[Multimorbidity and utilization of health services in the city of São Paulo, Brazil: prevalence and associated factors]. / Multimorbidade e utilização de serviços de saúde no município de São Paulo, Brasil: prevalência e fatores associados.

The scope of this paper was to estimate the prevalence of multimorbidity in the city of São Paulo and to verify the factors associated with the utilization of the health services. It involved a population based cross-sectional study based on data from the Health Survey in the city of São Paulo, in which descriptive analysis was conducted, and logistic regression models were developed using multimorbidity and sociodemographic independent variables, living conditions and use of health services as the outcome. A total of 3,184 individuals aged 20 years or older participated, with a mean age of 43.8 years. The prevalence of multimorbidity was 50.7% among women, 62.5% among those who reported some health problem and 55.1% among those who had recourse to health services in the last 2 weeks. A higher prevalence was identified among those who used the health service due to a mental health problem (66.1%), and in those who reported higher health expenditures in the preceding month (55.4%). Multimorbidity was more frequently associated with aging, in the population with a higher economic status, with worse self-rated health, who frequented health services for 6 months or less, who reported a health problem, or who had a health plan and opted for polypharmacy.

O objetivo foi estimar a prevalência de multimorbidade no município de São Paulo e verificar os fatores associados à utilização de serviços de saúde. Estudo transversal de base populacional a partir do Inquérito de Saúde do Município de São Paulo (ISA-Capital 2015), em que foi realizada análise descritiva e foram elaborados modelos de regressão logística utilizando como desfecho a multimorbidade e variáveis independentes sociodemográficas, de condições de vida e utilização de serviços de saúde. Participaram 3.184 indivíduos com 20 anos ou mais, idade média de 43,8 anos. A prevalência de multimorbidade foi de 50,7% entre as mulheres, 62,5% entre os que relataram algum problema de saúde e 55,1% entre os que utilizaram serviços de saúde nas duas últimas semanas. Foi identificada maior prevalência nos indivíduos que usaram serviço de saúde por problema de saúde mental (66,1%) e que informaram maiores despesas com saúde no último mês (55,4%). A multimorbidade foi mais frequente com o envelhecimento, na população com nível econômico mais elevado, com pior autoavaliação de saúde, que utilizou serviços de saúde há seis meses ou menos, que relatou problema de saúde, que tinha plano de saúde e fazia uso da polifarmácia.

Multimorbidity patterns and associated factors in a megacity: a cross-sectional study.

OBJECTIVE: To identify empirical patterns of multimorbidity and quantify their associations with socioeconomic, behavioral characteristics, and health outcomes in the megacity of São Paulo. METHODS: This was a cross-sectional study conducted through household interviews with residents aged 20 years or older in urban areas (n = 3,184). Latent class analysis was used to identify patterns among the co-existence of 22 health conditions. Age-adjusted prevalence ratios were estimated using Poisson regression. RESULTS: The analysis of latent classes showed 4 patterns of multimorbidity, whereas 58.6% of individuals were classified in the low disease probability group, followed by participants presenting cardiovascular conditions (15.9%), respiratory conditions (12.8%), and rheumatic, musculoskeletal, and emotional conditions (12.8%). Older individuals, with lower schooling and lower household income, presented higher multimorbidity prevalence in cardiovascular, respiratory, rheumatic, musculoskeletal, and emotional conditions patterns compared with the low disease probability pattern. CONCLUSION: The results showed four distinct patterns of multimorbidity in the megacity population, and these patterns are clinically recognizable and theoretically plausible. The identification of trends between patterns would make it feasible to estimate the magnitude of the challenge for the organization of health care policies.

Impairments and related social inequalities among adults: a population-based study in São Paulo city, Brazil.

The study of the association of social variables with the prevalence of impairments can provide subsidies for more adequate care and health policies for the most needy people by incorporating social aspects. This article aims to estimate the prevalence of diverse types of impairments, the degree of difficulty, limitations, and the need for help they cause and attest whether this prevalence differ by educational attainment in individuals aged 20 years or older. This is a populational cross-sectional study (2015 Health Survey of São Paulo-ISA Capital). Data from 3184 individuals were analyzed via educational attainment as exposure variable and outcome variables related to visual, hearing, intellectual, and mobility impairments. 19.9% of participants had visual, 7.8%, hearing, 2.7%, intellectual, and 7.4%, mobility impairments. Mobility and intellectual impairments limited participants' daily activities the most, 70.3% and 63.3%, respectively; who, thus, needed the most help: 48.9% and 48.5%, respectively. Lower schooling was associated with a higher prevalence of impairments, greater need for help due to visual and intellectual impairments, and greater limitations due to hearing and visual impairments.

Physical activity among older adults with multimorbidity: Evidence from a population-based health survey.

