Social inequalities in care for the elderly with diabetes in Brazil

Desigualdades sociales en la atención de las personas mayores con diabetes en Brasil

Desigualdades sociais na atenção a idosos com diabetes no Brasil

Rosália Garcia Neves Suele Manjourany Silva Duro Thaynã Ramos Flores Andrea Wendt Caroline dos Santos Costa Bruno Pereira Nunes Fernando César Wehrmeister Javier Muñiz Teresa Rosalia Pérez Castro Elaine Tomasi About the authors

ABSTRACT

Objective.

To measure the prevalence of various care services offered to the elderly with diabetes mellitus in Brazil, and to assess the social inequalities in these services.

Methods.

This cross-sectional, population-based study was carried out in 2013. The care services offered were evaluated in terms of the following eight indicators: recommendations to lower carbohydrates, to measure blood glucose, and to examine the feet; requests made for blood tests, for glycated hemoglobin tests, and for glycemic curve tests; and whether service users had had their eyes or feet examined in the previous year. We used the slope index of inequality and the concentration index to assess the inequalities among wealth quintiles.

Results.

A total of 1 685 elderly persons with diabetes were evaluated. Overall, 41.7% of them had had their eyes examined in the preceding year, 35.4% had had their feet examined in the preceding year, and 10.9% had been offered all eight of the care services. The largest absolute differences (in percentage points) between the first (poorest) and fifth (richest) wealth quintiles in terms of the care services that were offered to the users were for: a recommendation to measure blood glucose (25.8), a glycated hemoglobin test request (27.4), a glycemic curve test request (31.9), having the eyes examined in the preceding year (29.3), and having the feet examined in the preceding year (27.0).

Conclusion.

There were notable inequalities in the prevalences of the care services. In the future, measurement of blood glucose and examination of the feet should be emphasized, especially for elderly persons in a lower socioeconomic level.

Key words
Diabetes mellitus; health status disparities; quality of health care; quality indicators; health care; health services research; Brazil

RESUMEN

Objetivo.

Medir la prevalencia de los diversos servicios de atención que se ofrecen a las personas mayores con diabetes mellitus en Brasil y evaluar las desigualdades sociales en dichos servicios.

Métodos.

Este estudio transversal y basado en la población se llevó a cabo en el 2013. Los servicios de atención que se ofrecen se evaluaron en cuanto a los siguientes ocho indicadores: recomendaciones para reducir los carbohidratos, medir la glucemia y revisarse los pies; solicitudes de análisis de sangre, pruebas de glucohemoglobina y pruebas de la curva de glucemia; y si a los usuarios de los servicios les habían examinado los ojos o los pies en el último año. Usamos el índice de pendiente de la desigualdad y el índice de concentración para evaluar las desigualdades entre los quintiles de riqueza.

Resultados.

Se evaluó en total a 1.685 personas mayores con diabetes. En términos generales, en el último año les habían examinado los ojos a 41,7% de ellos, en el último año les habían examinado los pies a 35,4% y les habían ofrecido los ocho servicios de atención a 10,9%. Las mayores diferencias absolutas en puntos porcentuales entre el primer quintil de riqueza (los más pobres) y el quinto (los más ricos) en cuanto a los servicios de atención ofrecidos a los usuarios se encontraron en la recomendación de medir la glucemia (25,8), la solicitud de pruebas de glucohemoglobina (27,4), la solicitud de pruebas de curvas de glucemia (31,9), el examen de los ojos en el último año (29,3) y el examen de los pies en el último año (27,0).

Conclusiones.

Hubo notables desigualdades en la prevalencia de los servicios de atención. En el futuro, debe hacerse énfasis en la medición de la glucemia y el examen de los pies, especialmente en las personas mayores de un nivel socioeconómico bajo.

Palabras clave
Diabetes mellitus; disparidades en el estado de salud; calidad de la atención de salud; indicadores de calidad de la atención de salud; investigación en servicios de salud; Brasil

RESUMO

Objetivo.

Medir a prevalência de vários serviços de atenção oferecidos a idosos portadores de diabetes mellitus no Brasil e avaliar desigualdades sociais nestes serviços.

Métodos.

