Abstracts

Introduction

Arterial hypertension is considered the main modifiable risk factor for cardiovascular diseases (CVD) and kidney disease. It is defined by high blood pressure levels, or systolic blood pressure ≥ 140mmHg, and/or a diastolic blood pressure ≥ 90mmHg ¹1. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Brazilian guidelines of hypertension - 2020. Arq Bras Cardiol 2021; 116:516-658..

According to the World Health Organization (WHO), one in every four men and one in every five women had arterial hypertension in 2015 ²2. World Health Organization. Hypertension. https://www.who.int/news;room/fact;sheets/detail/hypertension (accessed on 06/Sep/2021).
https://www.who.int/news;room/fact;sheet... , and the global age standardized prevalence of arterial hypertension was estimated at 24.1% for men and 20.1% for women ³3. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19.1 million participants. Lancet 2017; 389:37-55.. Studies show a global increase in the number of people with this condition: in 1990, there were 2.18 billion people, and in 2019, 4.06 billion people ⁴4. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. The global burden of cardiovascular diseases and risks. J Am Coll Cardiol 2020; 76:2982-3021.. High systolic blood pressure was the second risk factor for disability-adjusted life years (DALYs) in 2019. Moreover, the total number of DALYs caused by high systolic blood pressure increased from 154 million (1990) to 235 million DALYs (2019), reaching 10.8 million deaths in 2019 ⁴4. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. The global burden of cardiovascular diseases and risks. J Am Coll Cardiol 2020; 76:2982-3021..

In Brazil, the frequency of medical diagnosis of arterial hypertension was 23.4%, which was higher for women (27.3%) than for men (21.2%) ⁵5. Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis, Secretaria de Vigilância em Saúde, Ministério da Saúde. Vigitel Brasil 2019: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal. Brasília: Ministério da Saúde; 2020.. Notably, estimates for hospitalization costs, ambulatory procedures, and medication provided by the Brazilian Unified National Health System (SUS) for the treatment of some noncommunicable diseases (NCDs) in 2018, indicated that arterial hypertension was responsible for 59% of the direct costs, corresponding to approximately BRL 2 billion per year ⁶6. Nilson EAF, Andrade RCS, Brito DA, Oliveira ML. Custos atribuíveis a obesidade, hipertensão e diabetes no Sistema Único de Saúde, Brasil, 2018. Rev Panam Salud Pública 2020; 44:e32..

Considering that care and access to health services are essential to prevent the worsening of NCDs, a study carried out in 2019 showed a significant increase in the prevalence of people who report care and use of health services to control arterial hypertension between 2003-2015, especially among older adults in the Municipality of São Paulo, Brazil ⁷7. Stopa SR, Cesar CLG, Alves MCGP, Barros MBA, Goldbaum M. Health services utilization to control arterial hypertension and diabetes mellitus in the city of São Paulo. Rev Bras Epidemiol 2019; 22:e190057.. Thus, our results indicate the importance of broadening the understanding of how adults with arterial hypertension use health services to control the disease in Brazil and, above all, provide data that can support health promotion strategies, reduce access barriers and inequalities.

Due to consequences of arterial hypertension for both individuals and the health system, it is required that health professionals focus on the treatment of health in general, especially on reducing the risk of future cardiovascular complications. Therefore, all the risk factors must be controlled conducting an integrated approach, involving both non-pharmacological (healthy eating habits, the practice of physical activities, and a reduction in alcohol consumption) and pharmacological strategies ⁸8. Whelton PK, Carey RM, Aronow WS, Casey Jr. DE, Collins KJ, Himmelfarb CD, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71:1269-324..

Besides the non-pharmacological and pharmacological strategies, it is necessary to pay particular attention to the social and health inequalities in the country, which represent a serious problem for the control and handling of arterial hypertension in primary healthcare (PHC). One literature review showed that in low- and middle-income countries there is an association between low socioeconomic levels and low educational attainment and NCDs, including arterial hypertension ⁹9. Niessen LW, Mohan D, Akuoku JK, Mirelman AJ, Ahmed S, Koehlmoos TP, et al. Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda. Lancet 2018; 391:2036-46..

