What is the burden of multimorbidity and the factors associated with its occurrence in elderly Brazilians? / ¿Cuál es la carga de multimorbilidad y los factores asociados a su ocurrencia en personas mayores brasileñas? / Qual é a carga de multimorbidade e os fatores associados à sua ocorrência em pessoas idosas brasileiras?

ABSTRACT Objective: To estimate the prevalence of multimorbidity in elderly people and its association with sociodemographic characteristics, lifestyle, and anthropometry. Methods: This was a cross-sectional study using data from the National Health Survey, 2019. A total of 22,728 elderly individuals from all 27 Brazilian states were randomly selected. Poisson regression models with robust variance were employed, and a significance level of 5% was adopted. Results: The prevalence of multimorbidity was 51.6% (95% CI: 50.4-52.7), with the highest estimates observed in the South and Southeast. Multimorbidity was associated with being female (aPR = 1.33; 95% CI: 1.27-1.39), being 80 years old or older (aPR = 1.12; 95% CI: 1.05-1.19), having low education (aPR = 1.16; 95% CI: 1.07-1.25), past cigarette use (aPR = 1.16; 95% CI: 1.11-1.21), insufficient physical activity (aPR = 1.13; 95% CI: 1.06-1.21), and screen use for 3 hours or more per day (aPR = 1.13; 95% CI: 1.08-1.18). Conclusion: Multimorbidity affects more than half of the elderly population in Brazil and is associated with social, demographic, and behavioral factors.

RESUMEN Objetivo: Estimar la prevalencia de multimorbilidad en personas mayores y su asociación con características sociodemográficas, estilo de vida y antropometría. Métodos: Estudio transversal, con datos de la Encuesta Nacional de Salud, 2019. Se seleccionaron aleatoriamente 22.728 personas mayores de los 27 estados brasileños. Se emplearon modelos de regresión de Poisson con varianza robusta y se adoptó un nivel de significancia del 5%. Resultados: La prevalencia de multimorbilidad fue del 51,6% (IC95%: 50,4-52,7), siendo las mayores estimaciones observadas en el Sur y Sudeste. La multimorbilidad se asoció con el sexo femenino (RPa=1,33; IC95%: 1,27-1,39), tener 80 años o más (RPa= 1,12; IC95%: 1,05-1,19), baja escolaridad (RPa=1,16; IC95%:1,07-1,25), consumo de cigarrillo en el pasado (RPa=1,16; IC95%:1,11-1,21), práctica insuficiente de actividad física (RPa= 1,13; IC95%:1,06-1,21) y uso de pantallas por 3 horas o más al día (RPa=1,13; IC95%:1,08-1,18). Conclusión: La multimorbilidad afecta a más de la mitad de la población anciana de Brasil y está asociada a factores sociales, demográficos y conductuales.

RESUMO Objetivo: Estimar a prevalência de multimorbidade em pessoas idosas e sua associação com características sociodemográficas, estilo de vida e antropometria. Métodos: Estudo transversal, com dados da Pesquisa Nacional de Saúde, 2019. Foram selecionadas aleatoriamente 22.728 pessoas idosas dos 27 estados brasileiros. Empregaram-se modelos de regressão de Poisson com variância robusta e adotou-se um nível de significância de 5%. Resultados: A prevalência de multimorbidade foi de 51,6% (IC95%: 50,4-52,7), sendo as maiores estimativas observadas no Sul e Sudeste. A multimorbidade foi associada ao sexo feminino (RPa=1,33; IC95%: 1,27-1,39), ter 80 anos ou mais (RPa= 1,12; IC95%: 1,05-1,19), baixa escolaridade (RPa=1,16; IC95%:1,07-1,25), consumo de cigarro no passado (RPa=1,16; IC95%:1,11-1,21), prática insuficiente de atividade física (RPa= 1,13; IC95%:1,06-1,21) e uso de telas por 3 horas ou mais por dia (RPa=1,13; IC95%:1,08-1,18). Conclusão: A multimorbidade afeta mais da metade da população idosa do Brasil e está associada a fatores sociais, demográficos e comportamentais.

Socioeconomic inequalities in health problems in the first two years of life: Pelotas (Brazil) birth cohort, 2015 / Desigualdades socioeconômicas em problemas de saúde nos primeiros dois anos de vida: coorte de nascimentos de Pelotas, Rio Grande do Sul, Brasil, 2015 / Desigualdades socioeconómicas en problemas sanitarios en los dos primeros años de vida: cohorte de nacimientos de Pelotas, Rio Grande do Sul, Brasil, 2015