Estudo transversal, de caráter populacional, realizado em 2013. Os serviços de atenção oferecidos foram avaliados quanto aos oito indicadores a seguir: recomendação de diminuir o consumo de carboidratos, medir a glicemia e examinar os pés; pedido de exames de sangue, hemoglobina glicada e curva glicêmica; e realização de exame dos olhos ou pés nos usuários do serviço durante o ano anterior. Foram utilizados o índice absoluto de desigualdade e o índice de concentração para avaliar as desigualdades entre quintis de renda.

Resultados.

Foram avaliados 1.685 idosos com diabetes. Destes, 41,7% haviam sido submetidos a exame dos olhos no ano anterior, 35,4% a exame dos pés, e a 10,9% haviam sido oferecidos todos os oito serviços de atenção. As maiores diferenças absolutas (em pontos percentuais) entre o primeiro (mais pobre) e quinto (mais rico) quintis de renda foram constatadas para os seguintes serviços de atenção: recomendação de medir a glicemia (25,8), pedido de exame de hemoglobina glicada (27,4), pedido de exame de curva glicêmica (31,9), exame de olhos no ano anterior (29,3) e exame dos pés no ano anterior (27,0).

Conclusão.

Foram constatadas desigualdades notáveis na prevalência dos serviços de atenção. Futuramente, deve-se dar ênfase à medição da glicemia e do exame dos pés, principalmente em idosos de nível socioeconômico mais baixo.

Palavras-chave
Diabetes mellitus; disparidades nos níveis de saúde; qualidade da assistência à saúde; indicadores de qualidade em assistência à saúde; pesquisa sobre serviços de saúde; Brasil

With the increase in the elderly population in recent years, chronic noncommunicable diseases (NCDs), which are more frequent in this age group, have become an important public health issue (11. Azevedo Barros MB, Francisco PMSB, Zanchetta LM, César CLG. Trends in social and demographic inequalities in the prevalence of chronic diseases in Brazil. PNAD: 2003–2008. Cien Saude Colet. 2011;16(9):3755–68., 22. Schmidt M, Duncan B, Silva G, Menezes A, Monteiro C, Barreto S. Doenças crônicas não-transmissíveis no Brasil: carga e desafios atuais. Lancet. 2011; 6736(11):60135–9.). Diabetes mellitus (DM) is an NCD that has a high occurrence, mainly among the elderly (11. Azevedo Barros MB, Francisco PMSB, Zanchetta LM, César CLG. Trends in social and demographic inequalities in the prevalence of chronic diseases in Brazil. PNAD: 2003–2008. Cien Saude Colet. 2011;16(9):3755–68.), and its complications increase health system costs, as well as the years of life lost due to disability and mortality (22. Schmidt M, Duncan B, Silva G, Menezes A, Monteiro C, Barreto S. Doenças crônicas não-transmissíveis no Brasil: carga e desafios atuais. Lancet. 2011; 6736(11):60135–9., 33. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2013;380(9859):2163–96.).

An individual with this condition has hyperglycemia and carbohydrate, protein, and fat metabolism disorders, resulting from defects in insulin secretion and/or action, which can lead to blindness, renal failure, and limb amputations (44. Brasil, Ministério da Saúde. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2013. (Cadernos de Atenção Básica, n° 35).). Furthermore, DM is associated with such comorbidities as obesity and arterial hypertension (44. Brasil, Ministério da Saúde. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2013. (Cadernos de Atenção Básica, n° 35).).

DM prevalence has been increasing worldwide (55. Noncommunicable Disease Risk Factor Collaboration. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants. Lancet. 2016;387(10027):1513–30.). In Brazil, according to the Chronic Disease Risk and Protection Factor Surveillance Telephone Survey (VIGITEL) (66. Brasil, Ministério da Saúde. VIGITEL Brasil 2006. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Secretaria de Vigilância em Saúde; 2007., 77. Brasil, Ministério da Saúde. VIGITEL Brasil 2015. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Agência de Saúde Suplementar; 2016.), in 2006, 19% of individuals aged 65 and over reported having diabetes. In 2015 that figure was 23%, representing a substantial increase in a short period of time.

