ABSTRACT:

Objective:

To investigate the determinants of self-rated health in Brazil and the influence of healthy lifestyles.

Methods:

We used data from the National Health Survey (PNS), 2013. The self-rated health was categorized as very good/good, fair, and poor/very poor. Differences in the distribution of self-rated health according to the age group and sex were tested. Logistic regression models were used to test the effects of educational level, race/skin color, and the presence of at least one noncommunicable chronic disease on poor/very poor health perception. In addition, the influence of healthy behaviors was tested controlling for the effects of sociodemographic factors and the presence of at least one chronic disease.

Results:

We analyzed 60,202 individuals; about 66.1% rated their health as very good/good and 5.9% as poor/very poor; about 47.1% reported the diagnosis of at least one noncommunicable chronic disease; and only 9.3% reported a "healthy lifestyle" (do not use tobacco products, consume fruits and vegetables properly, and do physical activity during leisure time). Among the sociodemographic factors, age, sex, educational level, and race were significantly associated with self-rated health and the presence of at least one chronic disease. The effects of all healthy behaviors were statistically significant even after controlling for the other determinants.

Conclusion:

Although the adoption of healthy lifestyles in Brazil is still insufficient, the association of healthy practices with self-perception of health found in this study is an indication that the Brazilian population is beginning to relate healthy behaviors to their well-being and better health evaluation.

Keywords:
Data collection; Morbilidad; Epidemiologic factors; Chronic disease; Healthy lifestyles; Brazil.

INTRODUCTION

Historically, the studies meant to establish that the health status of a population was based on mortality indicators. However, the increased longevity in developed countries brought the need for developing new health indicators, which would include measures of quality of life¹1. Asada Y, Ohkusa Y. Analysis of health-related quality of life (HRQL), its distribution, and its distribution by income in Japan, 1989 and 1998. Soc Sci Med 2004; 59(7): 1423-33.. Because a long life does not necessarily mean a healthy one, it is, nowadays, a consensus that mortality indicators are not enough in order to properly characterize the status of a population's health²2. Verbrugge LM, Jette AM. The disablement process. Soc Sci Med 1994; 38(1): 1-14. ³3. Luy M, Minagawa Y. Gender gaps-Life expectancy and proportion of life in poor health. Health Rep 2014; 25(12): 12-9..

Over the past decades, different health indicators that considered morbidity and the disabilities and functional limitations have been proposed in order to complement the studies on mortality⁴4. GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 385(9963): 117-71. ⁵5. Campos MR, Doellinger V dos R, Mendes LV, Costa M de F, Pimentel TG, Schramm JM. Morbidity and mortality associated with injuries: results of the Global Burden of Disease study in Brazil, 2008. Cad Saúde Pública 2015; 31(1): 121-36. ⁶6. Haro J, Tyrovolas S, Garin N, Diaz-Torne C, Carmona L, Riera L, et al. The burden of disease in Spain: results from the global burden of disease study 2010. BMC Med 2014; 12(1): 236.. In the health surveys, the self-rated health (SRH) has been widely used in order to describe the health status of a population⁷7. Verropoulou G. Specific versus general self-reported health indicators predicting mortality among older adults in Europe: disparities by gender employing SHARE longitudinal data. Int J Public Health 2014; 59(4): 665-78., to establish the differences of morbidity in populational subgroups, to compare the needs for services and health resources by geographic areas, and to calculate other mortality and morbidity indicators such as the hope of a healthy life⁸8. Devlin N, Hansen P, Herbison P. Variations in self-reported health status: results from a New Zealand survey. NZ Med J 2000; 113(1123): 517-20. ⁹9. Romero DE, Leite I da C, Szwarcwald CL. Healthy life expectancy in Brazil: applying the Sullivan method. Cad Saúde Pública 2005; 21(Suppl 1): 7-18. ¹⁰10. Nepomuceno MR, Turra CM. Trends in healthy life expectancy among older Brazilian women between 1998 and 2008. Rev Saúde Pública 2015; 49:1-8. ¹¹11. Jagger C, Gillies C, Moscone F, Cambois E, Van Oyen H, Nusselder W, et al. Inequalities in healthy life years in the 25 countries of the European Union in 2005: a cross-national meta-regression analysis. Lancet 2009; 372: 2124-31..