Thus, the Care Lines (CL) are strategies which seek to strengthen and to organize health services, guaranteeing both integrity and longitudinal health care at every level of healthcare network (RAS) ⁹9. Niessen LW, Mohan D, Akuoku JK, Mirelman AJ, Ahmed S, Koehlmoos TP, et al. Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda. Lancet 2018; 391:2036-46.. The Brazilian Ministry of Health has created protocols for the care of NCDs and arterial hypertension adults, including longitudinal follow-up by primary health professionals ¹⁰10. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2014. (Cadernos de Atenção Básica, 35).. Other determinations by the Brazilian Society of Cardiology (SBC) and the WHO also emphasize the continuous follow-up and monitoring of the NCD in adults, as well as access to medication and care ¹1. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Brazilian guidelines of hypertension - 2020. Arq Bras Cardiol 2021; 116:516-658.^,1111. World Health Organization. Global NCD target: prevent heart attacks and strokes through drug therapy and counselling. Geneva: World Health Organization; 2016.. The Brazilian National Health Survey (PNS) is destined to provide information regarding the determining and conditioning factors and health needs of the Brazilian population, allowing for more consistent and effective measures and supporting effective public policies. It also enables monitoring the health care provided, by monitoring access to health services, medications, and services among patients with NCDs ¹²12. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29:e2020315..

This study can contribute to decision-making by health services, especially SUS, and for the reorganizing of the CL for people with hypertension. This study aimed: (a) to compare the indicators of care and access to health services by adults who self-reported hypertension in 2013 and 2019; (b) to analyze those indicators for 2019 according to gender, age group, education and ethnicity.

Methodology

Study design and sampling

This is a cross-sectional quantitative and analytic study, which used data from the PNS conducted in 2013 and 2019 by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Brazilian Ministry of Health.

The PNS sample was from conglomerates in three stages of selection: primary units (census sectors or group of sectors), secondary units (households), and tertiary units (residing adults aged ≥ 18 years) ¹²12. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29:e2020315.^,1313. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014.^,1414. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza-Júnior PRB, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Ciênc Saúde Colet 2014; 19:333-42.. In 2013, in the third stage of selection, the resident was selected randomly among those who were aged 15 years or older, based on the list of residents obtained at the moment of the interview. However, to be comparable to the PNS 2019, the analyses of the current study were performed only with residents aged 18 years or older.

To calculate the size of the sample, our study considered the average values, variances, and effects of the sampling plan, assuming a no-response rate of 20%. In 2013, the size of the sample was approximately 80,000 households, and information was collected from 64,348 households ¹⁴14. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza-Júnior PRB, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Ciênc Saúde Colet 2014; 19:333-42.. In 2019, the sample was 108,525 households, and data was collected from 94,114 households ¹²12. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29:e2020315..

Due to the complex sampling design and distinct probabilities of selection, it is necessary to define the expansion factors and sample weights, for both households and selected residents in order to analyze the data from the PNS. More detail about the sampling plan has been published elsewhere ¹²12. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29:e2020315.^,1414. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza-Júnior PRB, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Ciênc Saúde Colet 2014; 19:333-42..

To ensure comparability between the two editions of the survey, IBGE performed a new calibration of the PNS 2013 expansion factors considering the revision of the population projection of Federation Units by gender and age.

Variables of the study

The prevalence of self-reported hypertensive adults was evaluated by the answer “yes” to the question: “Has any physician ever diagnosed you with arterial hypertension (high blood pressure)?”. The prevalence of adults who had never had their blood pressure checked was evaluated by the answer “never” to the question: “When was the last time you had your blood pressure checked?”.

