Services on Demand
Print version ISSN 0034-8910
Rev. Saúde Pública vol.42 n.6 São Paulo Dec. 2008 Epub Oct 09, 2008
Prevalencia de consultas médicas y factores asociados en Pelotas (Sur de Brasil), 1999-2000
Juvenal Soares Dias da CostaI, II; Mauri Caldeira ReisIII; Claudio Viana Silveira FilhoIII; Rogério da Silva LinharesIII; Fábio PiccininiIII
de Pós-Graduação em Saúde Coletiva. Universidade
do Vale do Rio dos Sinos. São Leopoldo, RS, Brasil
IIDepartamento de Medicina Social. Faculdade de Medicina. Universidade Federal de Pelotas (UFPel). Pelotas, RS, Brasil
IIIPrograma de Residência em Medicina Preventiva e Social. UFPel. Pelotas. RS, Brasil
To estimate the prevalence of visiting doctors and to analyze associated factors.
METHODS: Cross-sectional, population-based study performed in the city of Pelotas, Southern Brazil, between December 1999 and April 2000. A total of 1,962 individuals of both sexes, aged between 20 and 69 years and living in the urban area were included in this study. Data were collected with standardized, pre-coded questionnaires. The outcome "visited doctor during the 12 months prior to interview" was analyzed with socioeconomic and demographic factors, presence of chronic diseases and psychiatric disorders, nutritional status, smoking, alcohol consumption, and hospitalizations in the year prior to interview. Poisson regression was used, according to a hierarchical model, controlled by confounding variables, and considering a significance level of <0.05.
RESULTS: Among interviewees, 1,395 (70.9%) had visited a doctor in the period analyzed. Multivariate analysis among men revealed that individuals who showed higher prevalences of medical visits had a per capita family income higher than 10 minimum wages per month, were over 60 years of age, suffered from diabetes mellitus, had a body mass index equal to or above 25kg/m², and had been hospitalized. Women who had a per capita family income higher than six minimum wages per month, were over 60 years of age, white and non-smokers, suffered from hypertension and diabetes, and had been hospitalized showed higher outcome prevalences.
CONCLUSIONS: Health inequalities were identified in relation to ethnicity and family income. In addition, there was high prevalence of medical visits, especially among individuals who were older and suffered from certain chronic, non-communicable diseases.
Descriptors: Health Services, utilization. Office Visits. Socioeconomic Factors. Health Inequalities. Cross-Sectional Studies.
Estimar la prevalencia de consultas con un médico y analizar factores
asociados a ella.
MÉTODOS: Se realizó estudio transversal de base poblacional de diciembre de 1999 a abril de 2000, en la ciudad de Pelotas (Sur de Brasil). Fueron incluidos 1.962 individuos de ambos sexos, de 20 a 69 años, residentes en la zona urbana. Los datos fueron colectados por medio de cuestionarios estandarizados y pre-codificados. La condición "consultar con médico en los 12 meses antes de la entrevista" fue analizada con factores socioeconómicos, demográficos, presencia de enfermedades crónicas y disturbios psiquiátricos, estado nutricional, tabaquismo, consumo de bebidas alcohólicas e internación en el año anterior a la entrevista. Fue realizada una regresión de Poisson siguiendo el modelo jerarquizado, controlado por variables de confusión, considerando nivel de significancia <0,05.
RESULTADOS: Entre los entrevistados, 1.395 (70,9%) habían consultado con un médico en el período analizado. El análisis multivariado entre los hombres reveló que los individuos que presentaron mayor prevalencia de consultas con médico poseían renta familiar per capita mayor de 10 salarios mínimos, más de 60 años de edad, diabetes mellitas, índice de masa corporal mayor o igual a 25 kg/m2 y que habían sido hospitalizados. Las mujeres con renta familiar per capita por encima de seis salarios mínimos, con mas de 60 años, blancas, no fumadoras, con hipertensión arterial, con diabetes y las que habían sido hospitalizadas presentaron mayor prevalencia de la condición.
CONCLUSIONES: Fueron identificadas inequidades en salud con relación al color de la piel y renta familiar y alta prevalencia de consulta con médicos, principalmente entre los individuos de mayor edad y con algunas enfermedades crónicas no transmisibles.
Descriptores: Servicios de Salud, utilización. Visita a Consultorio Médico. Factores Socioeconómicos. Desigualdades en la Salud. Estudios Transversales.