Abstract: Brazil is characterized by an unfinished agenda of health inequalities, which impact health problems in the childhood. This study aimed to evaluate the socioeconomic inequalities of health problems in the early childhood. This is a prospective study, using data from the birth cohort carried out in the city of Pelotas (Rio Grande do Sul State, Brazil) in 2015. The outcomes were health problems presented at 12 and 24 months: cough, breathing difficulty, diarrhea, ear pain, pneumonia, urinary infection, hospitalization, and other health problems. Socioeconomic inequalities were measured applying the slope index of inequality (SII) and the concentration index (CIX), with wealth index and maternal schooling being the socioeconomic variables. The inequalities in the number of health problems were evaluated by Poisson regression. The perinatal sample comprised 4,275 children. At 12 months approximately 74% of the children presented 1 or more health problems, while at 24 months, approximately 44% presented 2 or more health problems. For all period, the mean number of health problems was 2.9 (standard deviation = 2.0). Higher frequencies were observed for children belonging to the poorest income quintile and with lower maternal education, except for 1 or more health problems at 24 months. The greatest absolute and relative inequality was observed for 2 or more health problems at 12 months (SII: -0.23, 95%CI: -0.29; -0.18 and CIX: -0.19, 95%CI: -0.25; -0.14). There is an opposite dose-response relation for the risk of accumulation of health problems according to maternal schooling (1.07, 95%CI: 1.04; 1.09) and wealth categories (1.03, 95%CI: 1.01; 1.04), in the full adjusted models. The study confirms inequalities due to health problems in Brazilian children, especially in the first year of life.

Resumo: O Brasil é marcado por uma agenda inacabada em relação às desigualdades na saúde, impactando os problemas de saúde da infância. O objetivo deste estudo foi avaliar as desigualdades socioeconômicas relacionadas aos problemas de saúde da primeira infância. Este é um estudo prospectivo com base na coorte de nascimentos realizado na cidade de Pelotas (Rio Grande do Sul, Brasil) em 2015. Os desfechos foram problemas de saúde apresentados aos 12 e 24 meses de idade: tosse, dificuldade para respirar, diarreia, dor de ouvido, pneumonia, infecção urinária, hospitalização e outros problemas de saúde. As desigualdades socioeconômicas foram aferidas usando o índice de desigualdade absoluta (SII, acrônimo em inglês) e o índice de concentração (CIX, acrônimo em inglês), considerando o índice de riqueza e escolaridade materna como variáveis socioeconômicas. A regressão de Poisson foi utilizada para avaliar as desigualdades no número de problemas de saúde. Um total de 4.275 crianças foram incluídas na análise. Aos 12 e 24 meses, aproximadamente 74% e 44% apresentaram 1 ou mais e 2 ou mais problemas de saúde, respectivamente. Para todo o período, o número médio de problemas de saúde foi de 2,9 (desvio padrão = 2.0). Maiores frequências foram observadas para crianças no quintil de renda mais baixa e com menor escolaridade materna, exceto para 1 ou mais problemas de saúde aos 24 meses. A maior desigualdade absoluta e relativa foi observada para 2 ou mais problemas de saúde aos 12 meses (SII: -0,23, IC95%: -0,29; -0,18 e CIX: -0,19, IC95%: -0,25; -0,14). Com base nos modelos ajustados, foi encontrada uma relação dose-resposta oposta para o acúmulo de problemas de saúde com base na escolaridade materna (1,07, IC95%: 1,04; 1,09) e nas categorias de riqueza (1,03, IC95%: 1,01; 1,04). Portanto, o estudo confirma as desigualdades relacionadas aos problemas de saúde em crianças brasileiras, especialmente no primeiro ano de vida.

Resumen: Las desigualdades sanitarias en Brasil afectan a la salud infantil. El objetivo de este estudio fue evaluar las desigualdades socioeconómicas de los problemas sanitarios de la primera infancia. Este es un estudio prospectivo de una cohorte de nacimientos realizada en la ciudad de Pelotas (Rio Grande do Sul, Brasil) en 2015. Los desenlaces fueron problemas sanitarios de niños de 12 y 24 meses de edad como tos, dificultad para respirar, diarrea, dolor de oído, neumonía, infección del tracto urinario, hospitalización, entre otros problemas. Las desigualdades socioeconómicas se midieron con el índice de desigualdad absoluta (SII, por sus siglas en inglés) y el índice de concentración (CIX, por sus siglas en inglés). El índice de ingresos y nivel educativo de la madre fueron las variables socioeconómicas. Las desigualdades en el número de problemas sanitarios se evaluaron mediante la regresión de Poisson. La muestra perinatal fue conformada por 4.275 niños. A los 12 y 24 meses, aproximadamente el 74% y el 44% de los niños tenían uno o más y dos o más problemas de salud, respectivamente. Durante el período, el número promedio de problemas sanitarios fue de 2,9 (desviación estandar = 2.0). Se observaron frecuencias más altas para los niños pertenecientes al quintil de ingresos más pobres y con el nivel educativo de la madre más bajo, a excepción de uno o más problemas de salud a los 24 meses. La mayor desigualdad absoluta y relativa se observó en dos o más problemas sanitarios a los 12 meses (SII: -0,23, IC95%: -0,29; -0,18 e CIX: -0,19, IC95%: -0,25; -0,14). Con base en los modelos ajustados, se encontró una relación dosis-respuesta opuesta para la acumulación de problemas sanitarios en cuanto al nivel educativo de la madre (1,07, IC95%: 1,04; 1,09) y a los ingresos (1,03, IC95%: 1,01; 1,04). Este estudio confirma las desigualdades por problemas sanitarios de niños brasileños, especialmente en el primer año de vida.