Among the adults who reported having arterial hypertension, the indicators referring to care and access to health services were evaluated.

(a) Proportion (%) of people who refer to having a medical diagnosis of arterial hypertension and had medication prescribed for them. Numerator: Q5b = 1/denominator: male: Q2a = 1; female: Q2a = 1 and Q2b = 2 (reported hypertension).

(b) Proportion (%) of people who have taken all the prescribed medication to control hypertension in the two weeks prior to the survey (Q6a = 1).

(c) Proportion of people who took some medication to control arterial hypertension and that obtained at least one medication from the program “We Have a Popular Pharmacy Here” (Aqui tem Farmácia Popular) (Q8a = 1 or 2).

(d) Proportion (%) of people who reported a medical diagnosis of arterial hypertension and had received medical care for hypertension within the last year (Q11a = 1 or 2).

(e) Proportion (%) of people who reported a medical diagnosis or arterial hypertension and had their last physician appointment at a basic health unit (Q12a = 2).

(f) Proportion (%) of people who reported a medical diagnosis of arterial hypertension and had an appointment with the same physician from the previous appointments. (Q16 = 1).

(g) Proportion (%) of people who had every appointment with a specialist, from the total number of people who reported a medical diagnosis of arterial hypertension [Q22 = 3 or (Q22 = 1 and Q23a = 1)].

(h) Proportion (%) of people who reported a medical diagnosis of arterial hypertension who were referred to schedule an appointment with a specialist and managed to have all the appointments with the specialist (Q23a = 1).

(i) Proportion (%) of people who reported a medical diagnosis of arterial hypertension and were hospitalized because of hypertension or a complication (Q26 = 1).

(j) Proportion (%) of people who reported a medical diagnosis of arterial hypertension and had a very intense or intense degree of limitation in their usual activities due to hypertension or to some complication (Q28 = 4 or 5).

If you want to find more details about the questions and the answer possibilities, have a look at the Supplementary Material (Box S1: http://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00125421_7485.pdf).

Statistical analysis

The prevalence and respective 95% confidence intervals (95%CI) of the indicators were estimated in 2013 and 2019. To analyze the comparisons of the indicators between the years studied, all indicators described above were considered, except for the items “prescribed medication” and “appointments with a specialist”, which were included only in the PNS 2019. The differences were evaluated by the Pearson’s chi-square test, considering p-value < 0.05.

For 2019, the prevalence ratios (PR) and 95%CI of the indicators were calculated according to gender (male and female); age group (18-29; 30-59; 60 years or older); education (no education or incomplete primary school; complete primary school and incomplete high school; complete high school and incomplete higher education; complete higher education); ethnicity (white, black, mixed-race; the other categories were added to the total, as they could not be individualized due to the small number of occurrences), using Poisson regression with robust variance. Furthermore, analyses were adjusted for gender, age, education level, and health plan. The level of significance was set at 5%.

The software for Stata, version 14.0 (https://www.stata.com) was used to analyze data using the survey method, which considers the effects of the sampling plan.

Ethical aspects

The PNS followed all recommendations set forth in Resolution n. 466/2012, which defines the directives and regulating norms for surveys involving human beings. The data from the PNS is available for access and public use, and both surveys were approved by the Brazilian National Ethics Research Committe (CONEP) from the Brazilian Ministry of Health, logged under protocol n. 328,159 for the 2013 edition and protocol n. 3,529,376 for the 2019 edition.

Results

In 2013, 60,202 individuals were evaluated and in 2019 88,531. Out of these, 21.4% (95%CI: 20.8; 22.0) of the adults reported arterial hypertension in 2013, while in 2019, the number had increased to 23.9% (95%CI: 23.5; 24.4). In 2013, 3% (95%CI: 2.7; 3.2) of the adult population reported never having had their blood pressure checked, while in 2019, the percentage had decreased to 1.6% (95%CI: 1.4; 1.8) (data not shown).

