Monitoring social inequalities in health - EPI...
Transcript of Monitoring social inequalities in health - EPI...
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Monitoring social inequalities in health
MarilisaBarros
DMPS/FCM/UNICAMP
Epi 2008 – Porto Alegre
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Inequalities are large and increasing in some
contexts and dimensions
They are preventable and
unfair
Why to monitor inequalities in
health?
The health services provided may increase the
inequalities
Behavior changes may enlargeinequalities
They cross all society: social,
economic , gender and race
groups
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Fonte:PNUD - Fundação João Pinheiro
%
Improvement oneconomic and social indicators in Brazil
Poor and indigent: 6 metropolitan regions, 2002-08
IPEA
IPEA
Gini Index among labor force – Brazil 2002-2008
HDI by Region
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Illiteracy to 10%
% of homes with sewage disposal to 51,3%
Houses with: Refrigerator: 91,4%Television: 94,8%Computer: 27,0%Internet access: 20,4%
PNAD 2007 Improvement oneconomic and social indicators in Brazil
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Percent of indigents. Brasil, 1996-2006
Fonte: Ipea-Unifem -SPM- IBGE
Persistence ofinequalities:
Brazil: one of the 10 countries with higher income concentration
2007:10 % poorer: 1,1% of income10% richer 43,2% of income
Fotos: Tomas May
%
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Monitoring inequalities in health
Mortality and Life Expectancy
Morbidity
The use of health services
Self-evaluation on health and quality of life
Surviving – Letality
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Monitoring Mortality:
The most vulnerabledemographic groups
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Infant Mortality in Brazil1950 - 2005
Coef/1000NV
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Infant Mortality in Brazil1950 - 2005
Coef/1000NV
RR=1,3
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2000
Infant Mortality in Brazilian municipalities -2000.
Fonte: IDHS/PUC Minas.Atlas do desenvolvimento humano de 2003.
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Infant mortality according to maternal schoolingCampinas, SP, 2000-2006.
Rate ratioIMR
Coe
f/100
0NV
Years of education
Years of education
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00,5
11,5
22,5
33,5
44,5
1 a 14 15 -19 20-29 30-39 40-59 60-69 70-79
Relation between mortality rates of the worstand the best SEL according to age groups.
Campinas, SP, 2000-2001.
age
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Violent deaths
The homicide epidemy
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105
Rod.Anhanguera
kilômetros
∋0
Estratos Socioeconômicos e Taxas deMortalidade (por 100.000 habitantes)
Muito Baixo - 80,0Baixo - 57,2Médio - 32,4Alto - 17,7Muito Alto - 7,1
Zona Urbana
Limite Municipal
Rodovias
105
Rod.Anhanguera
kilômetros
∋0
Estratos Socioeconômicos e Taxas deMortalidade (por 100.000 habitantes)
Muito Baixo - 80,0Baixo - 57,2Médio - 32,4Alto - 17,7Muito Alto - 7,1
Zona Urbana
Limite Municipal
Rodovias
(*) The urban census tracts (Census 2000) of Campinas were grouped into 5 strataaccording to the percent of family head with 12 or more years of schooling.Sources : SMS-Campinas. CCAS/DMPS/FCM-UNICAMP.
Map 1 – Homicide rates according to SEL of urban censustracts (*). Campinas, 2003-2004.
MC Restitutti, 2008
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Homicides according to SEL of census tracts. Men, 15 - 39 years. Campinas, 2003-04 e 2006-07.
Coef./ 100.000hab
RR=16
RR=4,4
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2003200320032003 2004200420042004 2005200520052005
2006200620062006 2007200720072007
Homicides according to home places. Campinas, SP, 2003-2007
MC Restitutti, 2008
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Homicide mortality rates of men 15 to 39 years, according to socioeconomic strata. Campinas, 1995
a 2007.
Sources: Datasus/MS 1995–1999, SIM/SMS de Campinas 2000-2007
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Lifeexpectancy
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69,3
69,7
72,7
71,5
71,266,9
68,8
70,1
65,8
66,1
65 70 75 80 85
Sul
Norte
Noroeste
Sudoeste
Leste
77,2
76,9
79,4
78,1
78,4
77,0
77,7
78,4
75,7
75,6
65 70 75 80 85
Sul
Norte
Noroeste
Sudoeste
Leste
Life expectancy in years
Lifeexpectanc
yaccordingto gender
and HealthDistrictArea .
Male
Female
2000 2005
Source: Boletim no. 40:Esperança de vida em Campinas:
http://www.fcm.unicamp.br/centros/ccas/
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Survival
inequalities
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Demographic profile of AIDS patients according to years ofschooling. South and Southeast Regions cohort of 1998-99.
Ione A. Guibu et al, 2008. Relatório encaminhado para MS-SVS
Gender AgeTransmission
Men
<9 years
12 or +
RM = 1,6
RM = 4,2
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0.00
0.25
0.50
0.75
1.00
0 1000 2000 3000 4000analysis time
grau = 1 grau = 2grau = 3
Kaplan-Meier survival estimates, by grau
AIDS survival acoording to schooling. Brazilian cohort of 1995 and 1996; and South /Southeast cohort of 1998-99.