Prevalence and factors associated with multimorbidity in adults in Brazil, according to sex: a population-based cross-sectional survey.

Introduction: Multimorbidity, defined as the coexistence of two or more chronic diseases in the same individual, represents a significant health challenge. However, there is limited evidence on its prevalence and associated factors in developing countries, such as Brazil, especially stratified by sex. Thus, this study aims to estimate the prevalence and analyze the factors associated with multimorbidity in Brazilian adults according to sex. Methods: Cross-sectional population-based household survey carried out with Brazilian adults aged 18 years or older. The sampling strategy consisted of a three-stage conglomerate plan. The three stages were performed through simple random sampling. Data were collected through individual interviews. Multimorbidity was classified based on a list of 14 self-reported chronic diseases/conditions. Poisson regression analysis was performed to estimate the magnitude of the association between sociodemographic and lifestyle factors with the prevalence of multimorbidity stratified by sex. Results: A total of 88,531 individuals were included. In absolute terms, the prevalence of multimorbidity was 29.4%. The frequency in men and women was 22.7 and 35.4%, respectively. Overall, multimorbidity was more prevalent among women, the older people, residents of the South and Southeast regions, urban area residents, former smokers, current smokers, physically inactive, overweight, and obese adults. Individuals with complete high school/incomplete higher education had a lower prevalence of multimorbidity than those with higher educational level. The associations between education and multimorbidity differed between sexes. In men, multimorbidity was inversely associated with the strata of complete middle school/incomplete high school and complete high school/incomplete higher education, while in women, the association between these variables was not observed. Physical inactivity was positively associated with a higher prevalence of multimorbidity only in men. An inverse association was verified between the recommended fruit and vegetable consumption and multimorbidity for the total sample and both sexes. Conclusion: One in four adults had multimorbidity. Prevalence increased with increasing age, among women, and was associated with some lifestyles. Multimorbidity was significantly associated with educational level and physical inactivity only in men. The results suggest the need to adopt integrated strategies to reduce the magnitude of multimorbidity, specific by gender, including actions for health promotion, disease prevention, health surveillance and comprehensive health care in Brazil.

Multimorbidity patterns: obesity as the main modifiable risk factor in adult women in Southern Brazil.

Objective: To identify multimorbidity patterns in women in southern Brazil, and its relationship with sociodemographic, lifestyle characteristics, and nutritional status, as well as to explore the main independent risk factor for the identified patterns. Subjects and methods: This is a cross-sectional, population-based study with 1,128 women (20-69 years), southern Brazil. Chronic conditions were identified using the therapeutic and chemical anatomical classification of continuous use of medications. Multimorbidity was assessed as ≥2 or ≥3 chronic conditions to identify dyads and triads. Poisson regression was used to explore risk factors in the different adjustment models. As independent variables evaluated, in addition to sociodemographic characteristics, lifestyle variables were included: consumption of fruits and vegetables, physical activity, alcohol consumption, smoking and nutritional status. Results: Eleven dyads (frequencies between 2.0% and 6.4%) and three triads (frequencies between 1.9% and 2.1%) of morbidities were identified in the study. Aging was related to a higher prevalence of all patterns, and obesity was a risk factor for multimorbidity patterns that contained conditions related to the cardiovascular and metabolic system and mental health. After adjustment, obesity increased the probability of "hypertension + common mental disorders (CMD)" (PR 3.63; 95% CI 1.94-6.78) and "dyslipidemia + CMD" (PR 3.69; 95% CI 1.08-12.65) by more than three times. Conclusion: This study identified common and important diseases in the patterns, associated with a common risk factor, obesity, that must be addressed by public health policies to prevent multimorbidity.

Multimorbidity and Sleep Patterns among Adults in a Peruvian Semi-Urban Area.

Objective To assess if the duration and quality of sleep vary due to the presence of multimorbidity. Materials and Methods We performed a secondary analysis using data from a population-based study involving adult subjects aged between 30 and 69 years residing in a semi-urban area of Tumbes, Peru. The duration (normal, short or prolonged) and quality (good or poor) of sleep were our outcome variables, whereas the exposure was multimorbidity (two or more chronic conditions). Crude and adjusted Poisson regression models were built to assess the association of interest, and prevalence ratios (PRs) and 95% confidence intervals (95%CIs) were reported. Results We analyzed data from 1,607 subjects with a mean age of 48.2 (standard deviation [SD]: ± 10.6) years, 809 (50.3%) of whom were women. Multimorbidity was present in 634 (39.5%; 95%CI: 37.1-41.9%) subjects, and 193 (12.1%; 95%CI: 10.5-13.7%) were short sleepers, 131 (8.2%; 95%CI: 6.9-9.6%) were long sleepers, and 312 (19.5%; 95%CI: 17.5-21.5%) had poor sleep quality. In the multivariable model, multimorbidity was associated with prolonged sleep duration (PR = 1.45; 95%CI: 1.03-2.04) and poor sleep quality (PR = 2.04; 95%CI: 1.65-2.52). Conclusions Multimorbidity was associated with prolonged, but not short, sleep duration, as well as with poor sleep quality. Our results suggest the need of assessing sleep patterns among adults with multimorbidity.