Figure 1 compares the health care indicators for arterial hypertension from the two surveys. In 2013, among the adults who reported hypertension, 81.6% (95%CI: 80.1; 82.7) mentioned that they were taking medication, while in 2019 the proportion increased to 86.9% (95%CI: 86.2; 87.7). In 2013, 35.8% (95%CI: 34.1; 37.7) of the hypertensive adults who took some type of medication to control hypertension had obtained at least one medication from the program “We Have a Popular Pharmacy Here”, and the proportion reduced to 45.1% (95%CI: 43.7; 46.5), in 2019. In 2013, 69.7%; (95%CI: 68.2; 71.2) of the adults with self-reported arterial hypertension had received medical care in the 12 months prior to the survey, and 46% (95%CI: 44.0; 47.7) had their last appointment at a basic health unit (UBS); in 2019, that proportion was 72.2% (95%CI: 71.1; 73.3) and 45.8% (95%CI: 44.5; 47.2), respectively. This study also investigated if the physician - with whom they had their appointment - was the same one as in previous appointments, and 56.5% (95%CI: 54.7; 58.1) of the interviewees responded affirmatively in 2013; in 2019, that proportion declined to 51.9% (95%CI: 50.6; 53.3). As regards being referred to a specialist, 87.1% (95%CI: 84.9; 89.4) mentioned that they had all of their appointments with specialists in 2013, while in 2019, the proportion was reduced to 79.1% (95%CI: 76.9; 81.2). From the total number of adults with self-reported arterial hypertension, 14% (95%CI: 12.9; 15.1) mentioned hospitalization due to the condition or complications related to it in 2013, whereas in 2019 that proportion was 15% (95%CI: 14.1; 15.9). Regarding the limitations, 4.7% (95%CI: 4.0; 5.4) of the hypertensive adults reported having an intense or very intense degree of limitation due to hypertension or to its complications, and that proportion decreased to 3% (95%CI: 2.7; 3.4) in 2019 (Figure 1).

Table 1 shows the care indicators for arterial hypertension in 2019, according to the interviewees’ gender. Women showed more reports of prescription (96.5%; 95%CI: 95.9; 97.0) and use of medications for arterial hypertension (89.6%; 95%CI: 88.6; 90.6). The proportion of adults who received medical care for arterial hypertension in the last 12 months (74.5%; 95%CI: 73.1; 75.8), who had their last consultation at a UBS (48.5%; 95%CI: 46.9; 50.2) and who were hospitalized for arterial hypertension or complications was also higher among women (15.9%; 95%CI: 14.8; 17.1). The other indicators showed similar proportions for all genders (Table 1).

Table 2 shows the differences in the care indicators for arterial hypertension, according to age group. In 2019, compared to young people aged 18-29 years, the older adults over 60 years reported more often having medication prescribed for arterial hypertension (98.8%; 95%CI: 98.4; 99.0) and making use of that medication (94.3%; 95%CI: 93.5; 94.9), greater access to the program "We Have a Popular Pharmacy Here" (45.1%; 95%CI: 43.5; 46.7), attendance by the same physician as in previous consultations (54.9%; 95%CI: 53.2; 56.7), referral to specialist physician (83.4; 95%CI: 80.6; 85.9) and all consultations with specialist physician (52.1%; 95%CI: 50.4; 53.9). The rest of the indicators showed similar proportions among the studied age groups (Table 2).

Table 3 describes the differences among arterial hypertension care indicators according to schooling level. The 2019 results show that individuals with complete higher education had less access to the “We Have a Popular Pharmacy Here” program. In individuals with complete high school/incomplete and complete higher education less medical assistance in the last year, having an intense or very intense limitation in performing daily activities and hospitalization for arterial hypertension or complications. On the other hand, the higher the schooling level, the greater the report of having performed all consultations with a specialist physician. Other indicators showed no statistically significant difference (Table 3).