Ione A. Guibu et al, 2008. Relatório para MS
Sobrevidas - Ano 1995
Meses
100806040200
Sob
revi
da A
cum
.
1,0
,9
,8
,7
,6
,5
,4
,3
,2
,1
0,0
Escolaridade
3
2
1
0
Sobrevidas - Ano 1996
Meses
1009080706050403020100
Sob
revi
da A
cum
.
1,0
,9
,8
,7
,6
,5
,4
,3
,2
,1
0,0
Escolaridade
3
2
1
0
Marins, JRP. PhD Thesis UNICAMP, 2004.
19951998/99
1996
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Schooling 1995 1996 1998/99
< 8 years 26,8 39,6 63,6*
12 or more 51,8 70,4 79,0
Difference 24,0 40,8 15,4
Aids patients (%) surviving 60 months since case notification. Brazilian cohort 1994,1995 and
South/Southeast cohorte of 1998/99
Marins JRP. PhD Thesis, UNICAMP, 2006.
Ione A Guibu et al. Relatório para MS, 2008.
*<9
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Inequalities in
diseases
prevalence
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Prevalence of chronic diseases according to education. PNAD, 2003 (adults: 18 years or +)
Barros et al, 2006; Cien & Saude Coletiva. 11(4):911-26.PRadj=2,90
PRadj=3,23
PRadj=3,22
PRadj=1,75
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Prevalence rates of reported chronic conditions according to education. PNAD, 2003. (0-3 / 11 or + years of schooling)
Ciência e Saúde Coletiva, 11(4): 911-26, 2006
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Behaviour and health
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Obesity
Smoking
Monitoring health behaviour by education2006/2007 - VIGITEL
Vegetable and fruits (5 or + days a week)
Leisure time physical activity
Schooling (in years)
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Use of healthservices
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Use of health services by educational level(ISA-SP: Campinas)
Schooling(in years)
SS
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Social and geographic inequalities in thehealth services access
(PNADs: 1998- 2003)
(use of services in the last 15 days by individuals with restrict activities in the last 15 days)
� The access to health services in Brazil is strongly influenced bysocial conditions and place of residence.
� Reduction on social inequalities (income and education).
� Increase on regional differences.
Travassos et al. Cien Saúde Coletiva (2006):
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Final comments
� We have nowadays in Brazil data basis that allows us to evaluatethe trend in the magnitude of social and regional inequalities of a set of health indicators.
� These systems allow us to analyze the inequalities in the country, among the states, regions, municipalities and inner cities levels.
� The evidences point out that the inequalities may decrease in some aspects of health while increasing in others.
� The changes in these trends may occur very quickly depending onthe various and dynamic processes of the health/disease determinants.
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Challenges
� Coverage and quality of the health information systems that still are insufficient in many areas of Brazil.
� Inclusion or improvement of social variables (education, occupation, race, income ...) in those systems.
� To produce analysis of inequalities and their tendency aiming at convincing the health administrators. To encourage the inclusion of policies and goals in equity in the usual planning and programming activities on health.
� Methods and tecniques (time trends, spatial analysis, measures of inequalities, periods surveys) to improve the process of monitoring.
�To identify the impact of health intervention on social inequalities and the actions with evident impact on reducing social differences on health.
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Self-evaluation of health and quality of life
(PNAD, Vigitel, Pesquisa Mundial)
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Self-rated healthSocial inequalities in Brazilian capitals – VIGITEL, 2006. (Proportion
with “poor” health - PR adjust. by age)
Education
Race
Brazilian Region
RSP – 2009Suplemento sobre Vigitel, 2006
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Adolescent pregnancy by education (in years). Campinas,SP, 2000-07.
%
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Alcohol - Women
Alcohol - Men
Alcoholic driving - MenUV protection
Monitoring health behavior by education2006/2007 - VIGITEL
Schooling (in years)
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Relation between mortality rates of the worstand the best SEL according to age groups.
Campinas, SP, 2000-2001 e 2004-06.
age
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Religion and Health (ISA-SP: Campinas, 2002)
Smoking
ObesityCommon Mental Disorder
Alcohol - CAGE
%
%
%
%
S
S
S
NS
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Delivery by cesarian section according to education (in years).
Campinas, 2000-2007.
%
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Mammography(50 a 69 years)
Papanicolaou(25 a 59 years)
Preventive examination by educational levelin Brazilian Capitals. Vigitel, 2007.
% %
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MortalityMortality rates rates byby externalexternal causes causes accordingaccording to to healthhealthdistrictsdistricts areasareas. Campinas, 2000. Campinas, 2000-- 06.06.
Sources: Datasus/MS, 2000–2004, SIM/SMS-Campinas, 2005-2006
Deaths /100.000 inhabitantes
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Rate ratios of homicide according to SEL of censustracts. Men, 15 - 39 years. Campinas, 2003-04 e
2006-07.
MC Restitutti, 2008
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Barros et al, 2006; C & SC. 11(4):911-26.