The individual perception of the health status has been considered as an important indicator by itself, because the level of welfare of an individual may influence their lifestyle¹²12. Zack MM, Centers for Disease Control and Prevention (CDC). Health-related quality of life - United States, 2006 and 2010. MMWR Surveill Summ 2013; 62(Suppl 3): 105-11.. On the other hand, the utility of the SRH also comes from its validity, established by their relations with the clinical conditions and with morbidity and mortality indicators¹³13. Theme-Filha MM, Szwarcwald CL, Souza Junior PR. Measurements of reported morbidity and interrelationships with health dimensions. Rev Saúde Pública 2008; 42(1): 73-81. ¹⁴14. Feng Q, Zhu H, Zhen Z, Gu D. Self-Rated Health, Interviewer-Rated Health, and Their Predictive Powers on Mortality in Old Age. J Gerontol B Psychol Sci Soc Sci 2015..

Researches have demonstrated that the perception of health, frequently, agrees with the evaluation made by the doctor¹⁵15. Nielsen TH. The Relationship Between Self-Rated Health and Hospital Records. Health Econ 2015.. In terms of mortality, because researchers confirmed the association between bad SRH and the increased risk of premature death still in the 1980s¹⁶16. Mossey JM, Shapiro E. Self-rated health: a predictor of mortality among the elderly. Am J Public Health 1982; 72(8): 800-8. ¹⁷17. Kaplan GA, Camacho T. Perceived health and mortality: a nine-year follow-up of the human population laboratory cohort. Am J Epidemiol 1983; 117(3): 292-304., several studies have demonstrated that a bad health perception is an important predictor of lower survival¹⁸18. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38(1): 21-37. ¹⁹19. Burstrom B, Fredlund P. Self rated health: Is it as good a predictor of subsequent mortality among adults in lower as well as in higher social classes? J Epidemiol Community Health 2001; 55(11): 836-40. ²⁰20. Razzaque A, Mustafa AH, Streatfield PK. Do self-reported health indicators predict mortality? Evidence from Matlab, Bangladesh. J Biosoc Sci 2014; 46(5): 621-34.. While the "objective" evaluation of the health status of an individual, from the medical point of view, refers to the identification of a disease indicated by a set of signals, symptoms, and laboratory results, the SRH is subjective, combining physical, emotional, and well-being and life satisfaction components²¹21. Blank N, Diderichsen F. The Prediction of different experiences of longterm illness: a longitudinal approach in Sweden. J Epidemiol Community Health 1996; 50(2): 156-61. ²²22. Mithen J, Aitken Z, Ziersch A, Kavanagh AM. Inequalities in social capital and health between people with and without disabilities. Soc Sci Med 2015; 126: 26-35.. Besides that, studies indicate that a poor health self-perception may occur even in the absence of diagnosis of a disease, suggesting that there are feelings that create a bad perception of one's own health before medical identification of the disease²³23. Froom P, Melamed S, Triber I, Ratson N, Hermoni D. Predicting self-reported health: the CORDIS study. Prev Med 2004; 39(2): 419-23..

Brazil is currently going through a period of epidemiological transition, with an expressive growth of chronic noncommunicable diseases (NCDs)²⁴24. Schmidt MI, Duncan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, et al. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 377(9781): 1949-61.. In the new scenario, efforts are being made for the promotion of healthy behaviors²⁵25. Ramos LR, Malta DC, Gomes GA, Bracco MM, Florindo AA, Mielke GI, et al. Prevalence of health promotion programs in primary health care units in Brazil. Rev Saúde Pública 2014; 48(5): 837-44. ²⁶26. Malta DC, Silva MMA, Albuquerque GM, Lima CM, Cavalcante T, Jaime PC, et al. A implementação das prioridades da Política Nacional de Promoção da Saúde, um balanço, 2006-2014. Ciênc Saúde Colet 2014; 19(11): 4301-11. not only in order to support the policies of prevention of chronic disease but also to improve the quality of life of the Brazilian population.