Table 4 shows the differences in health care for arterial hypertension, according to ethnicity. The 2019 results show that black people had higher reports of hospitalization and intense or very intense limitation of daily activities. Besides, when we observe the proportion of individuals who declared that the last appointment occurred with the same physician as in the previous appointments, and who were referred to specialists, the proportion was lower among black people. Mixed-race individuals had a higher proportion of medical assistance in the last year. Black individuals reported less appointments with the same physician as the previous appointment. Other indicators showed similar proportions (Table 4).

Discussion

This study compares the care indicators and access to health services by people with arterial hypertension in 2013/2019 and analyzes the results of the PNS 2019. The prevalence of arterial hypertension was, approximately, one fourth of the adult population, and women showed a greater prevalence than men. When comparing the studied years, most care indicators changed during the period. We observed an increase in the following indicators: use of medication; acquisition of at least one medication from the “We Have a Popular Pharmacy Here” program; and medical care in the year before 2019. On the other hand, the results showed a reduction in follow-up by the same physician, in the referral or appointment with a specialist, and in reports of intense or very intense degrees of limitation in performing daily activities due to hypertension or related complications. In 2019 care indicators showed inequalities with worse results for men, younger population, those with low schooling level, and black individuals.

Based on these results, we can note that the SBC and the WHO protocols have been followed in most cases. The vast majority of the population had their blood pressure checked previously. Individuals are considered hypertensive when their systolic blood pressure is ≥ 140mmHg and/or their diastolic blood pressure is ≥ 90mmHg, and the SBC recommends in order to diagnose arterial hypertension ¹1. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Brazilian guidelines of hypertension - 2020. Arq Bras Cardiol 2021; 116:516-658.. Other auxiliary measures which can be used to diagnose arterial hypertension are the ambulatory monitoring of blood pressure and home monitoring of blood pressure, as long as these measures are both logistically and economically feasible.

In 2019, the proportion of arterial hypertension diagnosis was higher than 2013, probably for population aging ⁴4. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. The global burden of cardiovascular diseases and risks. J Am Coll Cardiol 2020; 76:2982-3021.. From 2013 to 2019, we found a reduction in the reports of follow-up by the same physician , which may indicate a concern for longitudinal follow-up - an essential measure in PHC to ensure continuity and integrity of medical care ¹⁵15. Ministério da Saúde. Portaria nº 4.279, de 30 de dezembro de 2010. Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2010; 31 dec.^,1616. Mendes EV. As redes de atenção à saúde. Brasília: Organização Pan-Americana da Saúde; 2011.^,1717. Ministério da Saúde. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 sep.. There was also a reduction in referrals to specialists, which may have been caused by the higher resoluteness of PHC, as well as by measures of fiscal austerity ¹⁸18. Paes-Sousa R, Rasella D, Carepa-Sousa J. Economic policy and public health: fiscal balance and population wellbeing. Saúde Debate 2018; 42(n esp. 3):172-82.^,1919. Massuda A, Hone T, Leles FAG, Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Glob Health 2018; 3:e000829.. On the other hand, we observed an increase in the use of medication by the patients, use of “We Have a Popular Pharmacy Here”, program and receiving medical care in the previous year. A study conducted in 2016 showed that about one third of the hypertensive patients had already obtained at least one medicine in the “We Have a Popular Pharmacy Here” program. Note that, this strategy is an accessible source mainly for the most disadvantaged population since it contributes to health equity ²⁰20. Costa KS, Tavares NU, Mengue SS, Pereira MA, Malta DC, Silva Júnior JB. Obtenção de medicamentos para hipertensão e diabetes no Programa Farmácia Popular do Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2016; 25:33-44..