Worsening the high and increasing prevalence are inequalities in the occurrence of this disease, with people of a lower socioeconomic level being the most affected by DM and its complications (88. Mendes TAB, Goldbaum M, Segri NJ, Barros MBA, Cesar CLG, Carandina L, et al. Diabetes mellitus: fatores associados à prevalência em idosos, medidas e práticas de controle e uso dos serviços de saúde em São Paulo, Brasil. Cad Saude Publica. 2011;27(6):1233–43.1111. Francisco PMSB, Belon AP, de Azevedo Barros MB, Carandina L, Alves MCGP, Goldbaum M, et al. Diabetes auto-referido em idosos: prevalência, fatores associados e práticas de controle [Self-reported diabetes in the elderly: prevalence, associated factors, and control practices]. Cad Saude Publica. 2010;26(1):175–84.). In addition, inequalities in health service access and utilization still persist in Brazil (1212. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. O sistema de saúde brasileiro: história, avanços e desafios. Lancet. 2012;6736(11):60054–8.). Nunes et al. (1313. Nunes BP, Thumé E, Tomasi E, Duro SMS, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saude Publica. 2014;48(6):968–76.) showed that a lower socioeconomic level is associated with a higher probability of lack of access to health services, although inequalities in the utilization of these services have decreased (1414. Macinko J, Lima-Costa MF. Horizontal equity in health care utilization in Brazil, 1998–2008. Int J Equity Health. 2012;11(1):33., 1515. Lima-Costa MF, Facchini LA, Matos DL, Macinko J. Mudanças em dez anos das desigualdades sociais em saúde dos idosos brasileiros (1998–2008). Rev Saude Publica. 2012 Dec;46 Suppl 1:100–7.). With regard to the quality of the health services offered, inequalities were also observed between socioeconomic levels (1313. Nunes BP, Thumé E, Tomasi E, Duro SMS, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saude Publica. 2014;48(6):968–76., 1616. Facchini LA, Nunes BP, Duro SMS, Thumé E, Siqueira F, Fripp JC, et al. Iniquidades socioeconômicas no acesso e na qualidade da atenção ao diabetes entre idosos brasileiros. In: Conselho Nacional de Secretários de Saúde. CONASS debate: a crise contemporânea dos modelos de atenção à saúde. Brasília: CONASS; 2014:88–106.).

Despite the advances in Brazilian research on health service access and utilization, as well as the improvement in access in recent years (1313. Nunes BP, Thumé E, Tomasi E, Duro SMS, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saude Publica. 2014;48(6):968–76., 1414. Macinko J, Lima-Costa MF. Horizontal equity in health care utilization in Brazil, 1998–2008. Int J Equity Health. 2012;11(1):33., 1717. Nunes BP, Flores TR, Garcia LP, Chiavegatto Filho ADP, Thumé E, Facchini LA. Tendência temporal da falta de acesso aos serviços de saúde no Brasil, 1998–2013. Epidemiol Serv Saude. 2016;25(4):777–87.), inequalities persist (1717. Nunes BP, Flores TR, Garcia LP, Chiavegatto Filho ADP, Thumé E, Facchini LA. Tendência temporal da falta de acesso aos serviços de saúde no Brasil, 1998–2013. Epidemiol Serv Saude. 2016;25(4):777–87.). Further, there is a gap in the literature on the quality of care offered to the elderly with diabetes and on the magnitude of existing inequalities.

Most studies evaluating the quality of care offered to people with diabetes have been carried out in high-income countries, where it is easier to obtain indicators on health professional work processes (1818. Webster G, Sullivan-Taylor P, Terner M. Opportunities to improve diabetes prevention and care in Canada. Healthcare quarterly (Toronto, Ont). 2010;14(1):18–21.2121. Vidal Pardo J, Pérez Castro TR, López Álvarez X, García Soidán F, Santiago Pérez M, Muñiz J. Quality of care of patients with type-2 diabetes in Galicia (NW Spain) [OBTEDIGA project]. Int J Clin Pract. 2011;65(10):1067–75.). Among these indicators are the proportion of people having annual glycated hemoglobin and urine tests and feet, eye, and body mass index examinations, as well as receiving counseling on healthy lifestyles (1616. Facchini LA, Nunes BP, Duro SMS, Thumé E, Siqueira F, Fripp JC, et al. Iniquidades socioeconômicas no acesso e na qualidade da atenção ao diabetes entre idosos brasileiros. In: Conselho Nacional de Secretários de Saúde. CONASS debate: a crise contemporânea dos modelos de atenção à saúde. Brasília: CONASS; 2014:88–106., 1818. Webster G, Sullivan-Taylor P, Terner M. Opportunities to improve diabetes prevention and care in Canada. Healthcare quarterly (Toronto, Ont). 2010;14(1):18–21.2222. Wens J, Dirven K, Mathieu C, Paulus D, Van Royen P. Quality indicators for type-2 diabetes care in practice guidelines: an example from six European countries. Prim Care Diabetes. 2007;1:17–23.).