INTRODUCTION: The promotion of physical activity has been recognized as an important component in the management and prevention of multimorbidity, a condition that is increasing prevalent worldwide, including in Brazil. However, there is a scarcity of studies exploring the disparity in physical activity levels between individuals with and without multimorbidity. Therefore, the study aimed to estimate the prevalence of multimorbidity and physical activity among older adults, as well as analyze the relationship of a sufficient level of physical activity and multimorbidity, while considering sociodemographic characteristics of residents in São Paulo, Brazil. MATERIALS AND METHODS: Data from 1.019 participants aged 60 years or older (59.7% female; mean age 69.7±7.7) were collected from the Health Survey (ISA-Capital, 2015) conducted in the city of São Paulo, Brazil. We defined multimorbidity as the presence of two or more chronic conditions, and for physical activity, classified a sufficient level (≥150 min/week). Prevalence Ratios (PR) with 95% Confidence Intervals (95%CI) were estimated using univariate and multivariate Poisson regression to examine the relationship between multimorbidity and sufficient level of physical activity. RESULTS: 67.7% of the participants lived with multimorbidity, while 30.1% had achieved a sufficient level of physical activity. There was a higher prevalence of sufficient level of physical activity among older adults with two (PR = 1.38; 95%CI 1.02-1.88) and four (PR = 1.37; 95%CI 1.00-1.87) chronic conditions. Older adults with multimorbidity who were 70 years or older (PR = 1.77; 95%IC 1.13-2.77), female (PR = 1.65; 95%CI 1.16-2.36), without a partner (PR = 1.43; 95%IC 1.03-1.99), and had a per capita income of 1 to 2.5 (PR = 1.83; 95%IC 1.00-3.33) were more likely to achieve a sufficient level of physical activity compared to their peers without multimorbidity. CONCLUSIONS: The study highlights sociodemographic disparities in the sufficient level of physical activity among multimorbidity, suggesting the importance of considering these factors when planning public policies aimed at promoting physical activity.

Multimorbidade e utilização de serviços de saúde no município de São Paulo, Brasil: prevalência e fatores associados / Multimorbidity and utilization of health services in the city of São Paulo, Brazil: prevalence and associated factors

Resumo O objetivo foi estimar a prevalência de multimorbidade no município de São Paulo e verificar os fatores associados à utilização de serviços de saúde. Estudo transversal de base populacional a partir do Inquérito de Saúde do Município de São Paulo (ISA-Capital 2015), em que foi realizada análise descritiva e foram elaborados modelos de regressão logística utilizando como desfecho a multimorbidade e variáveis independentes sociodemográficas, de condições de vida e utilização de serviços de saúde. Participaram 3.184 indivíduos com 20 anos ou mais, idade média de 43,8 anos. A prevalência de multimorbidade foi de 50,7% entre as mulheres, 62,5% entre os que relataram algum problema de saúde e 55,1% entre os que utilizaram serviços de saúde nas duas últimas semanas. Foi identificada maior prevalência nos indivíduos que usaram serviço de saúde por problema de saúde mental (66,1%) e que informaram maiores despesas com saúde no último mês (55,4%). A multimorbidade foi mais frequente com o envelhecimento, na população com nível econômico mais elevado, com pior autoavaliação de saúde, que utilizou serviços de saúde há seis meses ou menos, que relatou problema de saúde, que tinha plano de saúde e fazia uso da polifarmácia.

Abstract The scope of this paper was to estimate the prevalence of multimorbidity in the city of São Paulo and to verify the factors associated with the utilization of the health services. It involved a population based cross-sectional study based on data from the Health Survey in the city of São Paulo, in which descriptive analysis was conducted, and logistic regression models were developed using multimorbidity and sociodemographic independent variables, living conditions and use of health services as the outcome. A total of 3,184 individuals aged 20 years or older participated, with a mean age of 43.8 years. The prevalence of multimorbidity was 50.7% among women, 62.5% among those who reported some health problem and 55.1% among those who had recourse to health services in the last 2 weeks. A higher prevalence was identified among those who used the health service due to a mental health problem (66.1%), and in those who reported higher health expenditures in the preceding month (55.4%). Multimorbidity was more frequently associated with aging, in the population with a higher economic status, with worse self-rated health, who frequented health services for 6 months or less, who reported a health problem, or who had a health plan and opted for polypharmacy.

Impairments and related social inequalities among adults: a population-based study in São Paulo city, Brazil / Deficiências e desigualdades sociais entre adultos: um estudo de base populacional na cidade de São Paulo, Brasil

Abstract The study of the association of social variables with the prevalence of impairments can provide subsidies for more adequate care and health policies for the most needy people by incorporating social aspects. This article aims to estimate the prevalence of diverse types of impairments, the degree of difficulty, limitations, and the need for help they cause and attest whether this prevalence differ by educational attainment in individuals aged 20 years or older. This is a populational cross-sectional study (2015 Health Survey of São Paulo-ISA Capital). Data from 3184 individuals were analyzed via educational attainment as exposure variable and outcome variables related to visual, hearing, intellectual, and mobility impairments. 19.9% of participants had visual, 7.8%, hearing, 2.7%, intellectual, and 7.4%, mobility impairments. Mobility and intellectual impairments limited participants' daily activities the most, 70.3% and 63.3%, respectively; who, thus, needed the most help: 48.9% and 48.5%, respectively. Lower schooling was associated with a higher prevalence of impairments, greater need for help due to visual and intellectual impairments, and greater limitations due to hearing and visual impairments.