Our study showed a higher prevalence of arterial hypertension among women, perhaps indicating a limitation of the self-report method of the PNS. Studies using blood pressure measurement show higher blood pressures in men ¹1. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Brazilian guidelines of hypertension - 2020. Arq Bras Cardiol 2021; 116:516-658.^,2121. Malta DC, Santos NB, Perillo RD, Szwarcwald CL. Prevalence of high blood pressure measured in the Brazilian population, National Health Survey, 2013. São Paulo Med J 2016; 134:163-70.. In general, the care indicators show that women seek services more often, have their blood pressure checked more often, and show better healthcare indicators ²¹21. Malta DC, Santos NB, Perillo RD, Szwarcwald CL. Prevalence of high blood pressure measured in the Brazilian population, National Health Survey, 2013. São Paulo Med J 2016; 134:163-70.^,2222. Lima-Costa MF, Matos DL, Camarano AA. Evolução das desigualdades sociais em saúde entre idosos e adultos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios (PNAD 1998, 2003). Ciênc Saúde Colet 2006; 11:941-50.^,2323. Levorato CD, Mello LM, Silva AS, Nunes AA. Fatores associados a` procura por servic¸os de sau´de numa perspectiva relacional de ge^nero. Ciênc Saúde Colet 2014; 19:1263-74.. Other studies described this same trend that can be understood in terms of the feelings of masculinity and a perception of needing less health care, since men feel stronger and less susceptible to illnesses <sup>24</sup>24. Coelho EBS, Schwarz E, Bolsoni CC, Conceic¸a~o TB. Poli´tica Nacional de Atenc¸a~o Integral a` Sau´de do Homem. Floriano´polis: Universidade Federal de Santa Catarina; 2018..

The analysis of ethnicity reveals inequalities in health care. Brazil is an unequal country, with countless examples of structural racism ²⁵25. Batista LE, Barros S. Confronting racism in health services. Cad Sau´de Pu´blica 2017; 33 Suppl 1:e00090516., regarding access to jobs, lower wages for black and mixed-race people, higher mortality of young black people, and different approach by security agents (whether public or private) towards blacks ²⁶26. Anunciac¸a~o D, Trad LAB, Ferreira T. "Hands up!": police stop-and-frisk, racism and structural violence among black youth from three capitals in the Brazilian Northeast. Sau´de Soc 2020; 29:e190271.. Our study showed inequalities related to ethnicity revealed by less access to specialists and by a continuity of health care.

Some results show the significance of the SUS and universal access to health to reduce these inequalities, since we did not find difference in the prescription and use of medicines for arterial hypertension, as well as for better access to basic health services, which are a gateway to health access for the Brazilian population. The SUS, in its 30 years of existence, has provided important advances to reduce morbidity, mortality, and health inequalities ¹⁹19. Massuda A, Hone T, Leles FAG, Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Glob Health 2018; 3:e000829.^,2727. Souza MFM, Malta DC, França EB, Barreto ML. Changes in health and disease in Brazil and its States in the 30 years since the Unified Healthcare System (SUS) was created. Ciênc Saúde Colet 2018; 23:1737-50..

The populations with lower education show higher prevalence of arterial hypertension hospitalization, limitations caused by this condition, and less access to specialized services. Other studies ²⁸28. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Ciênc Saúde Colet 2011; 16:3755-68.^,2929. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMAD, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51 Suppl 1:4s. also described those iniquities, and they are a result of social inequalities and socioeconomic disadvantages that affect those vulnerable populations, resulting in worse performance, as well as in more disabilities. We observed no difference in relation to medication prescription and access to medication. Moreover, population with low income and schooling level used more frequently the UBS, showing how important SUS is in the promotion of health equity ³⁰30. Magalhães Junior HM, Pinto HA. Atenção básica enquanto ordenadora da rede e coordenadora do cuidado: ainda uma utopia? Divulg Saúde Debate 2014; 51:14-29.. SUS reduces inequalities in health and allows those populations to have access to diagnosis, services, and treatment.