Studies with this approach are highly relevant for public health and for health system planning, since the provision of good-quality care can lead to better health outcomes, help control diseases, help avoid conditions caused by complications, and lower costs to the health system (2323. Walker RJ, Gebregziabher M, Martin-Harris B, Egede LE. Relationship between social determinants of health and processes and outcomes in adults with type 2 diabetes: validation of a conceptual framework. BMC Endocr Disord. 2014;14(1):82., 2424. Ricketts TC, Randolph R, Howard HA, Pathman D, Carey T. Hospitalization rates as indicators of access to primary care. Health Place. 2001;7(1):27–38.). Within this context, the aim of this study was to measure the prevalence of various care services offered to the elderly with diabetes mellitus in Brazil, and to assess the social inequalities in these services.

METHODS

This was a cross-sectional, population-based study that used data from the National Health Survey (PNS) carried out in Brazil in 2013 by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health (2525. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saude. 2015;24(2):207–16.). The sample in this study was representative of permanent residents living in urban and rural areas of municipalities of Brazil's five geographic regions, distributed over the country's 26 states and 1 federal district.

The sampling process was done in three stages. First, the census tracts were selected, then households, and finally individuals aged 18 or over. The sample was made up of 64 348 households. A total of 60 202 individuals answered the questionnaire on chronic diseases, including 23 815 who were 60 years of age or older (2525. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saude. 2015;24(2):207–16.).

Data collection was done by trained interviewers who used personal digital assistants for data storage. The questionnaire consisted of three parts. The first part collected household variables. The second part was on the general characteristics of all the residents of the household, including education level, work, income, disabilities, health plan coverage, utilization of health services, elderly health, mammography coverage, and characteristics of children under 2 years of age. In the third part, questions were directed to a randomly selected household resident 18 years or older about other characteristics of work and social support, perception of health status, accidents and violence, lifestyles, chronic diseases, women's health, prenatal care, oral health, and medical care. The data for individuals aged 60 years or older with DM were used in this study. More details on the sampling process used in the National Health Survey are available in an article by Souza-Júnior et al. (2525. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saude. 2015;24(2):207–16.).

To evaluate the care offered to the elderly with diabetes, the following recommendations, given by health professionals, were used as indicators: to reduce carbohydrates, to measure blood glucose, and to examine the feet. This information was obtained by asking the following question: “During any of your appointments for diabetes, did any doctor or other health professional make any of these recommendations to you?” In addition, information on requests made by the doctor or other health professional for blood tests, glycated hemoglobin tests, and glycemic curve tests were obtained through the following question: “During any of your appointments for diabetes, was any examination requested?” Elderly people with diabetes were also assessed regarding whether they had had their eyes and feet examined by a health professional in the preceding year. Finally, a variable was created that included the proportion of the elderly who received all the care indicators. All the variables evaluating the care offered to the elderly with diabetes were categorized as yes or no.

The independent variable was an asset index, validated in Brazil, constructed by means of principal component analyses (2626. Barros AJ, Victora CG. Indicador econômico para o Brasil baseado no censo demográfico de 2000. Rev Saude Publica. 2005;39(4):523–9.), using the following answers: type of housing (house, apartment, or rooming house, tenement, etc.), number of bedrooms, number of bathrooms, television (yes or no), refrigerator (yes or no), video/DVD player (yes or no), washing machine (yes or no), landline telephone (yes or no), mobile phone (yes or no), microwave (yes or no), computer (yes or no), motorcycle (yes or no), car (yes or no), Internet service (yes or no), and housemaid (yes or no).

This analysis assesses household wealth, with individuals classified according to the total household score and subsequently categorized into quintiles, where the first quintile (Q1) represents the poorest 20% of households and the fifth quintile (Q5) represents the wealthiest 20%.