Prevalence of chronic diseases according to education. PNAD, 2003 (adults: 18 years or +)
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ScalesSchooling (in years)
0 a 3 4 a 8 9 or +
Functional Capacity 65,6 73,9 79,7
Physical aspects 74,6 84,3 89,6
Pain 69,7 75,6 81,5
General health 67,2 70,4 75,6
Vitality 61,3 64,7 70,6
Emotional Aspects 82,6 88,1 90,2
Social Aspects 83,1 87,3 89,7
Mental health 67,7 69,2 76,0
Mean scores of SF-36 scales according to educationallevel. ISA-SP, 2001 – 2002.
Margareth Guimarães Lima et al. Master Thesis UNICAMP, 2008
(significant differences after adjustment for age and sex)
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� Desenvolvimento de pesquisaspesquisas interdisciplinaresinterdisciplinares paraproduzir evidências para intervenções e melhorcompreensão da associação do processo de globalização com os determinantes distais (“upstream variables”) do estado de saúde.(Labonté e Schrecker, 2007).
� Estimular iniciativas que buscam promover saúde e equidade por meio de: emponderamentoemponderamento, , participaparticipaççãoão e e capacidadecapacidade de de organizaorganizaççãoão dada populapopulaççãoão (Becker et al, 2007).
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� Importante ampliar possibilidade de participaparticipaççãoão dasdaspessoaspessoas queque vivemvivem a a situasituaççãoão de de pobrezapobreza e exclusãosocial nas atividades de desenvolvimento, planejamento, oferta e avaliação dos serviços de saúde, ampliando a participação nos processosprocessos de de decisãodecisão.
� Necessidade de definição de prioridades de problemas e de processos – Miller (2007) com a escolha de processosprocessos sociaissociais e e pluralpluralíísticossticos de açãomais que investimentos setoriais específicos.
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É necessário ir além das causas imediatas parafocar as “causas das causas”. E organizar um movimento global para fortalecer a busca daeqüidade entre países e no interior de cada país.
Busca que deve ser feita não apenas por razõeseconômicas, mas porque é certa, porque é justa.
(Marmot, 2007)
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www.fcm.unicamp.br/centros/ccas
FIM
É necessário ir além das causasimediatas para focar as “causas dascausas”. E organizar um movimentoglobal para fortalecer a busca daeqüidade entre países e no interior de cada país.
Busca que deve ser feita não apenaspor razões econômicas, mas porque écerta, porque é justa.
(Marmot, 2007)
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É necessário ir além das causasimediatas para focar as “causas dascausas”. E organizar um movimentoglobal para fortalecer a busca daeqüidade entre países e no interior de cada país.
Busca que deve ser feita nãoapenas por razões econômicas, mas porque é certa, porque é justa.
(Marmot, 2007)
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Homicídios por local de residência, 2003-2006
Restitutti MC
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Mas, o Brasil persiste entre os dez com as maiores concentrações de renda.Exibindo contrastes sociais profundos
O país do luxo:É o 3. país em realização de cirurgia plástica.O em consumo de cosméticos, perfumes..O em consumo de viagra e similares.Comércio de luxoUm jogador de futebol ganha
O país da misériaMilhões sem luz elétricaSem águaSem moradia decenteSem atendimento médico de qualidadeUma esportista ganhadora de medalha de bronze – mãe sem televisão para assistir.
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Medidas da magnitude das desigualdade Medidas da magnitude das desigualdade Medidas da magnitude das desigualdade Medidas da magnitude das desigualdade sociais em sasociais em sasociais em sasociais em saúúúúdededede
Índices que sumarizam as diferenças:
� Diferenças relativas e absolutas (RR e RA)
� Índices de efeito e de impacto total
� Medidas cruas ou modeladas
(15 tipos de medidas)
(Kusnt, A., 1997; Schneider et al, 2002)
Pan Am J Public Health, 12 (6) (2002) –editor: Carlos Castillo-Salgado
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Utilizando o conceito de classe social
�Trabalhadores manuais têm maior chance de se apresentarem mais prejudicados em vários domínios daauto-avaliação de saúde em estudo realizado na Suécia(Fors et al, 2007).
�Trabalhadores manuais na Finlândia apresentam riscosde morte por suicídio 2,3 vezes superior ao de trabalhadores não manuais, tendo a desigualdadeampliado entre 1970 e 1990 (Mäki e Martikainen, 2007).
�Estudo realizado em Barcelona utilizando os indicadoresde classe social de Wright aponta a contribuição original produzida pela abordagem de classe social na análise daauto-avaliação da saúde (Borrell et al, 2004).
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Desigualdades sociais em adultos e idosos (PNAD 1998 – PNAD 2003)
� Segmento de menor renda: menor uso de serviços de saúde
� A força de associação da renda com o uso de serviços não se modificou entre 1998 e 2003
� Não houve alteração na desigualdade social em saúde no período � ineficiência das políticas.
Lima-Costa et al, 2006
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5
10
15
20
25
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
%
Norte Sul Leste Sudoeste Noroeste Campinas
Figura 6 – Trend in the percentage of adolescent pregnancies,
according to Health Districts Areas. Campinas, 1995-2007.
Source:
Bol 41