Resumo O estudo da associação de variáveis ​​sociais com a prevalência de deficiências pode fornecer subsídios para uma atenção e políticas de saúde mais adequadas às pessoas mais carentes ao incorporar aspectos sociais. O objetivo deste artigo é estimar a prevalência de diversos tipos de deficiências, o grau de dificuldade, as limitações e a necessidade de ajuda e verificar se essa prevalência difere por escolaridade em indivíduos com 20 anos ou mais. Trata-se de um estudo transversal populacional (Inquérito de Saúde de São Paulo 2015 - ISA-Capital). Os dados de 3.184 indivíduos foram analisados ​​com a escolaridade como variável de exposição relacionada às deficiências visuais, auditivas, intelectuais e de mobilidade. Dezenove vírgula nove por cento dos participantes apresentavam deficiência visual, 7,8% auditiva, 2,7% intelectual e 7,4% de mobilidade. Mobilidade e deficiência intelectual foram as que mais limitaram as atividades diárias, 70,3% e 63,3%, respectivamente, sendo, portanto, as que mais necessitaram de ajuda: 48,9% e 48,5%, respectivamente. Menor nível de escolaridade mostrou associação com maior prevalência de deficiências, maior necessidade de ajuda por deficiência visual e intelectual e maiores limitações por deficiência auditiva e visual.

Multimorbidity patterns and associated factors in a megacity: a cross-sectional study

ABSTRACT OBJECTIVE To identify empirical patterns of multimorbidity and quantify their associations with socioeconomic, behavioral characteristics, and health outcomes in the megacity of São Paulo. METHODS This was a cross-sectional study conducted through household interviews with residents aged 20 years or older in urban areas (n = 3,184). Latent class analysis was used to identify patterns among the co-existence of 22 health conditions. Age-adjusted prevalence ratios were estimated using Poisson regression. RESULTS The analysis of latent classes showed 4 patterns of multimorbidity, whereas 58.6% of individuals were classified in the low disease probability group, followed by participants presenting cardiovascular conditions (15.9%), respiratory conditions (12.8%), and rheumatic, musculoskeletal, and emotional conditions (12.8%). Older individuals, with lower schooling and lower household income, presented higher multimorbidity prevalence in cardiovascular, respiratory, rheumatic, musculoskeletal, and emotional conditions patterns compared with the low disease probability pattern. CONCLUSION The results showed four distinct patterns of multimorbidity in the megacity population, and these patterns are clinically recognizable and theoretically plausible. The identification of trends between patterns would make it feasible to estimate the magnitude of the challenge for the organization of health care policies.

Analysis of education level in access and use of health care services, ISA-Capital, São Paulo, Brazil, 2003 and 2015.

The great socioeconomic inequality that prevails in Brazil and the existence of a national health system with universal coverage places the need to monitor the evolution and social inequities regarding access to these services. This study aims to analyze the changes in the prevalence of health care use and the extent of social inequality in the demand, use and, access, resolution of health problems, satisfaction, and health care use of Brazilian Unified National Health System (SUS) according to education levels in the population living in the urban area of the Municipality of São Paulo, in 2003 and 2015. We analyzed data from two population-based household health surveys (Health Survey in São Paulo City - ISA-Capital) from 2003 and 2015. Dependent variables related to health care use in the two weeks preceding the survey and due to diseases included demand, access, satisfaction, problem resolution, and the public or private nature of the service. Prevalence was estimated using level of education and prevalence ratios (PR) by the Poisson regression. In the period, the demand for health care, access, resolution, and use of public health care increased from 2003 to 2015. Inequities in public health care use changed from 2003 to 2015 according to level of education. We found no social inequities in health care use in the municipality of São Paulo regarding demand, access, satisfaction, and resolution according to levels of education. Results show progress in the use and resolution of health care services, as well as the strong concentration of the use of SUS by the population with lower education. Results indicate the progress that SUS has made, but also show persistent challenges in the use and access to services.

[Factors associated with inequalities in social conditions in the health of elderly white, brown and black people in the city of São Paulo, Brazil]. / Fatores associados às desigualdades das condições sociais na saúde de idosos brancos, pardos e pretos na cidade de São Paulo, Brasil.

The scope of this study is to identify determining factors of disparities in social conditions in the health of non-institutionalized elderly people in the city of São Paulo, from the standpoint of self-declaration of skin color. It is a cross-sectional study with a representative sample of 1,017 elderly participants in the "2015 Health Survey of the Municipality of São Paulo". The analysis used crude and adjusted Poisson regression models, reporting the prevalence ratio and 95% confidence intervals as a measure of association between the variables. In the adjusted analysis, brown and black skin color was positively associated with worse schooling, negative self-assessment of health status, health insurance and access to public health services. On the one hand, black skin color was no longer associated with the lowest income, however, it was associated with arterial hypertension. On the other hand, brown skin color was associated with low income, but not with arterial hypertension. Elderly black and brown people had worse health conditions, less access to private health services and socioeconomic resources. These results are compatible with the hypothesis of structural racism in São Paulo's society and may inform social health policies aimed at promoting health and social justice.