Multimorbidity of chronic noncommunicable diseases: Data from the Brazilian National Health Survey

Objective: To estimate the prevalence of simultaneity of obesity, hypertension and/or diabetes and the association with sociodemographic and lifestyle-related behavior variables. Methods: This is a cross-sectional study with data from the 2013 National Health Survey. The presence of two/three diseases (obesity, hypertension, and diabetes) was considered multimorbidity of noncommunicable diseases (NCDs). Proportional odds logistic regression model, stratified by sex, was used to assess the sociodemographic and lifestyle factors associated with multimorbidity of NCDs, considering the sample complexity and sample weights. Results: The prevalence of multimorbidity of NCDs was 9.6%. The odds of multimorbidity are higher with increasing age, among blacks, but lower in the north region when compared with other regions of the country for both sexes. The odds of multimorbidity of NDCs increased among women who had lower levels of education and spent more time TV watching, and among men who lived with a partner and did not practice the recommended leisure-time physical activity. Conclusion: Sociodemographic factors and lifestyle-related behaviors were associated with the presence of obesity, hypertension, and/or diabetes.

Objetivo: Estimar la prevalencia de simultaneidad de obesidad, hipertensión y/o diabetes y la asociación con variables sociodemográficas y relacionadas con el estilo de vida. Métodos: Los datos fueron obtenido en la Encuesta Nacional de Salud Brasileña, una encuesta a nivel nacional, realizada en los hogares brasileños y llevada a cabo en 2013. La presencia de dos /tres enfermedades (obesidad, hipertensión y diabetes) se consideró multimorbilidad de las enfermedades no transmisibles (ENT). El modelo de regresión logística de probabilidades proporcionales, estratificado por sexo, se utilizó para evaluar los factores sociodemográficos y de estilo de vida asociados con la multimorbilidad de las ENT, considerando la complejidad de la muestra y los pesos de la muestra. Resultados: La prevalencia de multimorbilidad de las ENT fue del 9,6%. Las probabilidades de multimorbilidad son más altas con el aumento de la edad, entre los negros, pero más bajas en la región norte en comparación con otras regiones del país para los dos sexos. Las probabilidades de multimorbilidad de las ENT aumentaron entre las mujeres que tenían niveles más bajos de educación y pasaban más tiempo viendo la televisión, y entre los hombres que vivían con una pareja y no practicaban la actividad física recomendada para el tiempo libre. Conclusión: Los factores sociodemográficos y los comportamientos relacionados con el estilo de vida se asociaron con la presencia de obesidad, hipertensión y/o diabetes.

Crianças hospitalizadas com necessidades de saúde especiais complexas: estudo de casos múltiplos / Infantes hospitalizados con necesidades de salud especiales complejas: estudio de casos múltiples / Hospitalized children with complex special healthcare needs: multiple case studies

Resumo Objetivo Descrever os casos clinicamente complexos de crianças com necessidades de saúde especiais em hospitalização contínua e analisar a natureza das demandas de cuidados clinicamente complexos durante a hospitalização. Métodos Estudo de casos múltiplos de três crianças clinicamente complexas hospitalizadas. A coleta de dados ocorreu, entre janeiro e março de 2020, em prontuário, na observação de cuidados e interação espontânea registrada em diário de campo e entrevista. Participaram sete pessoas, sendo dois familiares, três técnicos de enfermagem e duas enfermeiras. Aplicou-se a análise temática, orientando-se pela tipologia de demandas de cuidados de crianças com necessidades de saúde especiais e classificação de Collière. Resultados Os casos de meninas e menino, com três, dez e 11 anos de idade, e tempo de internação de 4 meses a 6 anos, geraram linhas de convergências com as demandas de cuidados de crianças com necessidades de saúde especiais, proporcionando sobrevivência, bem-estar e conforto. Desses casos extraíram-se demandas contínuas e complexas de cuidados de estimulação, apaziguamento, confortação e parecer convergentes com o de desenvolvimento e habituais modificados (banho, arrumar-se, alimentação e mobilidade); os cuidados de compensação, no manejo de tecnologias corporais e a administração de medicamentos de uso contínuo, convergiram para demandas de cuidados tecnológicos e medicamentosos Conclusão A necessidade de sobrevivência, determinada pela natureza clinicamente complexa da criança, direciona a prioridade dos cuidados no uso contínuo de múltiplos medicamentos e manejo de tecnologias, na segurança do ambiente hospitalar. Embora essenciais, precisa-se contemplar as outras demandas de cuidados de desenvolvimento e social integrando-as às clinicamente complexas.