Health service access measures are some of the criteria that guarantee health system quality. This is based on the principle that people have the right to use health systems. However, according to the Black Report,10 morbidity and mortality are higher among individuals who were not qualified or partially qualified for a job. Moreover, those who were not qualified used health services, especially services of a preventive nature, less frequently than the occupational groups.10 National studies have pointed to socioeconomic, gender and geographic differences in terms of health service utilization.16,18,22 According to epidemiological studies performed in the city of Pelotas, Southern Brazil, population groups who most frequently use health services show better indicators related to health care.4,5 In addition, the characteristics of the population groups who use these services less frequently have been shown, revealing inequalities in the local health system.5
Based on epidemiological data, factors that promote and/or hinder access to the health system could be identified, thus contributing to its rationalization and qualification.
The present study aimed to estimate the prevalence of medical visits and also to analyze associated factors.
Population-based, cross-sectional study performed between December 1999 and April 2000 with male and female individuals, aged between 20 and 69 years, living in the city of Pelotas urban area.
A project was developed with the Universidade Federal de Pelotas and the Universidade do Vale do Rio dos Sinos (Federal University of Pelotas and Vale do Rio dos Sinos University), involving multiple outcomes. The sample was calculated, based on estimates of prevalences of different outcomes included in this study, to guarantee 80% power, 5% alpha error, prevalence of events investigated varying between 25% and 75%, and a prevalence ratio of 2.0. The sample was increased by 10% to compensate for losses and refusals, and by other 15% to assure control of confusion factors in the multivariate analysis. Sample size was estimated as 1,800 individuals.
Sampling was carried out in multiple stages; first by conglomerates, when 40 census tracts and 30 homes from each tract were randomly selected. A total of 1,200 families and 1.5 person, aged between 20 and 69 years, were expected to be identified. In each tract, the starting point and block were randomly chosen. After choosing a home, the two homes following it were systematically ignored, and the third one was visited.
A total of 1,145 families (95.4%) were found, of which 55 refused to participate or were not found and thus classified as losses. All family members aged between 20 and 69 years were eligible and interviewed in private. Among the families found, 2,177 people were identified, and 1,968 within the age group studied were interviewed, totaling 9.8% of loss. Women of fertile age who were either pregnant or had delivered a baby in the 12 months preceding the interview, or yet individuals with limitations and inabilities, which cause them to be dependent on someone else to have access to health services, showed very low prevalences and were included in the analysis. In all, 1,962 adults were interviewed.
The instrument employed was a pre-coded, standardized questionnaire, applied by university students from the Universidade Federal de Pelotas who were not aware of the research objectives. Interviewers were trained to apply the questionnaire and take weight, height, and blood pressure measurements.
The outcome assessed was visiting doctors in the previous year, since the interview date.
Variables related to socioeconomic level were the following: economic class classification from the Associação Brasileira de Empresas de Pesquisas e Mercados - ABEPª(Brazilian Association of Research and Market Companies), per capita family income in minimum wages, and level of education. Economic class classification is a score based on wealth accumulation and level of education, where class A individuals show higher values.
The demographic variables analyzed were as follows: sex, age, ethnicity and marital status.
Life habits assessed were smoking and alcoholic beverage consumption. Smoking was considered as the habit of smoking, classifying individuals as non-smokers, ex-smokers, and smokers. Alcoholic beverage consumption was quantified in grams of ethanol consumed per day, considering frequency and type of beverage, and the cut-off point to define abuse was set at 30g/day.14
To assess nutritional status, the body mass index (BMI) was calculated for each individual, based on weight (kg) and height (m) measurements taken by interviewers. BMI values >25.0 were considered as overweight.
Comorbidity by some chronic, non-communicable diseases was analyzed: diabetes mellitus, systemic arterial hypertension, minor psychiatric disorders and chronic bronchitis. Presence of diabetes mellitus was reported by the interviewee. Arterial blood pressure measurement used was the average from two measurements taken during questionnaire application. Systemic arterial hypertension was defined as arterial blood pressure >160/95 mmHg (to increase specificity17), or by means of self-reported antihypertensive medication.
Presence of minor psychiatric disorders was established with the use of the Self Report Questionnaire (SRQ-20), with a cut-off point >6 for men and >7 for women.11 Chronic bronchitis was determined by the presence of productive cough on most days, for three months or more, for at least two consecutive years.21
Interviewees were asked about possible hospitalization in the period of one year prior to interview.
As quality control, simplified questionnaires were re-applied to 10% of the sample. Data were codified in Epi-Info with double-typing.