O objetivo deste estudo é identificar fatores determinantes das disparidades das condições sociais na saúde de idosos não institucionalizados na cidade de São Paulo, sob a perspectiva da autodeclaração da cor da pele. Estudo transversal com amostra representativa de 1.017 idosos participantes do "Inquérito de Saúde do Município de São Paulo 2015". A análise utilizou modelos de regressão de Poisson brutas e ajustadas, relatando a razão de prevalências e seus intervalos de 95% de confiança como medida de associação entre as variáveis. Na análise ajustada, a cor da pele parda e preta associou-se, positivamente, com a pior escolaridade, a autoavaliação do estado de saúde negativa, o plano de saúde e o acesso ao serviço de saúde público. De um lado, a cor da pele preta perdeu a associação com a pior renda, no entanto, associou-se com a hipertensão arterial. De outro lado, a cor da pele parda não se associou com a hipertensão arterial, mas com a renda baixa. Idosos pretos e pardos tiveram menos acesso a recursos socioeconômicos, às piores condições de saúde e, também, a serviços de saúde privados. Esses resultados são compatíveis com a hipótese de racismo estrutural na sociedade paulistana e podem instruir políticas sociais na saúde dirigidas à promoção de saúde e justiça social.

Fatores associados às desigualdades das condições sociais na saúde de idosos brancos, pardos e pretos na cidade de São Paulo, Brasil / Factors associated with inequalities in social conditions in the health of elderly white, brown and black people in the city of São Paulo, Brazil

Resumo O objetivo deste estudo é identificar fatores determinantes das disparidades das condições sociais na saúde de idosos não institucionalizados na cidade de São Paulo, sob a perspectiva da autodeclaração da cor da pele. Estudo transversal com amostra representativa de 1.017 idosos participantes do "Inquérito de Saúde do Município de São Paulo 2015". A análise utilizou modelos de regressão de Poisson brutas e ajustadas, relatando a razão de prevalências e seus intervalos de 95% de confiança como medida de associação entre as variáveis. Na análise ajustada, a cor da pele parda e preta associou-se, positivamente, com a pior escolaridade, a autoavaliação do estado de saúde negativa, o plano de saúde e o acesso ao serviço de saúde público. De um lado, a cor da pele preta perdeu a associação com a pior renda, no entanto, associou-se com a hipertensão arterial. De outro lado, a cor da pele parda não se associou com a hipertensão arterial, mas com a renda baixa. Idosos pretos e pardos tiveram menos acesso a recursos socioeconômicos, às piores condições de saúde e, também, a serviços de saúde privados. Esses resultados são compatíveis com a hipótese de racismo estrutural na sociedade paulistana e podem instruir políticas sociais na saúde dirigidas à promoção de saúde e justiça social.

Abstract The scope of this study is to identify determining factors of disparities in social conditions in the health of non-institutionalized elderly people in the city of São Paulo, from the standpoint of self-declaration of skin color. It is a cross-sectional study with a representative sample of 1,017 elderly participants in the "2015 Health Survey of the Municipality of São Paulo". The analysis used crude and adjusted Poisson regression models, reporting the prevalence ratio and 95% confidence intervals as a measure of association between the variables. In the adjusted analysis, brown and black skin color was positively associated with worse schooling, negative self-assessment of health status, health insurance and access to public health services. On the one hand, black skin color was no longer associated with the lowest income, however, it was associated with arterial hypertension. On the other hand, brown skin color was associated with low income, but not with arterial hypertension. Elderly black and brown people had worse health conditions, less access to private health services and socioeconomic resources. These results are compatible with the hypothesis of structural racism in São Paulo's society and may inform social health policies aimed at promoting health and social justice.

Social inequalities in access to cancer screening and early detection: A population-based study in the city of São Paulo, Brazil.

OBJECTIVE: This study monitors trends in access to cancer screening, focusing on mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA), assessing the magnitude of inequality in the city of São Paulo from 2003 to 2015 according to education level. METHOD: This is a cross-sectional population-based study conducted with data from the 2003, 2008, and 2015 editions of the Health Survey of the City of São Paulo (ISA-Capital). Outcome variables were the proportion of mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA) tests according to the protocols. Inequality was measured by education level according to years of study. For static analysis, Poisson regression was used to estimate proportion ratios. RESULTS: The proportion of Pap smears remained stationary at a high level (>89%) throughout the study period, while access to mammography and PSA tests significantly increased in the 2003‒2015 period. The present results indicate inequalities in access to cancer screening due to education, and being more expressive for mammography and PSA tests. However, this inequality significantly decreased over the period analyzed comparing the most educated individuals with those with the lowest educational level. In addition, an increase in the proportion of tests performed in the Brazilian Unified Health System was identified, especially for mammography and PSA tests, in the period 2003‒2015. CONCLUSIONS: The inequalities observed in the access to preventive exams were influenced by the level of education. The offer of exams was expanded, more significantly for mammography and PSA, especially among the less educated group.

