire is divided into three parts. The first two are answered by one resident and include questions on the household characteristics and on the social and economic level and health status of all inhabitants. The individual questionnaire is answered by an adult (aged 18 years or more), selected with equal probability among the adult residents, and focuses on morbidity and lifestyle. For this individual, measurements of weight, height, waist circumference and blood pressure are taken, as well as laboratory exams to characterize the lipid profile and blood glucose level, as well as determine the urine sodium content. The laboratory exams are taken in a subsample of 25% of the census sectors selected.

Utilization of medicines by the Brazilian population, 2003

The aim of the present study was to characterize the utilization of medicines by the Brazilian population, using data from the Brazilian World Health Survey. Medicines were grouped according to the active pharmaceutical ingredient based on an adaptation of the World Health Organization standard list of essential medicines. The analysis included the characteristics of individuals who keep medicines at home and who had used them within the reference period (within two weeks prior to the interview), according to presence of medical prescription. Nearly half of the participants (49.0%) reported use of medicines during the reference period. Older and wealthier individuals and those with chronic diseases or disabilities and with poor self-rated health keep and use medicines more frequently. For 25.0% of the individuals that had used medicines during the reference period, none of the drugs had been prescribed by a health professional. Among the individuals who had medicines prescribed in the last appointment, 13.0% were unable to obtain the prescribed medication (of these, 55.0% could not afford it). The most widely utilized group was that of the analgesics (22.0%), and only 51.0% of the individuals using this type of medicine had received a medical prescription for it.

Analysis of Data Collected by RDS Among Sex Workers in 10 Brazilian Cities, 2009: Estimation of the Prevalence of HIV, Variance, and Design Effect

Background:Respondent-driven sampling (RDS) is a chain-referral method that is being widely used to recruit most at-risk populations. Because the method is respondent driven, observations are dependent. However, few publications have focused on methodological challenges in the analysis of data collected by RDS. Methods:In this article, we propose a method for estimating the variance of the HIV prevalence rate, based on the Markov transition probabilities and within recruitment cluster variation. The method was applied to a female commercial sex workers study carried out in 10 Brazilian cities in 2008. Both the inverse of network size and the size of the city were considered in the estimation of overall sampling weights. The study included a behavior questionnaire and rapid tests for HIV and syphilis. Results:About 2523 interviews were conducted successfully, excluding the seeds. Results show a positive homophily between recruits for those HIV+; HIV- recruiters selected HIV+ recruits 4% of the time; HIV+ recruiters selected other HIV+ recruits 19.6% of the time, about 5 times higher. The prevalence rate was estimated at 4.8% (95% confidence interval: 3.4 to 6.1), and a design effect of 2.63. Conclusions:Using statistical methods for complex sample designs, it was possible to estimate HIV prevalence, standard error, and the design effect analytically. Additionally, the proposed analysis lends itself to logistic regression, permitting multivariate models. The stratification in cities has proved suitable for reducing the effect of design and can be adopted in other RDS studies, provided the weights of the strata are known.

Socioeconomic inequalities in the use of outpatient services in Brazil according to health care need: evidence from the World Health Survey

BackgroundThe Brazilian health system is founded on the principle of equity, meaning provision of equal care for equal needs. However, little is known about the impact of health policies in narrowing socioeconomic health inequalities. Using data from the Brazilian World Health Survey, this paper addresses socioeconomic inequalities in the use of outpatient services according to intensity of need.MethodsA three-stage cluster sampling was used to select 5000 adults (18 years and over). The non-response rate was 24.7% and calibration of the natural expansion factors was necessary to obtain the demographic structure of the Brazilian population. Utilization was established by use of outpatient services in the 12 months prior to the interview. Socioeconomic inequalities were analyzed by logistic regression models using years of schooling and private health insurance as independent variables, and controlling by age and sex. Effects of the socioeconomic variables on health services utilization were further analyzed according to self-rated health (good, fair and poor), considered as an indicator of intensity of health care need.ResultsAmong the 5000 respondents, 63.4% used an outpatient service in the year preceding the survey. The association of health services utilization and self-rated health was significant (p < 0.001). Regarding socioeconomic inequalities, the less educated used health services less frequently, despite presenting worse health conditions. Highly significant effects were found for both socioeconomic variables, years of schooling (p < 0.001) and private health insurance (p < 0.00), after controlling for age and sex. Stratifying by self-rated health, the effects of both socioeconomic variables were significant among those with good health status, but not statistically significant among those with poor self-rated health.ConclusionsThe analysis showed that the social gradient in outpatient services utilization decreases as the need is more intense. Among individuals with good self-rated health, possible explanations for the inequality are the lower use of preventive services and unequal supply of health services among the socially disadvantaged groups, or excessive use of health services by the wealthy. On the other hand, our results indicate an adequate performance of the Brazilian health system in narrowing socioeconomic inequalities in health in the most serious situations of need.

Health inequalities in Rio de Janeiro, Brazil: lower healthy life expectancy in socioeconomically disadvantaged areas.

OBJECTIVES We investigated deprivation and inequalities in life expectancy and healthy life expectancy by location in Rio de Janeiro, Brazil. METHODS We conducted a health survey of 576 adults in 2006. Census tracts were stratified by income level and categorization as a slum. We determined health status by degree of functional limitation, according to the approach proposed by the World Health Organization. We calculated healthy life expectancies by Sullivans method with abridged life table. RESULTS We found the worst indicators in the slum stratum. The life expectancy at birth of men living in the richest parts of the city was 12.8 years longer than that of men living in deprived areas. For both men and women older than age 65 years, healthy life expectancy was more than twice as high in the richest sector as in the slum sector. CONCLUSIONS Our analysis detailed the excess burden of poor health experienced by disadvantaged populations of Rio de Janeiro. Policy efforts are needed to reduce social inequalities in health in this city, especially among the elderly.

