Health services utilization in the Brazilian Amazon: panel of two cross-sectional studies

Tiguman, Gustavo Magno Baldin; Silva, Marcus Tolentino; Galvão, Taís Freire

doi:10.11606/s1518-8787.2022056003663

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Sumário

Original Article • Rev. Saúde Pública 56 • 2022 • https://doi.org/10.11606/s1518-8787.2022056003663 copy

Health services utilization in the Brazilian Amazon: panel of two cross-sectional studies

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To investigate the use of health services among adults living in Manaus, Amazonas.

METHODS

This was a panel of two cross-sectional studies conducted in Manaus in 2015 and 2019. Individuals aged ≥ 18 years were selected by probabilistic sampling and interviewed at home. The study outcomes were doctor visits and hospitalizations in the previous 12 months, and unmet surgical needs. Variations between 2015 and 2019 were tested using chi-squared goodness-of-fit test. Poisson regression with robust variance was employed to calculate the prevalence ratios (PR) of the outcomes with 95% confidence intervals (95%CI).

RESULTS

The surveys included 5,800 participants in total. Visits to the doctor decreased from 2015 (78.7%) to 2019 (76.3%; p < 0.001), hospital admissions increased from 2015 (7.9%) to 2019 (11.5%; p < 0.001), and unmet surgical needs decreased in the period (15.9% to 12.1%; p < 0.001). These variations were particularly observed in vulnerable individuals – sicker; poorer; non-whites; and those belonging to lower social classes, with less access to education, formal jobs, and health insurance (p < 0.05). Doctor visits were higher in people with fair health status (PR = 1.09; 95%CI 1.06–1.12), health insurance (PR = 1.13; 95%CI 1.09–1.17), and chronic diseases (p < 0.001) but lower in men (PR = 0.87; 95%CI 0.84–0.90) and informal workers (PR = 0.89; 95%CI 0.84–0.94). Hospitalizations were higher in people with worse health statuses (p < 0.001), without partners (PR = 1.27; 95%CI 1.05–1.53), and with multimorbidity (PR = 1.68; 95%CI 1.33–2.12) but lower in men (PR = 0.55; 95%CI 0.44–0.68), older adults (p < 0.001), informal workers (PR = 0.67; 95%CI 0.51–0.89), and unemployed (PR = 0.72; 95%CI 0.53–0.97). Unmet surgical needs were higher in older adults (p < 0.001), middle-class people (PR = 1.24; 95%CI 1.01–1.55), worse health statuses (p < 0.001), and chronic diseases (p < 0.001) but lower in men (PR = 0.76; 95%CI 0.65–0.86).

CONCLUSIONS

From 2015 to 2019, less people visited the doctor, more were admitted to hospitals, and less were in need of surgery or aware of that need, potentially indicating poorer access to health services.

Adult; Health Services Accessibility; Health Care Quality, Access, and Evaluation; Health Services Coverage, trends

Variables	Participants’ characteristics				Visits to the doctor				Hospital admissions				Unmet need for surgery