Social inequalities in access to cancer screening and early detection: A population-based study in the city of São Paulo, Brazil

Abstract Objective: This study monitors trends in access to cancer screening, focusing on mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA), assessing the magnitude of inequality in the city of São Paulo from 2003 to 2015 according to education level. Method: This is a cross-sectional population-based study conducted with data from the 2003, 2008, and 2015 editions of the Health Survey of the City of São Paulo (ISA-Capital). Outcome variables were the proportion of mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA) tests according to the protocols. Inequality was measured by education level according to years of study. For static analysis, Poisson regression was used to estimate proportion ratios. Results: The proportion of Pap smears remained stationary at a high level (>89%) throughout the study period, while access to mammography and PSA tests significantly increased in the 2003-2015 period. The present results indicate inequalities in access to cancer screening due to education, and being more expressive for mammography and PSA tests. However, this inequality significantly decreased over the period analyzed comparing the most educated individuals with those with the lowest educational level. In addition, an increase in the proportion of tests performed in the Brazilian Unified Health System was identified, especially for mammography and PSA tests, in the period 2003-2015. Conclusions: The inequalities observed in the access to preventive exams were influenced by the level of education. The offer of exams was expanded, more significantly for mammography and PSA, especially among the less educated group.

Analysis of education level in access and use of health care services, ISA-Capital, São Paulo, Brazil, 2003 and 2015 / Análise da escolaridade no acesso e utilização de serviços de saúde, ISA-Capital, São Paulo, Brasil, 2003 e 2015 / Análisis de la educación en el acceso y el uso de los servicios de salud, ISA-Capital, São Paulo, Brasil, 2003 y 2015

The great socioeconomic inequality that prevails in Brazil and the existence of a national health system with universal coverage places the need to monitor the evolution and social inequities regarding access to these services. This study aims to analyze the changes in the prevalence of health care use and the extent of social inequality in the demand, use and, access, resolution of health problems, satisfaction, and health care use of Brazilian Unified National Health System (SUS) according to education levels in the population living in the urban area of the Municipality of São Paulo, in 2003 and 2015. We analyzed data from two population-based household health surveys (Health Survey in São Paulo City - ISA-Capital) from 2003 and 2015. Dependent variables related to health care use in the two weeks preceding the survey and due to diseases included demand, access, satisfaction, problem resolution, and the public or private nature of the service. Prevalence was estimated using level of education and prevalence ratios (PR) by the Poisson regression. In the period, the demand for health care, access, resolution, and use of public health care increased from 2003 to 2015. Inequities in public health care use changed from 2003 to 2015 according to level of education. We found no social inequities in health care use in the municipality of São Paulo regarding demand, access, satisfaction, and resolution according to levels of education. Results show progress in the use and resolution of health care services, as well as the strong concentration of the use of SUS by the population with lower education. Results indicate the progress that SUS has made, but also show persistent challenges in the use and access to services.

A grande iniquidade socioeconômica que prevalece no Brasil e a existência de um sistema nacional de saúde com cobertura universal torna necessário o acompanhamento da evolução e das iniquidades sociais no acesso aos serviços. Analisar as mudanças na prevalência do uso de serviços de saúde e o grau de iniquidade social considerando a demanda, o uso e acesso, resolução de problemas de saúde, satisfação e utilização dos serviços de saúde do Sistema Único de Saúde (SUS), segundo o nível de escolaridade, na população residente na zona urbana do Município de São Paulo, em 2003 e 2015. Foram analisados dados de dois inquéritos domiciliares de saúde de base populacional (Inquérito de Saúde do Município de São Paulo - ISA-Capital) de 2003 e 2015. As variáveis dependentes relacionadas à utilização de serviços de saúde nas duas semanas anteriores à pesquisa e devido à presença de alguma doença incluem: demanda, acesso, satisfação, resolução do problema e a natureza pública ou privada do serviço. A prevalência foi estimada por meio da escolaridade e das razões de prevalência (RP) por regressão de Poisson. Entre 2003 e 2015, a demanda por cuidados de saúde, acesso, resolutividade e utilização de serviços públicos de saúde aumentou. As iniquidades no uso da saúde pública mudaram de 2003 para 2015 quando se trata do nível de escolaridade. Não foram encontradas iniquidades sociais na utilização dos serviços de saúde no Município de São Paulo em termos de demanda, acesso, satisfação e resolutividade, segundo o nível de escolaridade. Os resultados mostram avanços na utilização e resolutividade dos serviços de saúde, bem como uma forte concentração do uso do SUS pela população com menor nível de escolaridade. Os resultados indicam os avanços do SUS, mas também mostram que ainda há desafios no uso e acesso aos serviços.