Saúde nas fronteiras: acesso e demandas de estrangeiros e brasileiros não residentes ao SUS nas cidades de fronteira com países do MERCOSUL na perspectiva dos secretários municipais de saúde

In the context of forming common markets, border areas require special attention, since they anticipate the effects of integration processes. Along borders, different political, monetary, security, and social systems coexist; the intensification of flows resulting from integration raises challenges for the health systems, requiring specific policies focused on guaranteeing the right to health. This article presents the results of a study on the conditions for access to (and demands for) health services in the MERCOSUR border cities. A survey was performed with municipal health secretaries in the 69 Brazilian cities in the States of Rio Grande do Sul, Santa Catarina, Paraná, and Mato Grosso do Sul that border on the other MERCOSUR countries. The study attempted to identify the services demanded by the border population, mechanisms used for access, flows between services and systems, response strategies, and local agreements. Initiatives for cooperation between Brazilian and foreign local administrators were identified in nearly half of the municipalities and can orient the formulation of guidelines for border situations, allowing improvement in comprehensive access to health care.No contexto de formacao de mercados comuns, as regioes de fronteira adquirem especial atencao, pois antecipam efeitos dos processos de integracao. Nas fronteiras convivem diferentes sistemas politicos, monetarios, de seguranca e protecao social, e a intensificacao de fluxos decorrentes da integracao gera novos desafios para os sistemas de saude, exigindo politicas especificas direcionadas a garantia do direito a saude nas regioes fronteiricas. Este trabalho apresenta resultados de pesquisa com o objetivo de analisar condicoes de acesso e demandas por servicos de saude em cidades fronteiricas do MERCOSUL. Foi realizado inquerito com secretarios municipais de saude das 69 localidades brasileiras da linha de fronteira com paises do MERCOSUL referentes aos Estados do Rio Grande do Sul, Santa Catarina, Parana e Mato Grosso do Sul. Buscou-se identificar acoes demandadas pela populacao fronteirica, mecanismos utilizados para acesso, fluxos entre servicos e sistemas, estrategias de resposta e acordos locais. Iniciativas de cooperacao entre gestores locais brasileiros e estrangeiros, identificadas em quase metade dos municipios, podem orientar a formulacao de diretrizes para situacoes de fronteira que possibilitem a melhoria do acesso integral a atencao a saude.

Perception of health state and the use of vignettes to calibrate for socioeconomic status: results of the World Health Survey in Brazil, 2003

As part of the World Health Organization (WHO) project focused on assessing the performance of national health systems, the World Health Survey (WHS) was carried out in many member countries. In order to enable comparison of self-rated health between different cultures of the same country or between different nations, the WHS questionnaire included vignettes of sample cases, that is, hypothetical stories that describe the health problems of third parties. The objective of the present study is to evaluate the possibility of using vignette ratings to implement a socioeconomic calibration scale for self-rated health in Brazil. Using Brazilian WHS data, perceptions of state of health, measured through two different strategies (self-rating and vignette-rating), were compared. The effects of socioeconomic status (educational level and number of household assets) on health domain ratings were estimated via multiple regression models, controlled for age and sex. The effects of socioeconomic status were significant for the majority of health domains in the case of self-perception, but statistically null in the case of third party ratings. It is concluded that the WHO vignettes are not appropriate for calibrating self-rated health measures in Brazil.

O processo de desenvolvimento da Pesquisa Nacional de Saúde no Brasil, 2013

Este trabalho teve o objetivo de relatar a fase preparatoria da Pesquisa Nacional de Saude (PNS) e a experiencia de execucao do trabalho de campo, com o intuito de colaborar para o desenvolvimento e aprimoramento da metodologia de construcao de inqueritos populacionais em saude no pais. A elaboracao da PNS iniciou-se em 2009 e passou por um amplo processo de consulta, envolvendo pesquisadores e representantes das areas tecnicas do Ministerio da Saude. De setembro de 2012 a junho de 2013, foram aplicados testes sobre o questionario e realizado estudo-piloto. Aprovado o projeto da pesquisa pela Comissao Nacional de Etica em Pesquisa (CONEP) em julho de 2013, realizou-se o treinamento do pessoal de campo. O trabalho de campo iniciou-se em agosto de 2013 e teve duracao de seis meses. A primeira divulgacao de resultados ocorreu em dezembro de 2014, relativa aos estilos de vida, autopercepcao da saude e doencas cronicas.Este trabalho teve o objetivo de relatar a fase preparatoria da Pesquisa Nacional de Saude (PNS) e a experiencia de execucao do trabalho de campo, com o intuito de colaborar para o desenvolvimento e aprimoramento da metodologia de construcao de inqueritos populacionais em saude no pais. A elaboracao da PNS iniciou-se em 2009 e passou por um amplo processo de consulta, envolvendo pesquisadores e representantes das areas tecnicas do Ministerio da Saude. De setembro de 2012 a junho de 2013, foram aplicados testes sobre o questionario e realizado estudo-piloto. Aprovado o projeto da pesquisa pela Comissao Nacional de Etica em Pesquisa (CONEP) em julho de 2013, realizou-se o treinamento do pessoal de campo. O trabalho de campo iniciou-se em agosto de 2013 e teve duracao de seis meses. A primeira divulgacao de resultados ocorreu em dezembro de 2014, relativa aos estilos de vida, autopercepcao da saude e doencas cronicas.