Using the data from the National Health Survey (Pesquisa Nacional de Saúde -PNS) of 2013, this study possessed the objective of investigating the SRH of Brazilians, in order to identify the main sociodemographic determinants, establishing the difference by the occurrence/absence of diagnosis of at least one chronic disease, and analyzing the influence of healthy behaviors in the perception of the health status.

METHODOLOGY

The PNS was a home-based research carried out by the Ministry of Health and the Oswaldo Cruz Foundation in partnership with the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE) in the years of 2013 and 2014. The project was approved by the National Research Ethics Commission (CONEP) in June 2013.

The sample of the PNS is a subsample of the Master Sample of the Integrated System of Household Surveys (Sistema Integrado de Pesquisas Domiciliares - SIPD) from IBGE²⁷27. Freitas MPS, Lila MF, Azevedo RV, Antonaci GA. Amostra Mestra para o Sistema Integrado de Pesquisas Domiciliares. Rio de Janeiro: IBGE; 2007. (Texto para discussão, nº 23). Disponível em: Disponível em: http://www.ibge.gov.br/home/estatistica/indicadores/sipd/texto_discussao_23.pdf (Acessado em 02 de fevereiro de 2015).
http://www.ibge.gov.br/home/estatistica/... . It was selected by cluster sampling in three stages, with stratification of the primary sampling units (PSUs). In the first stage, for each stratum, the selection of the PSUs was performed by simple random sampling. In the second stage, for each PSU, a fixed number of households were selected in a random manner. In the third stage, for each household, a resident aged 18 years or older was randomly selected.

In total, 81,254 households were visited, of which 69,994 households were occupied. A total of 64,348 household interviews were performed and 60,202 with the selected residents.

In this study, the information of the individual questionnaire was analyzed. The analysis of the SRH was based on the following questions: "In general, how do you evaluate your health?" The answers varied from 1 (very good) to 5 (very bad), which were grouped in three categories (very good/good; regular; and bad/very bad).

The following sociodemographic characteristics were considered: gender (male; female); age range (18 - 29; 30 - 39; 40 - 49; 50 - 59; 60 - 69; and 70+ years); education degree (no instruction/incomplete elementary school; complete elementary school/incomplete high school; complete high school/incomplete college degree; and complete college degree); and race/color (Caucasian/white; black; brown; and other).

The variable presence/absence of a NCD consisted of answers to all the questions related to the diagnosis of chronic diseases: "Has any doctor ever diagnosed you with ____________?", including hypertension, diabetes, heart diseases, stroke (AVC), asthma, arthritis, chronic spine problem, musculoskeletal disorder related to work (MSD), depression, other mental disorder, lung disease, cancer, chronic kidney failure, and other chronic physical or mental disease not previously specified. The presence of NCD was considered when there was at least one affirmative answer and the absence of it when all the answers were negative.

For the analysis of the influence of healthy behaviors on the SRH, the following habits were considered: smoking (currently smokes any tobacco product; has already smoked a tobacco product; and has never smoked); physical activity in leisure (practice of physical activity in leisure at the recommended level - 150 minutes or more of light/moderate physical activities or 75 minutes or more in vigorous physical activity a week); and recommended consumption of vegetables and fruits (consumption of vegetable and fruit at least 5 times a day). In addition, a variable called "healthy lifestyle" was composed, adding up people who possess all the healthy habits.

A statistical application was used, which takes into account the effect of the sampling plan. For the SRH associations, test with the groups of age and gender and the χ²-homogeneity tests were used. For a multivariate analysis, models of logistic regression were used, presenting as variables the self-assessment answer bad/very bad and as independent variables age, gender, education degree, race/color, and the presence of at least one NCD. In addition to that, the effects of healthy behaviors were tested with controlled sociodemographic factors and the presence of some NCD.