Resumen Objetivo Describir los casos clínicamente complejos de infantes con necesidades de salud especiales en hospitalización continua y analizar la naturaleza de las demandas de cuidados clínicamente complejos durante la hospitalización. Métodos Estudio de casos múltiples de tres infantes hospitalizados clínicamente complejos. La recopilación de datos se realizó de enero a marzo de 2020, en la historia clínica, en la observación de cuidados e interacción espontánea registrada en un diario de campo y en entrevista. Participaron siete personas, de las cuales dos eran familiares, tres técnicos de enfermería y dos enfermeras. Se aplicó el análisis temático, orientándose por la tipología de demandas de cuidados de infantes con necesidades de salud especiales y clasificación de Collière. Resultados Los casos de las niñas y el niño, de 3, 10 y 11 años, entre 4 meses y 6 años de tiempo de internación, generaron líneas convergentes con las demandas de cuidados de infantes con necesidades de salud especiales, donde se proporciona supervivencia, bienestar y consuelo. De estos casos se observaron demandas continuas y complejas de cuidados de estimulación, apaciguamiento, consuelo y opinión convergentes con los del desarrollo y los habituales modificados (baño, arreglarse, alimentación y movilidad); los cuidados de compensación, con el manejo de tecnologías corporales y la administración de medicamentos de uso continuo, convergieron en las demandas de cuidados tecnológicos y medicamentosos. Conclusión La necesidad de supervivencia, determinada por la naturaleza clínicamente compleja del infante, direcciona la prioridad de los cuidados en el uso continuo de múltiples medicamentos y en el manejo de tecnologías para la seguridad del ambiente hospitalario. Aunque sean esenciales, es necesario contemplar otras demandas de cuidados de desarrollo y sociales e integrarlas a las clínicamente complejas.

Abstract Objective To describe the medically complex cases of children with special healthcare needs in continuous hospitalization and to analyze the nature of medically complex care demands during hospitalization. Methods This is a multiple case study of three hospitalized medically complex children. Data collection occurred between January and March 2020 in the medical records in the observation of care and spontaneous interaction documented in a fieldwork note and interview. Seven people participated, two family members, three nursing technicians, and two nurses. Thematic analysis was applied, guided by the typologies of Collière's care and the demands of children with special healthcare needs. Results The cases included girls and a boy aged three, ten, and 11 years, and hospitalization time from 4 months to 6 years. They all generated lines of convergence with the care demands of children with special healthcare needs, providing survival, well-being, and comfort. These cases extracted continuous and complex care demands of stimulation, pacification, and comfort; and seemed convergent with developmental and modified daily life activities (bath, grooming, feed, and mobility) care. Compensating care in managing bodily technologies and administering continuous-use medication converged with demands for technological and medication care. Conclusion The need for survival, determined by children's medically complex nature, directs the priority of care to the continuous use of multiple medications, the management of technologies, and the safety of hospital environments. Although essential, it is necessary to consider the other developmental and social care demands, integrating them with the medically complex ones.

Multimorbidity patterns: obesity as the main modifiable risk factor in adult women in Southern Brazil

ABSTRACT Objective: To identify multimorbidity patterns in women in southern Brazil, and its relationship with sociodemographic, lifestyle characteristics, and nutritional status, as well as to explore the main independent risk factor for the identified patterns. Subjects and methods: This is a cross-sectional, population-based study with 1,128 women (20-69 years), southern Brazil. Chronic conditions were identified using the therapeutic and chemical anatomical classification of continuous use of medications. Multimorbidity was assessed as ≥2 or ≥3 chronic conditions to identify dyads and triads. Poisson regression was used to explore risk factors in the different adjustment models. As independent variables evaluated, in addition to sociodemographic characteristics, lifestyle variables were included: consumption of fruits and vegetables, physical activity, alcohol consumption, smoking and nutritional status. Results: Eleven dyads (frequencies between 2.0% and 6.4%) and three triads (frequencies between 1.9% and 2.1%) of morbidities were identified in the study. Aging was related to a higher prevalence of all patterns, and obesity was a risk factor for multimorbidity patterns that contained conditions related to the cardiovascular and metabolic system and mental health. After adjustment, obesity increased the probability of "hypertension + common mental disorders (CMD)" (PR 3.63; 95% CI 1.94-6.78) and "dyslipidemia + CMD" (PR 3.69; 95% CI 1.08-12.65) by more than three times. Conclusion: This study identified common and important diseases in the patterns, associated with a common risk factor, obesity, that must be addressed by public health policies to prevent multimorbidity.