Two indices were calculated to measure inequalities: the slope index of inequality (SII) and the concentration index (CI) (2727. Mackenbach JP, Kunst AE. Measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from Europe. Soc Sci Med. 1997;44(6):757–71., 2828. Silva ICM, Restrepo-Mendez MC, Costa JC, Ewerling F, Hellwig F, Ferreira LZ, et al. Mensuração de desigualdades sociais em saúde: conceitos e abordagens metodológicas no contexto brasileiro. Epidemiol Serv Saude. 2018;27(1): e000100017.). SII expresses the absolute difference in percentage points (pp) between the poorest and richest quintile, using a logistic regression model. The CI is based on a scale from -100 to +100, with zero representing equal distribution across the wealth scale. Positive CI values indicate a pro-rich distribution. The SII expresses absolute inequality, whereas the CI expresses relative inequality (2727. Mackenbach JP, Kunst AE. Measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from Europe. Soc Sci Med. 1997;44(6):757–71., 2828. Silva ICM, Restrepo-Mendez MC, Costa JC, Ewerling F, Hellwig F, Ferreira LZ, et al. Mensuração de desigualdades sociais em saúde: conceitos e abordagens metodológicas no contexto brasileiro. Epidemiol Serv Saude. 2018;27(1): e000100017.). More information about these two measures is available in the articles by Mackenbach and Kunst (2727. Mackenbach JP, Kunst AE. Measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from Europe. Soc Sci Med. 1997;44(6):757–71.) and Silva et al. (2828. Silva ICM, Restrepo-Mendez MC, Costa JC, Ewerling F, Hellwig F, Ferreira LZ, et al. Mensuração de desigualdades sociais em saúde: conceitos e abordagens metodológicas no contexto brasileiro. Epidemiol Serv Saude. 2018;27(1): e000100017.).

The prevalence and 95% confidence intervals of each indicator of the quality of care offered and the prevalence according to the quintiles of the asset indices were calculated. In addition, the magnitude of the inequalities of each indicator was estimated in relation to the asset indices, using SII and CI and 95% confidence intervals. All analyses were carried out using Stata 12.1 software (StataCorp LP, College Station, Texas, United States of America), using the “svy” command. That command takes into account the survey design, including sampling weights of the individual and clustering.

The PNS project was approved by the National Commission for Ethics in Research (CONEP) in June 2013, under protocol 10853812.7.0000.0008. All the participants signed the terms of consent, thus following ethical principles.

RESULTS

Out of the 23 815 elderly persons interviewed, 1 896 individuals reported a previous medical diagnosis of DM. From these 1 896, 1 685 of them (89%) had received medical care because of diabetes and answered the questions about the care services used, thus making up the sample of this study.

Regarding the characteristics of the included individuals, 61.9% were female, 54.2% were between 60 and 69 years old, 56.2% said they had white skin color, 55.4% lived with a partner, and the majority had either no formal education (32.8%) or an incomplete elementary education (41.8%) (Table 1).

TABLE 1
Description of the sample according to sociodemographic characteristics in the elderly with diabetes mellitus. Brazil, 2013 (N = 1 685)

Figure 1 shows the prevalence of each of the indicators studied for the entire sample. Among the recommendations given, the most prevalent were to reduce carbohydrates (85.2%) and to measure blood glucose (62.6%), while 54.8% received a recommendation to examine their feet. With respect to the requested examinations, blood and glycated hemoglobin were the most frequent (93.1% and 72.9%, respectively), whereas the glycemic curve was least requested (59.4%). Fewer than half had had their eyes (41.7%) or feet (35.4%) examined in the preceding year, while 10.9% had been offered all eight of the care services that were assessed.

FIGURE 1
Prevalence (%) of the care services offered to elderly persons with diabetes mellitus for the entire sample, Brazil, 2013, (N = 1 685)

In terms of the analysis of the inequalities, for all the care services, the highest prevalences were found in the quintile with the highest score in the asset index (richest). As the asset index quintile score increased, so did the proportions for recommendations to measure blood glucose and to examine the feet, for a glycemic curve request, and for having had the eyes examined in the preceding year (Figure 2).

FIGURE 2
Prevalence (%) of care services offered to elderly persons with diabetes mellitus, according to wealth index, Brazil, 2013 (N = 1 685)aaThe first quintile (Q1) represents the poorest 20% of households, and the fifth quintile (Q5) represents the wealthiest 20%.