RESULTS

A total of 60,202 individuals investigated by the PNS were analyzed (47.1% male and 52.9% female subjects) (Table 1). The age varied from 18 to 101 years, with a mean value of 43 years and median of 41 years. The distribution by age range showed that 81.9% of them were aged between 18 and 59 years and 18.1% aged 60 years or older.

The results by education degree showed that 38.9% of them do not possess complete elementary school degree and that 12.8% of them possessed a complete college degree. In relation to the color of the skin/race, 47.5% of them reported themselves as white/Caucasian, 42.0%, brown, and 9.2%, black (Table 1).

In relation to one's health self-perception, 66.1% of them evaluated their health as very good or good; 28% as regular; and 5.9% as bad or very bad. Among all the individuals investigated in the PNS, 47.1% reported the diagnosis of at least one chronic disease (Table 1).

As for the healthy behaviors evaluated, 14.7% of them currently smoke tobacco products, 17.5% of them have already smoked a tobacco product, and 67.8% of them have never smoked; 37.3% consumed the recommended amount of fruits and vegetables; and about 22.5% of them practiced physical activity in leisure time at the recommended level. However, on the basis of the data in Table 1, it may be observed that only 9.3% of them possessed a "healthy lifestyle" (did not use tobacco products, consumed an adequate intake of fruits and vegetables, and practiced physical activities in leisure at the recommended level) (Table 1).

In Table 2, the distributions of self-evaluation of the health status according to gender and age range are presented. The comparison by age range shows a significant gradient (p < 0.001) with the increasing age: the proportion to the very good/good SRH decreases from 81.6%, among people between 18 and 29 years of age, to 41.4%, in the group of those who are 70 years or older. The differences by gender were also observed. The self-perception of health is always worse among women, regardless of their age range. On average, the difference in the proportion of the good/very good SRH for female subjects (62.4%) in relation to that found for male subjects (70.3%) is almost 8%.

The results of the logistic regression models are presented in Table 3, showing as variable answer, the bad/very bad self-assessment, showed, first, that all sociodemographic factors considered in the study possessed significant effects (p < 0.01). As for age, a direct association was evidenced, that is, the older the individual, the higher the bad perception percentage of their own health. As for the differences by gender, women revealed worse SRH than men, and in relation to race/color, the non-Caucasian/white individuals showed a poorer evaluation of their health than that by the Caucasian/white people. The effects of the education degree were highly significant. The odds ratio (OR) of showing a bad/very bad evaluation of their own health was nine times higher among those who possessed incomplete elementary school degree, when compared with those who completed college degree, and seven times higher in the model adjusted by age, gender, race/color, and the presence of at least one NCD.

The results presented in Table 3 show, additionally, the significant effects (p < 0.01) of the presence of NCDs on the bad/very bad SRH. The OR was 5.3 times higher among individuals who were diagnosed with at least one of the NCD, when compared with the others, even after the control of sociodemographic factors.

On the other hand, the multivariate logistic regression model presented in Table 4 shows the influence of healthy behaviors on the SRH. Inverse and statistically significant associations were evident for the physical activity at the recommended level and for the adequate intake of fruits and vegetables with the bad/very bad perception of one's own health, while the effects of smoking, both for current or past use of tobacco products, were directly associated with the outcome (p < 0.001), even after the control of sociodemographic factors and the diagnosis of at least one NCD.

DISCUSSION

The results of the World Health Survey (WHS), a populational-based household survey carried out in Brazil in 2003, evidenced a proportion of very good/good self-assessment of 53%, varying from 47% among women and 60% among men²⁸28. Szwarcwald CL, Souza-Júnior PR, Esteves MA, Damacena GN, Viacava F. Socio-demographic determinants of self-rated health in Brazil. Cad Saúde Pública 2005; 21(Suppl 1): 54-64.. Ten years later, using exactly the same question used in the previous research, the PNS showed a much higher proportion of good perception for both genders: 66% for the total sample, 62% among women, and 70% among men. By considering the aging Brazilian population and the expressive growth of NCD, this result is, apparently, paradoxical.