Notably, a significant portion of adults with arterial hypertension had the last appointment at a UBS, along with free access to medication, to treatment inputs, to health promotion actions, and to health care. The UBS is the front door to SUS, coordinating the care for people with NCDs ¹⁵15. Ministério da Saúde. Portaria nº 4.279, de 30 de dezembro de 2010. Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2010; 31 dec.^,1616. Mendes EV. As redes de atenção à saúde. Brasília: Organização Pan-Americana da Saúde; 2011.^,1717. Ministério da Saúde. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 sep.^,3131. Secretaria de Atenção à Saúde, Ministério da Saúde. Diretrizes para o cuidado das pessoas com doenças crônicas nas redes de atenção à saúde e nas linhas de cuidado prioritárias. Brasília: Ministério da Saúde; 2013.. The care provided to individuals with NCDs must be provided in an integral and articulated manner, and health promotion must be prioritized. Moreover, protection, surveillance, disease prevention, and medical care, together with individual specificities, should also be considered ¹⁵15. Ministério da Saúde. Portaria nº 4.279, de 30 de dezembro de 2010. Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2010; 31 dec.^,1616. Mendes EV. As redes de atenção à saúde. Brasília: Organização Pan-Americana da Saúde; 2011.^,1717. Ministério da Saúde. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 sep.^,3131. Secretaria de Atenção à Saúde, Ministério da Saúde. Diretrizes para o cuidado das pessoas com doenças crônicas nas redes de atenção à saúde e nas linhas de cuidado prioritárias. Brasília: Ministério da Saúde; 2013..

Therefore, considering access to care for hypertension, lower education and ethnical profile are factors of inequity. This fact increases the demand for affirmative public policies to fight the social inequalities in Brazil ²⁸28. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Ciênc Saúde Colet 2011; 16:3755-68.^,3232. Instituto Brasileiro de Geografia e Estatística. Síntese de indicadores sociais 2010: uma análise das condições de vida da população brasileira. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2010.^,3333. Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface (Botucatu) 2009; 13:383-94.^,3434. Lopes F. Para além da barreira dos números: desigualdades raciais e saúde. Cad Saúde Pública 2005; 21:1595-601.. Aging causes progressive hardening and loss of complacency of the main arteries, explaining the higher prevalence of such problems for older adults ¹1. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Brazilian guidelines of hypertension - 2020. Arq Bras Cardiol 2021; 116:516-658.. However, the older adults tend to seek health services more often ³⁵35. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública 2017; 51 Suppl 1:3s., and this study identified that, in general, the healthcare indicators were better for the people aged 60 years and over, including those who more often search for services, and medical care, medications, as well as a higher proportion of hospitalizations and disabilities.

After 2016, Brazil underwent a deep economic crisis and has resorted to fiscal austerity measures, which resulted in a worse performance in the field of health and an increase in the indicators of morbimortality ¹⁸18. Paes-Sousa R, Rasella D, Carepa-Sousa J. Economic policy and public health: fiscal balance and population wellbeing. Saúde Debate 2018; 42(n esp. 3):172-82.^,3636. Paes-Sousa R, Schramm JMA, Mendes LVP. Fiscal austerity and the health sector: the cost of adjustments. Ciênc Saúde Colet 2019; 24:4375-84.^,3737. Silva AGD, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Ciênc Saúde Colet 2021; 26:1193-206.. The Gross Domestic Product (GDP) has declined, and consequently, the investments in health, at the Federal level, as well as at the state and municipal levels ¹⁸18. Paes-Sousa R, Rasella D, Carepa-Sousa J. Economic policy and public health: fiscal balance and population wellbeing. Saúde Debate 2018; 42(n esp. 3):172-82.. In 2019, SUS lost BRL 20 billion in investments due to Constitutional Amendment n. 95/2016³⁸38. Conselho Nacional de Saúde. Saúde perdeu R$ 20 bilhões em 2019 por causa da EC 95/2016. https://conselho.saude.gov.br/ultimas-noticias-cns/1044-saude-perdeu-r-20-bilhoes-em-2019-por-causa-da-ec-95-2016 (accessed on 15/Sep/2021).
https://conselho.saude.gov.br/ultimas-no... . The PNS shows that a great majority of the population depends on, and uses SUS; therefore, these budget cuts and austerity policies may have terrible consequences upon the performance of SUS. However, the PNS 2019 shows that most of the indicators of PHC in dealing with hypertension have changed. Moreover, it indicated that, especially those with lower schooling level and black depending most on public services are more affected. Thus, it is essential to rebuild the budget and increase the investments in SUS.