Among the care services that were evaluated, five showed the largest absolute differences (represented by SII) between the prevalence in the first and fifth quintiles, all being greater than 20 pp: recommendation to measure blood glucose (25.8 pp), glycated hemoglobin request (27.4 pp), glycemic curve request (31.9 pp), eyes examined in the preceding year (29.3 pp), and feet examined in the preceding year (27.0 pp). The relative inequalities (CI) were higher in the glycemic curve request, eyes and feet examined in the preceding year, and the variable encompassing all the indicators (Table 2).

TABLE 2
Slope index of inequality and concentration index, with 95% confidence intervals, for each care service offered to the elderly with diabetes mellitus, Brazil, 2013 (N = 1 685)

In addition, a general decrease in relative inequality (CI) was seen as the prevalence increased (Figure 3). In contrast, with absolute inequality (SII), some indicators showed greater differences between the richest and the poorest quintiles, even when they had higher proportions.

FIGURE 3
Prevalence of the care indicators offered to elderly with diabetes mellitus and the slope index of inequality (SII) and the concentration index (CI), Brazil, 2013 (N = 1 685)

DISCUSSION

Our findings showed inequalities in the care offered to elderly with diabetes mellitus. Five indicators (recommendation to measure blood glucose, glycated hemoglobin request, glycemic curve request, eyes examined in the preceding year, and feet examined in the preceding year) presented a difference between the prevalences in the first quintile and the fifth quintile, with all being greater than 20 pp. Furthermore, only 1 in every 10 elderly persons with diabetes received all the care services that were evaluated. Fewer than half had had their feet and eyes examined by a health professional in the preceding year. This is a worrying situation since these are procedures recommended for the provision of good-quality care (44. Brasil, Ministério da Saúde. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2013. (Cadernos de Atenção Básica, n° 35).). In 2009, Facchini et al. (1616. Facchini LA, Nunes BP, Duro SMS, Thumé E, Siqueira F, Fripp JC, et al. Iniquidades socioeconômicas no acesso e na qualidade da atenção ao diabetes entre idosos brasileiros. In: Conselho Nacional de Secretários de Saúde. CONASS debate: a crise contemporânea dos modelos de atenção à saúde. Brasília: CONASS; 2014:88–106.) found a comparable prevalence (36.6%) of feet examination in the preceding year among elderly Brazilians. This suggests that the quality of care offered to this population is still a challenge, in spite of the increased access to and expansion of primary care, as well as programs focused on NCDs. A study in Spain found a similar problem, with only 14.4% of adults with diabetes having had their feet examined in the previous year (2121. Vidal Pardo J, Pérez Castro TR, López Álvarez X, García Soidán F, Santiago Pérez M, Muñiz J. Quality of care of patients with type-2 diabetes in Galicia (NW Spain) [OBTEDIGA project]. Int J Clin Pract. 2011;65(10):1067–75.).

Although the prevalence of recommendations made to DM patients is high, there are marked inequalities, which increase as the asset index score rises. The elderly with the highest asset scores also had the highest prevalence rates, which may be explained by greater access to health services by this portion of the population (1313. Nunes BP, Thumé E, Tomasi E, Duro SMS, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saude Publica. 2014;48(6):968–76.) and by the opportunity to choose a health service with a wider range of care services for this disease (88. Mendes TAB, Goldbaum M, Segri NJ, Barros MBA, Cesar CLG, Carandina L, et al. Diabetes mellitus: fatores associados à prevalência em idosos, medidas e práticas de controle e uso dos serviços de saúde em São Paulo, Brasil. Cad Saude Publica. 2011;27(6):1233–43., 1616. Facchini LA, Nunes BP, Duro SMS, Thumé E, Siqueira F, Fripp JC, et al. Iniquidades socioeconômicas no acesso e na qualidade da atenção ao diabetes entre idosos brasileiros. In: Conselho Nacional de Secretários de Saúde. CONASS debate: a crise contemporânea dos modelos de atenção à saúde. Brasília: CONASS; 2014:88–106.). Other studies (1010. Stopa SR, César CLG, Segri NJ, Goldbaum M, Guimarães VMV, Alves MCGP, et al. Diabetes autorreferido em idosos: comparação das prevalências e medidas de controle. Rev Saude Publica. 2014;48(4):554–62., 1616. Facchini LA, Nunes BP, Duro SMS, Thumé E, Siqueira F, Fripp JC, et al. Iniquidades socioeconômicas no acesso e na qualidade da atenção ao diabetes entre idosos brasileiros. In: Conselho Nacional de Secretários de Saúde. CONASS debate: a crise contemporânea dos modelos de atenção à saúde. Brasília: CONASS; 2014:88–106., 1818. Webster G, Sullivan-Taylor P, Terner M. Opportunities to improve diabetes prevention and care in Canada. Healthcare quarterly (Toronto, Ont). 2010;14(1):18–21.) that evaluated themes related to interventions or health indicators have also found similar trends.