In fact, in this study, 47% of the interviewed people reported the diagnosis of at least one NCD. Among these people, the percentage of very good/good self-assessment was significantly lower (48.4%) in relation to the people who did not report the diagnosis of chronic diseases (81.9%). Thus, a likely explanation for the increase in the proportion of Brazilians who assessed their health as very good or good is in the improvement of the quality of life of the Brazilian population in terms of socioeconomic conditions and health assistance²⁹29. Victora CG, Barreto ML, do Carmo Leal M, Monteiro CA, Schmidt MI, Paim J, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377(9782): 2042-53.. Recent national studies have pointed out the influence of the improvement of socioeconomic conditions and the impact of the reduction of income inequality and the progress made in health attention on the morbidity and mortality indicators³⁰30. Soares GP, Brum JD, Oliveira GM, Klein CH, Souza e Silva NA. Evolution of socioeconomic indicators and cardiovascular mortality in three Brazilian states. Arq Bras Cardiol 2013; 100(2): 147-56. ³¹31. Rasella D, Aquino R, Barreto ML. Impact of income inequality on life expectancy in a highly unequal developing country: the case of Brazil. J Epidemiol Community Health 2013; 67(8): 661-6..

Such hypothesis is supported by the large association found in the PNS among the sociodemographic characteristics and the SRH. International and national works had already indicated the effects of socioeconomic conditions on the perception of the health status³²32. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saúde Pública 2003; 19: 745-57. ³³33. Dachs JNW. Determinantes das desigualdades na auto-avaliação do estudo de saúde no Brasil: análise dos dados da PNAD/1998. Ciênc Saúde Colet 2002; 7: 641-57. ³⁴34. Martikainen P, Adda J, Ferrie JE, Smith GD, Marmot M. Effects of income and health on GHQ depression and poor self rated health in white collar women and men in the Whitehall II study. Journal of Epidemiology and Community Health 2003; 57: 718-23. ³⁵35. Kim J. Socioeconomic inequalities in self-rated health among middle-aged and older adults. Soc Work Health Care 2011; 50(2): 124-42.. In complete education, material difficulties, lower social status, and work situation, in addition to environmental factors, have proven themselves as important determinants in health self-perception, following a negative gradient to the poorest social groups³⁶36. Franks P, Gold MR, Fiscella K. Sociodemographics, self-rated health, and mortality in the US. Soc Sci Med 2003; 56(12): 2505-14. ³⁷37. Chandola T, Ferrie J, Sacker A, Marmot M. Social inequalities in self reported health in early old age: follow-up of prospective cohort study. BMJ 2007; 334(7601): 990. ³⁸38. Cummins S, Stafford M, Macintyre S, Marmot M, Ellaway A. Neighbourhood environment and its association with self rated health: evidence from Scotland and England. J Epidemiol Community Health 2005; 59(3): 207-13. ³⁹39. Szwarcwald CL, da Mota JC, Damacena GN, Pereira TG. Health inequalities in Rio de Janeiro, Brazil: lower healthy life expectancy in socioeconomically disadvantaged areas. Am J Public Health 2011; 101(3): 517-23..

Among the socioeconomic indicators, the level of education has been, probably, the most used, being considered more stable than the occupational situation and the outcome, which may vary over time⁴⁰40. Heistaro S, Vartiainen E, Puska P. Trends in self-rated health in Finland 1972-1992. Prev Med 1996;25(5): 625-32.. However, one of the limitations of this study is that the household income per capita is still not available for analysis. As pointed out³⁴34. Martikainen P, Adda J, Ferrie JE, Smith GD, Marmot M. Effects of income and health on GHQ depression and poor self rated health in white collar women and men in the Whitehall II study. Journal of Epidemiology and Community Health 2003; 57: 718-23., the level of income reflects not only the material needs of life, such as the possibility of having good nutrition and adequate housing, but also it is a social welfare marker.