Lifestyle, high Body Mass Index, and markers of socioeconomic conditions associated with multimorbidity in women

ABSTRACT: Objective: This study aimed to identify the prevalence of multimorbidity and its associated factors in women in southern Brazil. Methods: We conducted a cross-sectional, population-based study with a sample of 1,128 women (age 20-69 years), living in São Leopoldo, southern Brazil. Multimorbidity was defined as two or more chronic conditions measured using the therapeutic and chemical anatomical classification of continuous use medications prescribed by a physician. Poisson regression model with robust variance was used to assess the association between sociodemographic and lifestyle variables and multimorbidity. Results: The prevalence of multimorbidity was 21.7% (95%CI 19.3-24.2), and 26 chronic conditions were identified. A direct linear association was observed with age and income and an inverse association with education. Being unemployed was a risk factor for multimorbidity (PR 1.95; 95%CI 1.51-2.52). Alcohol consumption (moderate or excessive) had a protective effect. Overweight and obese women were 53% (PR 1.53; 95%CI 1.09-2.15) and 76% (PR 1.76; 95%CI 1.27-2.45) more likely to have multimorbidity than eutrophic women. Conclusion: Over 20% of the adult women had multimorbidity, and its occurrence was strongly associated with socioeconomic characteristics, such as fewer years of schooling, higher income, and not having an occupation. The results regarding alcohol consumption are still insufficient to propose a public policy for the prevention of multimorbidity. Excess weight was an independent risk factor and should be addressed in public health policies for the prevention and management of multimorbidity.

Uso de serviços de saúde e multimorbidade: contribuições para o debate sobre desigualdades sociais em saúde / Use of health services and multimorbidity: contributions to the debate on social inequalities in health

A multimorbidade tem sido cada vez mais comum em todo o mundo. O acesso a serviços de saúde eficazes e equitativos que atendam às necessidades das doenças crônicas não-transmissíveis (DCNT) ainda é limitado em muitos países. Nesse sentido, o presente estudo teve por objetivo identificar a relação entre a multimorbidade e a utilização de diferentes serviços de saúde e avaliar a associação entre fatores contextuais e individuais e o uso de serviços de saúde em indivíduos com multimorbidade no Brasil de 1998 a 2013. Trata-se de um estudo em painéis utilizando dados do suplemento de saúde da Pesquisa Nacional de Amostras por Domicílios de 1998, 2003 e 2008 e dados da Pesquisa Nacional de Saúde realizada em 2013. A população de estudo foi composta por adultos com idade maior ou igual a 18 anos e classificados como tendo multimorbidade (presença de dois ou mais problemas crônicos em um mesmo indivíduo). Foram considerados três desfechos de utilização de serviços de saúde: busca por serviços de saúde nos últimos quinze dias, consulta médica nos últimos doze meses e hospitalizações nos últimos doze meses. Modelos de regressão de Poisson estratificados por sexo foram utilizados para estimar as razões de prevalência brutas e ajustadas e seus respectivos intervalos de confiança de 95% para cada desfecho de uso de serviços de saúde e multimorbidade, por ano. Modelos de regressão de Poisson multinível em dois níveis foram utilizados para estimar as razões de prevalência ajustadas por variáveis independentes individuais e contextuais e seus respectivos intervalos de confiança a 95%, para os três desfechos, por ano de painel. Houve aumento da prevalência de procura por serviços de saúde e consultas médicas nos últimos 12 meses entre 1998 e 2013, independentemente da classificação de multimorbidade. A prevalência de hospitalizações diminuiu ao longo do período do estudo e foi duas vezes maior em indivíduos com multimorbidade. Ter multimorbidade aumentou a utilização de serviços de saúde para os três desfechos em estudo, sendo mais expressivo entre os homens. Fatores individuais relacionados ao uso de serviços de saúde se modificaram segundo tipo de serviço de saúde investigado. Características contextuais de vulnerabilidade social, organização dos serviços de saúde e índices de saúde mostraram influência na busca por serviços de saúde e nas hospitalizações, não apresentando associação com consultas médicas. Este estudo constatou que indivíduos com multimorbidade apresentam níveis mais elevados de utilização de serviços de saúde. Além disso, revelou que o uso de serviços de saúde está associado de forma variável com os fatores predisponentes, capacitantes e de necessidade em pessoas com multimorbidade. Esses resultados apontam para a necessidade de integrar todos os fatores individuais e contextuais no planejamento do acesso à saúde e, assim, reduzir as desigualdades no acesso aos serviços de saúde nessa população.

Background: Multimorbidity has been increasingly common throughout the world. Access to effective and equitable health services that address the needs of chronic non-communicable diseases (NCDs) is still limited in many countries. In this sense, the present study aimed to identify the relationship between multimorbidity and the use of different health services and to assess the association between contextual and individual factors and the use of health services in individuals with multimorbidity in Brazil from 1998 to 2013. Methods: This is a panel study using data from the health supplement of 1998, 2003, and 2008 National Survey of Samples by Households and data from the National Health Survey conducted in 2013. The study population consisted of adults of age 18 years of age or older and classified as having multimorbidity (presence of two or more chronic problems in the same individual). Three health service utilization outcomes were considered: search for health services in the last fifteen days, medical consultation in the last twelve months, and hospitalisations in the last twelve months. Poisson regression models stratified by sex were used to estimate the crude and adjusted prevalence ratios and their respective 95% confidence intervals for each health service use and multimorbidity outcome per year. Two-level multilevel Poisson regression models were used to estimate the prevalence ratios adjusted for individual and contextual independent variables and their respective 95% confidence intervals, for the three outcomes, by panel year. Results: There was an increase in the prevalence of demand for health services and medical consultations in the last 12 months between 1998 and 2013, regardless of the multimorbidity classification. The prevalence of hospitalisations decreased over the study period and was twice as high in individuals with multimorbidity. Having multimorbidity increased the use of health services for the three outcomes under study, being more expressive among men. Individual factors related to the use of health services changed according to the type of health service investigated. Contextual characteristics of social vulnerability, organization of health services, and health indices influenced the search for health services and hospitalisations, with no association with medical appointments. Conclusion: This study found that individuals with multimorbidity have higher levels of use of health services. Furthermore, it revealed that the use of health services is variably associated with predisposing, enabling, and need factors in people with multimorbidity. These results point to the need to integrate all individual and contextual factors in planning access to health and, thus, reduce inequalities in access to health services in this population.