Although the arterial hypertension is associated with genetic conditions, we must consider the relationship between the arterial hypertension and socioeconomic factors, such as low schooling level, low family income, and inadequate housing conditions ³⁹39. Schmidt MI, Duncan BB, Hoffmann JF, Moura L, Malta DC, Carvalho RMSV, et al. Prevalence of diabetes and hypertension based on self;reported morbidity survey, Brazil, 2006. Rev Saúde Pública 2009; 43 Suppl 2:74-82.^,4040. Andrade MV, Noronha K, Oliveira CL, Cardoso CS, Calazans JA, Julião NA, et al. Análise da linha de cuidado para pacientes com diabetes mellitus e hipertensão arterial: a experiência de um município de pequeno porte no Brasil. Rev Bras Estud Popul 2019; 36:e0104.. The importance of metabolic risk factors and hypertension should also be mentioned: dyslipidemia, abdominal obesity, and intolerance to glucose and diabetes mellitus; however, the behavioral risk factors, such as inadequate nutrition, lack of physical activity, abusive alcohol consumption, and smoking, are modifiable and can change even the intermediate risk factors (metabolic) ¹1. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Brazilian guidelines of hypertension - 2020. Arq Bras Cardiol 2021; 116:516-658.^,4141. Beaglehole R, Bonita R, Horton R, Ezzati M, Bhala N, Amuyunzu-Nyamongo M, et al. Measuring progress on NCDs: one goal and five targets. Lancet 2012; 380:1283-5.^,4242. World Health Organization. Noncommunicable diseases progress monitor 2020. Geneva: World Health Organization; 2020..

The most important limitations of the cross-sectional study are the impossibility of identifying if the exposure precedes or is a consequence of the health-related disease, that is, a cause-and-effect relationship. Regarding the data, the arterial hypertension diagnosis was self-reported by the adult and registered by an interviewer, being, therefore, subject to information bias. This type of bias may over or underestimate the results. However, studies comparing reported information and measurements have good reproducibility ¹²12. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29:e2020315.. Moreover, our study did not evaluate the quality of medical care, which might affect the increase or decrease in demand to health services. Our study advances in adjusting the presence of a health plan, since it expresses the better reality of how population with arterial hypertension use health services.

Conclusion

This study identified an increase in prevalence of arterial hypertension. By contrast, we noticed that even when faced with threats to SUS, medical care, especially primary care, was still provided, with detection and early follow-up for adults with arterial hypertension. However, there are great inequalities when socioeconomic data is considered, mainly among males, black, low educated, and young age.

Considering this scenario, it becomes even more essential to invest in SUS and in public policies to reduce inequalities, as well as propose actions to raise awareness of antihypertensive use, guidance, and appointments with specialists and diagnostic support. The need to progress in regulatory policies and health actions which guide health promotion for the entire population is evident, for instance, the reduction of sodium in foods, the encouragement of physical activities practicing, the prevention of smoking and alcohol consumption, as well as medical care when necessary.

Acknowledgments

We thank the Brazilian National Research Council (CNPq), for the Research Productivity granted to Deborah Carvalho Malta. We also thank the Brazilian Graduate Studies Coordinating Board (CAPES), for the PhD scholarship received by Fabiana Martins Dias de Andrade, and the Brazilian Ministry of Health for the funding via the Brazilian National Health Survey Execution Term (TED/PNS 18/2019).

References

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