Absolute inequalities are not consistent. Even with higher prevalence, the differences between the poorest quintile and the richest one are still present, indicating that the elderly who are considered richer present the best prevalence. However, relative inequality decreased as prevalence increased, probably because more people are benefiting and only a small portion are not receiving the intervention, thus making this scenario less unequal. A small amount of inequality still existing in these cases may occur due to extreme levels of wealth and poverty. An example of this is found in one of the individual indicators, the blood test request, which had the highest prevalence and the lowest relative inequality. On the other hand, feet examined in the preceding year had lower prevalence and the highest relative inequality.

There are inequalities in the occurrence of DM, with the disease being more prevalent in elderly people of a lower socioeconomic level (88. Mendes TAB, Goldbaum M, Segri NJ, Barros MBA, Cesar CLG, Carandina L, et al. Diabetes mellitus: fatores associados à prevalência em idosos, medidas e práticas de controle e uso dos serviços de saúde em São Paulo, Brasil. Cad Saude Publica. 2011;27(6):1233–43., 99. Iser BPM, Stopa SR, Chueiri PS, Szwarcwald CL, Malta DC, Monteiro HOC, et al. Prevalência de diabetes autorreferido no Brasil: resultados da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saude. 2015;24(2):305–14.). In addition, people with lower socioeconomic status have less access to health services and receive worse care (1313. Nunes BP, Thumé E, Tomasi E, Duro SMS, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saude Publica. 2014;48(6):968–76., 1616. Facchini LA, Nunes BP, Duro SMS, Thumé E, Siqueira F, Fripp JC, et al. Iniquidades socioeconômicas no acesso e na qualidade da atenção ao diabetes entre idosos brasileiros. In: Conselho Nacional de Secretários de Saúde. CONASS debate: a crise contemporânea dos modelos de atenção à saúde. Brasília: CONASS; 2014:88–106.). It was precisely the portion of the population that needed care the most that had the lowest prevalence of care interventions evaluated. This result is compatible with a study that evaluated care for people with diabetes in Canada (1818. Webster G, Sullivan-Taylor P, Terner M. Opportunities to improve diabetes prevention and care in Canada. Healthcare quarterly (Toronto, Ont). 2010;14(1):18–21.).

Using the constructed index of assets as a socioeconomic level proxy, it is possible to state that elderly people with less purchasing power are less likely to receive measures for health promotion and the prevention of complications caused by diabetes. It is common knowledge that patients with chronic diseases should receive guidance regarding a more accurate management of their health conditions in all contacts with the health service. However, studies carried out with adults and elderly have found that the recommendations were not followed in 80% of the cases, even among individuals who had at least one NCD. In general, differences regarding schooling and socioeconomic level were found in relation to some recommendations (2929. Silva SM, Facchini LA, Tomasi E, Piccini R, Thume E, Silveira DS, et al. Advice for salt, sugar and fat intake habits among adults: a national-based study. Rev Bras Epidemiol. 2013;16(4):995–1004., 3030. Flores TR, Nunes BP, Assunção MCF, Bertoldi AD. Hábitos saudáveis: que tipo de orientação a população idosa está recebendo dos profissionais de saúde? Rev Bras Epidemiol. 2016;19(1):167–80.).

In the care of people with NCDs, there have been advances both in primary care and in the strengthening of the bond between service users and health services themselves, centered on strategies that ensure improvement (albeit at a slow pace) (44. Brasil, Ministério da Saúde. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2013. (Cadernos de Atenção Básica, n° 35).). These strategies are based on health promotion, through recommendations about healthy habits and the prevention of complications caused by diabetes and other diseases (44. Brasil, Ministério da Saúde. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2013. (Cadernos de Atenção Básica, n° 35)., 3131. Assunção MCF, Santos IS, Gigante DP. Atenção primária em diabetes no Sul do Brasil: estrutura, processo e resultado. Rev Saude Publica. 2001;35(1):88–95., 3232. Mendes EV. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da Estratégia de Saúde da Família. Brasília: Organização Pan-Americana da Saúde; 2012.).