Effect of education and multimorbidity on mortality among older adults: findings from the health, well-being and ageing cohort study (SABE).

OBJECTIVES: This study assessed the moderating role of education on the relationship between multimorbidity and mortality among older adults in Brazil. STUDY DESIGN: This was a cohort study. METHODS: This study used data from 1768 participants of the Health, Well-Being and Ageing Cohort Study (SABE) who were assessed between 2006 and 2015. The Cox Proportional Risks Model was used to evaluate the association between multimorbidity (two or more chronic diseases) and mortality. An interaction term between education and multimorbidity was included to test the moderating role of education in this association. RESULTS: The average follow-up time was 4.5 years, with a total of 589 deaths in the period. Multimorbidity increased the risk of mortality (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.27-1.91), and this association was not moderated by education (HR 1.06, 95% CI 1.00-1.13; P value = 0.07). CONCLUSIONS: The impact of education and multimorbidity on mortality emphasises the need for an integrated approach directed towards the social determinants of health to prevent multimorbidity and its burden among older adults.

Trends in the use of health services and their relationship with multimorbidity in Brazil, 1998-2013.

BACKGROUND: Chronic non-communicable diseases (NCDs) are the leading cause of multimorbidity. Access to effective and equitable health services that meet NCDs' needs is still limited in many countries. This constitutes the main barrier to coping with NCDs, especially in minimising the suffering of those who are already sick. The present study aimed to identify the relationship between multimorbidity and the use of different health services in Brazil from 1998 to 2013. METHODS: This is a panel study using data from the health supplement of the National Household Sample Survey of 1998, 2003 and 2008 and data from the National Health Survey carried out in 2013. Three health service utilization outcomes were considered: 1. search for health services in the last 15 days (excluding dental services), 2. medical consultation in the previous 12 months and 3. hospitalisations over the last 12 months. Multimorbidity was assessed by counting the number of morbidities from a list of 10 morbidities. Poisson regression models stratified by sex were used to estimate the crude and adjusted prevalence ratios and their respective 95% confidence intervals for each outcome of health service use and multimorbidity, per year. RESULTS: There was an increase in the prevalence of demand for health services and medical consultations in the last 12 months between 1998 and 2013, regardless of the multimorbidity classification. The prevalence of hospitalisations has decreased over the study period and increased twofold in individuals with multimorbidity. Having multimorbidity increased the use of health services for the three outcomes under the study, being more expressive among men. CONCLUSIONS: This study found that individuals with multimorbidity have higher levels of use of health services. Better understand the multimorbidity epidemiology and the associated impacts on the use and costs of health services can increase the quality of care provided to these patients and reduce rising health care costs.

Características de las mujeres de edad mediana / Characteristics of middle-aged women

Introducción: Pocos estudios han sido publicados en relación con las características del climaterio de la mujer de edad mediana. Por la importancia de esta información para realizar acciones de promoción de salud, en este grupo poblacional, se realizó la presente investigación. Objetivo: Describir las características sociodemográficas, identificar alteraciones de la salud y características biológicas relacionadas con el climaterio, en mujeres de edad mediana. Métodos: Se realizó un estudio descriptivo, de corte transversal. Se estudió una muestra aleatoria de 309 mujeres de 40 a 59 años, mediante muestreo por conglomerados bietápico, del área de salud del Policlínico "Julián Grimau", La Habana, en el primer semestre del año 2017. Para recoger los datos se utilizó un cuestionario semiestructurado, aplicado mediante entrevista. Como medida de resumen para las variables cualitativas se utilizó el porcentaje. Resultados: El 52,8 por ciento de las mujeres estudiadas era trabajadora y el 42,7 por ciento tenía escolaridad preuniversitaria. Recibieron información con mayor frecuencia las mujeres universitarias y las preuniversitarias. La hipertensión arterial fue declarada por el 35,0 por ciento de las féminas, la osteoartrosis 25,9 por ciento, diabetes mellitus en el 10,7 por ciento. La mayoría de las hipertensas era obesa o tenía sobrepeso. Conclusiones: Las mujeres de edad mediana del área de salud estudiada, tenían escolaridad preuniversitaria predominantemente, estaban en la perimenopausia, con sobrepeso y obesidad e hipertensión arterial(AU)