La gran desigualdad socioeconómica que prevalece en Brasil y la existencia de un sistema nacional de salud con cobertura universal hace necesario el seguimiento de la evolución y de las desigualdades sociales en el acceso a los servicios. Analizar los cambios en la prevalencia del uso de servicios de salud y el grado de desigualdad social considerando la demanda, el uso y acceso, resolución de problemas de salud, satisfacción y utilización de los servicios de salud del Sistema Único de Salud brasileño (SUS), según el nivel de educación, en la población residente en la zona urbana del Municipio de São Paulo, en 2003 y 2015. Se analizaron los datos de dos encuestas de salud domiciliaria de base poblacional (Encuesta de Salud en el Municipio de São Paulo - ISA-Capital) de 2003 y 2015. Las variables dependientes relacionadas con el uso de los servicios de salud en las dos semanas anteriores a la investigación y debido a la presencia de alguna enfermedad incluyen: la demanda, el acceso, la satisfacción, la resolución del problema y la naturaleza pública o privada del servicio. La prevalencia se estimó mediante la educación y las razones de prevalencia (RP) mediante regresión de Poisson. Entre 2003 y 2015, aumentó la demanda de atención médica, el acceso, la resolución y el uso de los servicios de salud pública. Las desigualdades en el uso de la salud pública cambiaron de 2003 a 2015 en lo que respecta al nivel de educación. No fueron encontradas desigualdades sociales en la utilización de los servicios de salud en el municipio de São Paulo en términos de demanda, acceso, satisfacción y resolutividad, según el nivel de educación. Los resultados muestran avances en la utilización y la resolutividad de los servicios de salud, así como una fuerte concentración del uso del SUS por parte de la población con menor nivel de educación. Los resultados indican los avances del SUS, pero también muestran que todavía hay desafíos en el uso y acceso a los servicios.

Prevalence of multimorbidity in older adults in São Paulo, Brazil: a study with ISA-Capital.

OBJECTIVE: To estimate the prevalence of multimorbidity in older adults in São Paulo, Brazil. METHODS: A cross-sectional study based on the 2015 ISA-Capital population-based survey, with a subsample of 1,019 older adults aged ≥ 60 years old. Multimorbidity was categorized considering two or more chronic diseases, based on a previously defined list. The data were analyzed in univariate and multiple models with Poisson regression. RESULTS: The prevalence of multimorbidity was 40% (95%CI: 36.6-43.8), being higher in women (PR a = 1.95 [compared to men]; 95%CI: 1.58-2.40), in individuals aged ≥ 75 years old (PR a = 1.25 [compared to individuals aged ≥ 60 to 64 years old]; 95%CI: 1.01-1.60), in Black people (PR a = 1.28 [compared to White people]; 95%CI: 1.04-1.59), in high-income people (PR a = 1.27 [compared to low income]; 95%CI: 1.09-1.50) and in former smokers (PR a = 1.30 [compared to those who never smoked]; 95%CI: 1.05-1.60), and lower in smokers (PR a = 0.72 [compared to those who never smoked]; 95%CI: 1.09-1.50). CONCLUSION: The prevalence of multimorbidity was lower than that reported in most of the reviewed studies, but consistently associated with gender, age, race/skin color, smoking habit and socioeconomic status. The standardization of conceptual and methodological criteria for estimation is a challenge to relieve problems in the planning and management of health care systems for older populations.

Differences in Cost-Effectiveness of Adherence to Nutritional Recommendations: Why, Where, and What?

Cost-effectiveness analysis of diets may comprise an important tool to promote food security; however, studies show divergent evidence regarding the relationship between diet quality and cost in diverse populations. Thus, this study assesses differences in cost-effectiveness ratios regarding adherence to nutritional recommendations using data representative of the population level in Sao Paulo municipality, Brazil. Information from adolescents and adult individuals (n = 1742) was used to estimate diet quality and cost in 2015. Differences in cost-effectiveness ratios were investigated through application of two diet quality indexes and exploration of individuals' personal and contextual characteristics. Results indicated that higher diet cost was associated with higher adherence to nutritional recommendations at the national level and inversely associated with adherence to international recommendations. Purchasing foods in street markets was linked to healthier diets at lower costs, and protein consumption was associated with higher diet cost regardless of diet quality; however, diet quality was linked to type of protein consumed by individuals. Differences in cost-effectiveness ratios were attributable to methodological choices in measuring dietary quality (why); individuals' personal and contextual characteristics, in particular, access to retail equipment (where); and certain food choices (what). Therefore, cost-effectiveness analyses should be tailored to policy goals and local environments to ensure proper assessment of nutrition programs and to foster improvements in nutritional diet quality at lower cost.

Prevalence of multimorbidity in older adults in São Paulo, Brazil: a study with ISA-Capital / Prevalência de multimorbidade em idosos em São Paulo, Brasil: um estudo com o ISA-Capital