In terms of limitations of the study, it is worth mentioning the lack of a recall period in the questions used to define the operational outcomes (indicators). This may result in older people who have had DM for a longer period remembering more about the care indicators that were evaluated, since these persons may have consulted with health professionals more often. Moreover, without information about this period, it is more difficult to infer what the current status of the care quality is, since the person may have received the evaluated recommendations a long time before. Therefore, the results with the care indicators may be overestimated. If a 12-month recall period had been used, as is generally the case for studies in this field (1616. Facchini LA, Nunes BP, Duro SMS, Thumé E, Siqueira F, Fripp JC, et al. Iniquidades socioeconômicas no acesso e na qualidade da atenção ao diabetes entre idosos brasileiros. In: Conselho Nacional de Secretários de Saúde. CONASS debate: a crise contemporânea dos modelos de atenção à saúde. Brasília: CONASS; 2014:88–106., 2929. Silva SM, Facchini LA, Tomasi E, Piccini R, Thume E, Silveira DS, et al. Advice for salt, sugar and fat intake habits among adults: a national-based study. Rev Bras Epidemiol. 2013;16(4):995–1004., 3030. Flores TR, Nunes BP, Assunção MCF, Bertoldi AD. Hábitos saudáveis: que tipo de orientação a população idosa está recebendo dos profissionais de saúde? Rev Bras Epidemiol. 2016;19(1):167–80.), the outcome prevalence rates might have been even lower.

The care offered to the elderly with DM show inequalities, with the people of lower socioeconomic status receiving lower-quality care. Challenges persist for comprehensive care, both on the part of health systems (especially regarding the elderly) and for individuals themselves with respect to self-care of their health conditions. With diabetes, for example, self-care is related to the measurement of blood glucose, self-examination of the feet, food control, and lifestyle (44. Brasil, Ministério da Saúde. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2013. (Cadernos de Atenção Básica, n° 35)., 3333. Grant RW, Kirkman MS. Trends in the evidence level for the American Diabetes Association's “Standards of Medical Care in Diabetes” from 2005 to 2014. Diabetes Care. 2015;38:6–8.). Actions aimed at health promotion and prevention of diseases are the responsibility of health professionals, and these activities should be performed in all contacts with service users (44. Brasil, Ministério da Saúde. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2013. (Cadernos de Atenção Básica, n° 35)., 3232. Mendes EV. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da Estratégia de Saúde da Família. Brasília: Organização Pan-Americana da Saúde; 2012.). However, self-care of DM is also essential, because it empowers individuals to manage their health, including following the recommendations they receive during their contacts with health services (44. Brasil, Ministério da Saúde. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2013. (Cadernos de Atenção Básica, n° 35)., 3232. Mendes EV. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da Estratégia de Saúde da Família. Brasília: Organização Pan-Americana da Saúde; 2012., 3434. Agborsangaya CB, Gee ME, Johnson ST, Dunbar P, Langlois M-F, Leiter LA, et al. Determinants of lifestyle behavior in type 2 diabetes: results of the 2011 cross-sectional survey on living with chronic diseases in Canada. BMC Public Health. 2013;13(1):451.).

Finally, more emphasis should be given to health promotion and illness prevention actions. This is especially true for the most vulnerable elderly, that is, the ones from a lower socioeconomic level, so that they can become aware of the importance of self-management of their health condition. Also, there is a need for studies that evaluate both the reports made by individuals and the work process of health teams, in order to help existing programs to reduce persisting inequalities.

  • Suggested citation Neves RG, Duro SMS, Flores TR, Wendt A, Costa CS, Nunes BP, et al. Social inequalities in care for the elderly with diabetes in Brazil. Rev Panam Salud Publica. 2018;42:e88. https://doi.org/10.26633/RPSP.2018.88
  • Disclaimer. Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH or PAHO.

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History

  • Received
    22 Nov 2017
  • Accepted
    16 Mar 2018
  • Online publication
    16 Aug 2018
Organización Panamericana de la Salud Washington - Washington - United States
E-mail: contacto_rpsp@paho.org