In the crude analysis, prevalence ratios and 95% confidence intervals (95% CI) were calculated, and linear tendency and chi-square test were performed when indicated.3 According to the literature, women use health services more frequently than men do, thus crude and adjusted analyses were stratified by sex.5,18,22 Analyses were made with the SPSS 13.0. software.
Poisson regression was the multivariate analysis performed, using the Stata software, according to a hierarchical model, so that confounding variables were controlled.2,23 Variables with a significance level of P<0.20 in the crude analysis were introduced in the model, and those with a significance level of P<0.05 remained in the model. Figure 1 shows the hierarchical model adopted: socioeconomic and demographic variables were included on the first level; on the second level, life habits and morbidity; on the third level, the variable "hospitalizations in the previous year".
The research project was approved by the Research Ethics Committee of Universidade Federal de Pelotas School of Medicine.
Among interviewees, 1,395 (70.9%; 95%CI[69.1;73.1]) had visited a doctor in the year prior to interview. All the 846 (43%) male individuals had an average of 1.8 (95%CI[1.6;2.0]) medical visits in the previous year, whereas the 1,122 (57%) women interviewed had an average of 4.7 (95%CI[4.1;5.2]) visits.
Table 1 shows the sample characteristics according to sex.
Class C predominated among both men and women, the majority of them had a per capita family income <3 minimum wages per month, and approximately half of them had not completed grades 5 through 8 (G5 - G8) in school. Likewise, among both sexes, the majority were younger than 50 years of age, white, and married or cohabitating. Over half of the men reported they were either smokers or ex-smokers, almost a third consumed alcoholic beverages abusively, and approximately half were overweight. As regards smoking, less than half of the female interviewees reported they were smokers or ex-smokers, 3.8% of them consumed alcohol abusively, and more than half were overweight.
In terms of morbidity, 5.1% of men mentioned diabetes mellitus, 21.4% had arterial hypertension, 21% minor psychiatric disorders, and 4.7% chronic bronchitis. Among women, the presence of minor psychiatric disorders predominated, 5.9% mentioned diabetes mellitus, 25.1% had hypertension, and 4.1% chronic bronchitis. Prevalence of hospitalization among men was 6.3%, whereas among women, 21.7%.
Bivariate analysis showed that the higher the economic class, per capita income and level of education, the more likely men and women were to visit a doctor. These three factors showed significant linear tendency test results (Tables 2 and 3).
Men aged between 30 and 39 years were 20% less likely to visit a doctor in the previous 12 months than those aged over 60 years (reference category).
There were no percentage differences of medical visits in terms of ethnic group or marital status (Table 2). As regards age among women, effect measures were greater in the 40-to-49-year and 60-to-69-year age groups (Table 3). Frequency of medical visits was 9% higher among those classified as white. Marital status analysis showed that widows visited doctors 4% more frequently. In the assessment of male behavioral variables, smoking (p=0.04) and obesity (p=0.001) were associated with medical visits. In terms of female life habits, bivariate analysis showed that smokers were 10% less likely to visit a doctor than those who never smoked. There were no statistically significant differences between alcohol consumption and BMI (Table 3).
Among morbidities, men who reported diabetes mellitus visited doctors more often. Arterial hypertension, presence of minor psychiatric disorders and chronic bronchitis did not show statistically significant association with medical visits among men. Only the occurrence of hospitalization in the previous year was significantly associated. Among women, presence of diabetes mellitus and hypertension showed higher prevalences of medical visits. Presence of minor psychiatric disorders and chronic bronchitis were not associated with the outcome (Table 3). Like men, occurrence of hospitalization in the previous year was related to a higher frequency of visits to doctors (p<0.01).
In the multivariate analysis (Table 2), men with a per capita family income between 3.01 and six minimum wages per month and those with an income higher than 10.01 minimum wages per month visited doctors more often after adjustment for level of education and age. The effect of age was kept in the 60-to-69-year age group. After adjustment for the income and age variables, individuals who reported they had diabetes mellitus, were overweight or had been hospitalized visited doctors more frequently. Among women, multivariate analysis (Table 3) showed that people with a per capita family income from six minimum wages per month, in the 40-to-49-year and above-60-year age groups, and classified as white visited doctors more often. Women who did not smoke, mentioned diabetes mellitus and arterial hypertension, and had been hospitalized in the previous year showed higher outcome prevalences (Table 3).