ABSTRACT OBJECTIVE To estimate the prevalence of multimorbidity in older adults in São Paulo, Brazil. METHODS A cross-sectional study based on the 2015 ISA-Capital population-based survey, with a subsample of 1,019 older adults aged ≥ 60 years old. Multimorbidity was categorized considering two or more chronic diseases, based on a previously defined list. The data were analyzed in univariate and multiple models with Poisson regression. RESULTS The prevalence of multimorbidity was 40% (95%CI: 36.6-43.8), being higher in women (PR a = 1.95 [compared to men]; 95%CI: 1.58-2.40), in individuals aged ≥ 75 years old (PR a = 1.25 [compared to individuals aged ≥ 60 to 64 years old]; 95%CI: 1.01-1.60), in Black people (PR a = 1.28 [compared to White people]; 95%CI: 1.04-1.59), in high-income people (PR a = 1.27 [compared to low income]; 95%CI: 1.09-1.50) and in former smokers (PR a = 1.30 [compared to those who never smoked]; 95%CI: 1.05-1.60), and lower in smokers (PR a = 0.72 [compared to those who never smoked]; 95%CI: 1.09-1.50). CONCLUSION The prevalence of multimorbidity was lower than that reported in most of the reviewed studies, but consistently associated with gender, age, race/skin color, smoking habit and socioeconomic status. The standardization of conceptual and methodological criteria for estimation is a challenge to relieve problems in the planning and management of health care systems for older populations.

RESUMO OBJETIVO Estimar a prevalência de multimorbidade em idosos em São Paulo, Brasil. MÉTODOS Estudo transversal, aninhado ao inquérito de base populacional ISA-Capital, de 2015, com sub amostra de 1.019 idosos com 60 anos ou mais. A multimorbidade foi categorizada considerando duas ou mais doenças crônicas, a partir de uma lista previamente definida. Os dados foram analisados em modelos univariado e múltiplo com a regressão de Poisson. RESULTADOS A prevalência de multimorbidade foi de 40% (IC95% 36,6-43,8), sendo maior nas mulheres (RP a = 1,95 [comparado com homens]; IC95% 1,58-2,40), nos indivíduos com 75 anos ou mais (RP a = 1,25 [comparado com indivíduos de 60 a 64 anos]; IC95% 1,01-1,60), nos pretos (RP a = 1,28 [comparado com brancos]; IC95% 1,04-1,59), nas pessoas de alta renda (RP a = 1,27 [comparado com baixa renda]; IC95% 1,09-1,50) e nos ex-fumantes (RP a = 1,30 [comparado com quem nunca fumou]; IC95% 1,05-1,60) e menor nos que se declararam fumantes (RP a = 0,72 [comparado com quem nunca fumou]; IC95% 1,09-1,50). CONCLUSÕES A prevalência de multimorbidade foi inferior à reportada na maioria dos estudos revisados, mas há consistência sobre sua associação com sexo, idade, cor da pele, tabagismo e nível socioeconômico. A padronização de critérios conceituais e metodológicos para a sua estimação é um desafio para mitigar problemas no planejamento e gestão de sistemas de saúde para populações cada vez mais envelhecidas.

Use of medicines in São Paulo, Brazil, and State Health Care Coverage, 2003 and 2015.

OBJECTIVES: To analyze the use and acquisition of medicines in São Paulo, Brazil, in 2003 and 2015, according to sociodemographic factors, socioeconomic status, and health conditions of the population. METHODS: Data were obtained from population health surveys "ISA-Capital". Descriptive analysis, bivariate analysis, and logistic regression models were used to evaluate the use of medicines and coverage by the Brazilian Unified Health System (SUS) according to socioeconomic status and health conditions in two periods: 2003 and 2015. RESULTS: From 2003 to 2015, the surveys showed an increase in the income and education level of the study population. There was no increase in the prevalence of chronic diseases and use of medicines from 2003 to 2015. The provision of medicines by SUS was higher in 2015 than in 2003, and the coverage by SUS was higher in the population with lower education level and income in both 2003 and 2015. CONCLUSIONS: The use of medicines, mainly for chronic disease control, did not change over the years, and there was an increase in SUS coverage for medicines during 2003-2015 in all population groups, with a greater impact on the lower socioeconomic status population. The programs of the provision of medicines implanted since 2003 had influenced the greater SUS coverage for medicines and in the reduction of inequalities in access to medicines.

Changes in total physical activity, leisure and commuting in the largest city in Latin America, 2003-2015.

OBJECTIVE: To analyze the prevalence of physical inactivity and the average time of practice of total physical activity and by domains (leisure and commuting), according to gender, age group and schooling, between 2003 and 2015, in residents of the urban area of the city of São Paulo. METHODS: Data from Household Health Surveys in the Municipality of São Paulo (2003: n = 2,514; 2015: n = 4,043). The International Physical Activity Questionnaire was used to measure total, leisure, and commuting physical activity. Results were presented in < 10 minute/week periods, physical inactivity and minutes/week, according to evaluation period, sex, age and schooling. RESULTS: Prevalence of < 10 minutes/week periods in 2003 and 2015 were: 22.5 and 28.9% for the total; 56.7 and 58.3% for leisure; and 35.2 and 39.9% for commuting, with significant change only in the total item, among adolescents (10.3 to 18.8%). For physical inactivity, prevalence rates were: 54.9 and 61.6% (total); 78.2 and 78.9% (leisure); and 72 and 79.9% (commuting), with significant changes only for commuting among adults (67.8 to 77.4%). For the average in minutes per week, in total, there was a significant decrease for female adolescents (138.2 minute/week) and adults with 0-8 (122.6 minutes/week) and 9-11 years (96.7 minutes/week) years of schooling; in commuting, there was a reduction for female adolescents (95 minutes/week); and male adults (95 minutes/week) and female adults (82 minutes/week). CONCLUSIONS: There were no reductions in the prevalence of < 10 min/week periods or leisure physical inactivity. Commuting physical inactivity has become even more common.