Another important result of this study was the positive effect of the healthy behaviors considered here: the fact of not smoking, the practicing of physical activities, and the adequate intake of fruit and vegetable. The influence of the lifestyle in the good health self-perception occurred both among people who did not report any NCD and among those who reported at least one disease. Healthy habits effects have also been evidenced in many countries⁴¹41. Borg V, Kristensen TS. Social class and self-rated health: can the gradient be explained by differences in life style or work environment? Soc Sci Med 2000; 51: 1019-30. ⁴²42. Mood C. Life-style and self-rated global health in Sweden: a prospective analysis spanning three decades. Prev Med 2013; 57(6): 802-6. ⁴³43. Jankovic N, Geelen A, Streppel MT, de Groot LC, Orfanos P, van den Hooven EH, et al. Adherence to a healthy diet according to the World Health Organization guidelines and all-cause mortality in elderly adults from Europe and the United States. Am J Epidemiol 2014; 180(10): 978-88. ⁴⁴44. Kendig H, Browning CJ, Thomas SA, Wells Y. Health, lifestyle, and gender influences on aging well: an Australian longitudinal analysis to guide health promotion. Front Public Health 2014; 2: 70. ⁴⁵45. Rosenkranz RR, Duncan MJ, Rosenkranz SK, Kolt GS. Active lifestyles related to excellent self-rated health and quality of life: cross sectional findings from 194,545 participants in The 45 and Up Study. BMC Public Health 2013; 13: 1071..

The adoption of healthy behaviors has been growing in Brazil. Notable, for example, is the decrease in the use of tobacco products in Brazil⁴⁶46. Malta DC, Oliveira TP, Luz M, Stopa SR, Silva Junior JB, Reis AA. Smoking trend indicators in Brazilian capitals, 2006-2013. Ciênc Saúde Colet 2015; 20(3): 631-40., as a result of public policies against smoking, such as the prohibition of its publicity and advertizement, the prohibition of smoking in enclosed places, the limited exposure of products in sales outlets, the warning messages in the packages, and the increased taxes⁴⁷47. Silva ST, Martins MC, Faria FR, Cotta RM. Combate ao Tabagismo no Brasil: a importância estratégica das ações governamentais. Ciênc Saúde Colet 2014; 19(2): 539-52.. Individuals who currently use tobacco products may be evaluating their health poorly not only because of some health problem but also for being informed on the harmful effects of smoking. The PNS showed that 52% of current smokers thought about quitting smoking owing to the warnings in the cigarette packages⁴⁸48. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística - IBGE. Diretoria de Pesquisas Coordenação de Trabalho e Rendimento. Pesquisa Nacional de Saúde: Percepção do estado de saúde, estilos de vida e doenças Crônicas. Rio de Janeiro: IBGE 2014. p. 181. (data not presented in this work).

Efforts are being made, additionally, in order to encourage the practice of physical activities, such as the Health Academy Program (programa Academia da Saúde )⁴⁹49. Reis RS, Kelly CM, Parra DC, Barros M, Gomes G, Malta D, et al. Developing a research agenda for promoting physical activity in Brazil through environmental and policy change. Rev Panam Salud Publica 2012; 32(2): 93-100.. Although the benefit of physical activity practice in leisure and the intake of five portions or more of fruits and vegetables are properly recognized for the prevention of various chronic diseases⁵⁰50. World Health Organization (WHO). The World Health Report - Reducing Risks, Promoting Healthy Life. Geneva: WHO; 2002., the adoption of these behaviors by the Brazilian population is, without a doubt, not enough.

CONCLUSION

Although the adoption of healthy lifestyles is still little frequent in the Brazilian population, the association of healthy behaviors with the perception of health found in this study, even with the control of the effects of socioeconomic factors and with the presence of at least one NCD, is an indication that the Brazilian population is starting to relate healthy lifestyles to their well-being and to a better assessment of their health.

References

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History