The main methodological difficulty for studies that investigate service utilization is the lack of outcome validation. Studies on health service utilization are subject to imperfections in terms of quality of information provided by interviewees. Some authors point to the difficulty in validating health service utilization.8,15 Despite these limitations, data employed in the analysis originated from a population-based sample, whose make-up in terms of sex and gender was comparable to that found in the city of Pelotas 2000 census, thus confirming that they are representative.
In this study, prevalence of medical visits in the previous year was high. Among the 1,962 interviewees, 1,395 (70.9%; 95%CI[69.1;73.1]) had visited a doctor in the year prior to interview. Mendonza-Sassi & Beria,13 in a systematic review on health service utilization, observed that in countries such as the United States, Norway, Ireland, and Brazil the coverage of medical visits during one year reached 60% to 70% of the population. In the city of Pelotas, a study performed in 1992 showed that the utilization coverage in the same age group was 70%.5 In the city of Rio Grande, Southern Brazil, a population-based, cross-sectional study revealed that 66% of individuals at age 15 or older had visited a doctor in the year prior to interview.12
Data obtained in this study show that, among both sexes, older people visited doctors more frequently. Travassos et al,22 while assessing data from the Pesquisa Nacional por Amostra de Domicílios - PNAD (National Household Sample Survey) conducted in 1998, in Brazil, did not find differences in age among women, but observed that, among men, older individuals showed higher frequency of health service utilization. Other authors5,12 found an association between older age group and higher frequency of medical visits. Older individuals showed higher prevalence of chronic, non-communicable diseases that have a greater influence on health, requiring more contact with services.3,9
The prevalence of medical visits in the population assessed was 9% (95%CI: 1.00;1.18) higher among white women than non-white ones. This finding corroborates what was found by Travassos et al,22 in the PNAD survey conducted in 1998, where a frequency 14% (95%CI: 1.03;1.26) higher of health service utilization by white women was observed. The following studies, also performed in the city of Pelotas, showed that the quality of health care for women classified as non-white was worse than that received by white women. Quadros et al19 showed that non-white women had less coverage for cytopathological exams and Sclowitz et al20 revealed low coverage of exams conducted by non-white women. Thus, this finding identifies a population group that must be prioritized by health services.
Moreover, among women exclusively, marital status influenced the frequency of medical visits: those who were separated visited doctors less often in the period of one year prior to interview. Capilheira & Santos4 had already observed that in the city of Pelotas, separated women showed a 0.89 prevalence ratio for medical visit presence in the three months preceding assessment.
When the relation between per capita family income and outcome is analyzed, there were higher frequencies of medical visits in the period of one year among women with higher income. Studies have shown lower health service utilization by populations with low socioeconomic level,12,16,22 even though, as already pointed out, these populations have greater need to use health services,6 thus evidencing inequality. To seek for health equality means to eliminate inequalities systematically associated with underlying social disadvantages or marginalization. The health system has the responsibility to facilitate utilization by those who most need it, reducing the burden of diseases. Thus, health services can be promising locations for policies aimed at equality and interventions to reduce impoverishment, due to health care costs, and to prevent decrease in social class due to diseases.24
Among men, obesity was associated with a higher frequency of medical visits in the previous year, as observed by Capilheira & Santos.4 In this study, for both sexes, the diabetes mellitus reference was associated with higher frequency of medical visits. The association between the presence of chronic diseases and higher health service utilization has been reported by other authors.1 These findings were positive, revealing that people with recognized needs seek health services.6
Individuals of both sexes, who had been hospitalized, had used health services more frequently. Guerra & Ramos-Cerqueira7 observed comparable behavior in the city of São Paulo (Southeastern Brazil), with a frequency of hospitalizations 75% higher among individuals with higher prevalences of medical visits in the year prior to interview.
The present study described characteristics of the population that visited doctors during one year. However, the reasons that led these individuals to use health services could not be pinpointed. Some suppositions may justify these differences, such as difficulty to access these services, self-perception of health, flawed health care model, and the presence or absence of the family health program.
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Correspondence: Received: 1/14/2008
Juvenal Soares Dias da Costa
Av. Duque de Caxias, 250
96030-002 Pelotas, RS, Brasil
Research supported by the Fundação de Amparo à Pesquisa do Rio Grande do Sul - Fapergs (State of Rio Grande do Sul Research Foundation) (Processo n. 98/1767.5) and the Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq (National Council for Scientific and Technological Development) (CNPq - Processos n. 520884/99 and n. 52025/99-7).