Introduction: Few studies have been published in relation to the climacteric characteristics of the middle-aged woman. Due to the importance of this information to carry out health promotion actions, in this population group, the present investigation was carried out. Objective: Describe the sociodemographic characteristics, identify health alterations and biological characteristics related to the climacteric. Methods: The study classifies as descriptive, cross-sectional. A random sample of 309 women aged 40 to 59 years was studied, by means of two-stage cluster sampling, from the health area of Julián Grimau Policlinic, Havana, in the first semester of 2017. To collect the data a semi-structured questionnaire was used, applied through an interview. The percentage was used as a summary measure for the qualitative variables. Results: 52.8 percent of the women studied were working and 42.7 percent had pre-university education. Information was received more frequently by university and pre-university women. Hypertension was declared by 35.0 percent of females, osteoarthrosis 25.9 percent, diabetes mellitus in 10.7 percent. The majority of hypertensive women were obese and overweight. Conclusions: The middle-aged women of the health area studied had predominantly pre-university education, in perimenopause, with overweight and obesity and arterial hypertension(AU)

Effectiveness of a case management model for the comprehensive provision of health services to multi-pathological people.

AIM: To determine the effectiveness of a case management model for approaching multi-pathological people in a health promoting entity of the contributory healthcare scheme in Bogotá, Colombia between 2018 - . DESIGN: Mixed methods research. METHOD: The study contemplates two components: a quantitative component using a quasi-experimental analytical design before and after longitudinal intervention to determine the effectiveness of the case management model and a qualitative descriptive design to understand the experience of the participants about the model. The Administrative Department of Science, Technology and Innovation of Colombia (Colciencias) funded this project by means of call 777-November 2017, under the financing agreement No. 848-December 2017. DISCUSSION: Addressing problems deriving from the structure of the Colombian healthcare system is crucial for implementing case management models. Furthermore, the effectiveness of such models may be affected by power relations and market failures, but the proved potential of a model may represent a generalized benefit for the Colombian health system. IMPACT: In Colombia, considering complications and management of chronic non-communicable diseases as isolated cases is considered as the highest cost events in healthcare provision, since an average of 12.8 million pesos is invested in each patient. This has led to rethink the management in these patients by means of a comprehensive model that guarantees the effectiveness of healthcare delivery, in the framework of a healthcare system heavily affected by payment capacity, where the market has a strong predominance, such as the case of Colombia. TRIAL REGISTRATION NUMBER: RPCEC00000293.

Association between chronic conditions and health-related quality of life: differences by level of urbanization in Peru.

PURPOSE: To evaluate the role of urbanization as an effect modifier for the association between specific chronic conditions and number of conditions with health-related quality of life (QOL). METHODS: We analyzed cross-sectional data from the CRONICAS Cohort Study conducted in Lima (highly urbanized), Tumbes (semi-urban), as well as rural and urban sites in Puno. Exposures of interest were chronic bronchitis, depressive mood, hypertension, type 2 diabetes, and a composite variable aggregating the number of chronic conditions (the four exposures plus heart disease and stroke). QOL outcomes were assessed with EuroQol's EQ-5D visual analogue scale (EQ-VAS). We fitted linear regressions with robust variance to evaluate the associations of interest. Study site was assessed as a potential effect modifier using the likelihood-ratio (LR) test. RESULTS: We evaluated data on 2433 subjects: 51.3% were female, mean age was 57.2 years. Study site was found to be an effect modifier only for the association between depressive mood and EQ-VAS score (LR test p < 0.001). Compared to those without depressive mood, participants with depressive mood scored -13.7 points on the EQ-VAS in Lima, -7.9 in urban Puno, -11.0 in semi-urban Tumbes, and -2.7 in rural Puno. Study site was not found to be an effect modifier for the association between the number of chronic conditions and EQ-VAS (LR test p = 0.64). CONCLUSION: The impact of depressive mood on EQ-VAS was larger in urban than in rural sites, while site was not an effect modifier for the remaining associations.

Factors associated with tobacco use among patients with multiple chronic conditions.

BACKGROUND: Cigarette smoking is an important risk factor for disease onset and progression among the major chronic diseases accounting for most morbidity and mortality in the world. Our objective was to identify characteristics associated with tobacco use among patients with multiple chronic conditions (MCC). METHODS: This cross-sectional study was implemented at the Center HIPERDIA Minas Juiz de Fora, Brazil, which manages patients with high cardiovascular risk, hypertension, diabetes mellitus and chronic kidney disease. RESULTS: Of 1558 participants, 12% were current smokers; 41% former smokers and 47%, never smokers. In univariate analyses, current smoking was associated with gender, age, physical activity, alcohol use, depressive symptoms, overweight, and atherosclerosis. In multinomial analyses, multiple chronic conditions were associated with the current or previous use of tobacco; COPD and atherosclerotic disease were more prevalent among patients who were current smokers. CONCLUSIONS: Cigarette smoking was as prevalent in this high population as in the general population. Smokers had worse clinical profiles compared to former smokers or never smokers. Aggressive smoking cessation support should yield considerable health benefits and health care cost savings within patients with MCC, especially, those with high cardiovascular risk.