Changes in total physical activity, leisure and commuting in the largest city in Latin America, 2003-2015 / Mudanças na atividade física total, de lazer e deslocamento na maior cidade da América Latina, 2003-2015

ABSTRACT: Objective: To analyze the prevalence of physical inactivity and the average time of practice of total physical activity and by domains (leisure and commuting), according to gender, age group and schooling, between 2003 and 2015, in residents of the urban area of the city of São Paulo. Methods: Data from Household Health Surveys in the Municipality of São Paulo (2003: n = 2,514; 2015: n = 4,043). The International Physical Activity Questionnaire was used to measure total, leisure, and commuting physical activity. Results were presented in < 10 minute/week periods, physical inactivity and minutes/week, according to evaluation period, sex, age and schooling. Results: Prevalence of < 10 minutes/week periods in 2003 and 2015 were: 22.5 and 28.9% for the total; 56.7 and 58.3% for leisure; and 35.2 and 39.9% for commuting, with significant change only in the total item, among adolescents (10.3 to 18.8%). For physical inactivity, prevalence rates were: 54.9 and 61.6% (total); 78.2 and 78.9% (leisure); and 72 and 79.9% (commuting), with significant changes only for commuting among adults (67.8 to 77.4%). For the average in minutes per week, in total, there was a significant decrease for female adolescents (138.2 minute/week) and adults with 0-8 (122.6 minutes/week) and 9-11 years (96.7 minutes/week) years of schooling; in commuting, there was a reduction for female adolescents (95 minutes/week); and male adults (95 minutes/week) and female adults (82 minutes/week). Conclusions: There were no reductions in the prevalence of < 10 min/week periods or leisure physical inactivity. Commuting physical inactivity has become even more common.

RESUMO: Objetivo: Analisar a prevalência de inatividade física e o tempo médio de prática de atividade física total e por domínios (lazer e deslocamento), de acordo com sexo, faixa etária e escolaridade, em residentes de área urbana do munícipio de São Paulo, entre os anos de 2003 e 2015. Métodos: Utilizaram-se dados dos Inquéritos Domiciliares de Saúde no Município de São Paulo (2013: n = 2.514; 2015: n = 4.043). O International Physical Activity Questionnaire foi utilizado para mensurar a atividade física total, de lazer e deslocamento. Resultados foram apresentados em períodos de < 10 minutos/semana, inatividade física e minutos/semana, conforme período de avaliação, faixa etária, sexo e escolaridade. Resultados: As prevalências dos períodos < 10 minutos/semana em 2003 e 2015 foram 22,5 e 28,9% para total; 56,7 e 58,3% para lazer; e 35,2 e 39,9% para deslocamento, com mudança significativa no total em adolescentes, de 10,3 para 18,8%. Para inatividade física, as prevalências foram 54,9 e 61,6% para total; 78,2 e 78,9% para lazer; e 72 e 79,9% para deslocamento, com mudanças significativas no deslocamento em adultos, de 67,8 para 77,4%. Para as médias de atividade física total, houve diminuição significativa para adolescentes do sexo feminino (138,2 minutos/semana) e adultos com escolaridade de 0-8 (122,6 minutos/semana) e 9-11 anos (96,7 minutos/semana); no deslocamento, houve diminuição para adolescentes do sexo feminino (95 minutos/semana) e adultos do sexo masculino (95 minutos/semana) e feminino (82 minutos/semana). Conclusão: Não foram encontradas diminuições na prevalência dos períodos < 10 minutos/semana e na inatividade física no lazer. A inatividade física no deslocamento ficou ainda maior.

Use of medicines in São Paulo, Brazil, and State Health Care Coverage, 2003 and 2015

OBJECTIVES: To analyze the use and acquisition of medicines in São Paulo, Brazil, in 2003 and 2015, according to sociodemographic factors, socioeconomic status, and health conditions of the population. METHODS: Data were obtained from population health surveys "ISA-Capital". Descriptive analysis, bivariate analysis, and logistic regression models were used to evaluate the use of medicines and coverage by the Brazilian Unified Health System (SUS) according to socioeconomic status and health conditions in two periods: 2003 and 2015. RESULTS: From 2003 to 2015, the surveys showed an increase in the income and education level of the study population. There was no increase in the prevalence of chronic diseases and use of medicines from 2003 to 2015. The provision of medicines by SUS was higher in 2015 than in 2003, and the coverage by SUS was higher in the population with lower education level and income in both 2003 and 2015. CONCLUSIONS: The use of medicines, mainly for chronic disease control, did not change over the years, and there was an increase in SUS coverage for medicines during 2003-2015 in all population groups, with a greater impact on the lower socioeconomic status population. The programs of the provision of medicines implanted since 2003 had influenced the greater SUS coverage for medicines and in the reduction of inequalities in access to medicines.