	2015		2019		2015		2019		2015		2019		2015		2019

	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
Sex
Women	1,856	65.1	1,233	64.7	1,538	83.1	992	80.7	186	9.9	175	14.1	330	18.0	165	13.6
Men	1,623	34.9	1,088	35.3	1,139	70.7	742	68.4	67	4.2	75	6.8	188	12.0	99	9.4
Age group (years)
18–24	716	16.2	405	13.5	525	75.5	284	71.2	62	9.9	50	13.6	56	8.3	24	6.0
25–34	1,010	31.4	586	25.2	752	76.8	440	77.4	67	7.5	82	16.0	114	12.1	50	8.9
35–44	744	22.2	553	25.0	589	80.2	404	74.4	50	7.2	57	10.7	134	19.2	74	14.6
45–59	674	19.0	526	23.9	525	78.6	406	78.3	48	7.6	43	8.7	139	21.0	76	14.7
≥ 60	335	11.2	251	12.4	286	86.4	200	80.0	26	8.1	18	7.2	75	22.6	40	15.4
Race/skin color
White	545	15.3	283	12.1	406	75.8	220	79.1	40	8.0	31	11.9	76	14.9	27	9.8
Black	241	6.7	215	8.7	199	83.4	142	67.7	20	8.9	16	8.0	32	13.2	18	8.3
Asian	129	3.9	66	2.8	111	86.2	50	77.9	12	10.2	11	16.7	17	14.2	8	14.6
Brown	2,533	73.1	1,677	72.9	1,938	78.5	1,269	77.3	178	7.6	187	11.9	388	16.5	204	13.0
Indigenous	31	1.0	80	3.5	23	77.9	53	66.6	3	11.8	5	6.2	5	19.4	7	8.8
Marital status
With partner	1,266	37.8	898	39.7	1,020	81.2	683	77.3	89	7.6	76	8.8	220	18.0	107	12.5
Without partner	2,213	62.2	1,423	60.3	1,657	77.3	1,051	75.7	164	8.0	174	13.3	298	14.7	157	11.9
Social class
A/B	555	14.9	282	11.5	438	80.6	224	80.0	41	8.1	19	7.0	60	11.2	31	11.6
C	2,006	57.5	1,244	53.5	1,524	77.8	929	76.5	136	7.5	136	11.7	307	16.6	132	11.5
D/E	918	27.6	795	35.0	715	79.7	581	74.9	76	8.7	95	12.7	151	17.1	101	13.3
Educational level
Higher education or above	131	3.9	153	6.9	101	78.8	127	83.9	13	11.7	10	7.1	21	16.6	24	17.3
High school	1,695	47.2	1,171	49.4	1,278	77.3	875	76.3	114	7.4	111	10.7	211	13.3	120	11.2
Elementary school	562	15.6	432	18.0	431	78.4	318	75.9	42	7.9	68	16.1	71	13.5	45	11.4
Less than elementary school	1,091	33.3	565	25.7	867	81.0	414	74.8	84	8.1	61	11.0	215	20.7	75	13.1
Occupation
Formal job	652	16.6	415	16.1	515	80.2	315	78.4	53	9.1	34	9.2	80	13.3	47	12.3
Informal job	978	26.2	665	27.5	683	72.3	461	70.7	43	4.7	57	9.1	168	18.4	60	9.6
Retired	270	8.7	162	7.6	231	86.4	136	83.7	21	8.3	15	9.5	60	23.2	35	20.5
Student/housewife	1,069	34.2	632	31.3	838	79.9	506	80.9	106	10.4	92	15.2	153	15.4	80	13.3
Unemployed	510	14.3	447	17.5	410	81.5	316	72.2	30	6.1	52	11.8	57	11.7	42	10.2
Health status
Good	2,243	62.7	1,498	62.5	1,641	75.0	1,059	72.2	130	6.3	114	8.1	226	10.9	107	7.6
Fair	1,012	30.3	671	30.4	852	85.4	548	83.1	92	9.7	106	16.6	236	24.3	113	17.6
Poor	224	7.0	152	7.1	184	82.9	127	84.1	31	14.5	30	19.5	56	25.1	44	28.6
Health insurance
No	3,027	87.0	1,978	85.3	2,278	77.2	1,449	74.9	215	7.7	215	11.6	461	16.3	226	12.1
Yes	452	13.0	343	14.7	399	89.2	285	84.8	38	9.5	35	11.1	57	13.7	38	12.1
Number of chronic diseases
0	1,377	37.4	921	37.4	970	72.5	594	66.4	66	5.2	80	9.8	113	9.2	46	5.3
1	989	28.1	682	29.0	775	79.9	507	75.0	64	7.0	70	10.9	130	13.5	66	9.9
≥ 2	1,113	34.5	718	33.6	932	84.6	633	88.6	123	11.4	100	13.9	275	25.3	152	21.7
Total	3,479	100.0	2,321	100.0	2,677	78.7	1,734	76.3	253	7.9	250	11.5	518	15.9	264	12.1

Variables	Visits to the doctor			Hospitalizations			Unmet need for surgery

	Absolute variation (%)	Relative variation	p	Absolute variation (%)	Relative variation	p	Absolute variation (%)	Relative variation	p
Sex
Women	-2.4	1.0	0.013	4.2	1.4	< 0.001	-4.4	0.8	< 0.001
Men	-2.3	1.0	0.070	2.6	1.6	< 0.001	-2.6	0.8	0.003
Age group (years)
18–24	-4.3	0.9	0.012	3.7	1.4	0.099	-2.3	0.7	0.083
25–34	0.6	1.0	0.325	8.5	2.1	< 0.001	-3.2	0.7	0.008
35–44	-5.8	0.9	< 0.001	3.5	1.5	0.005	-4.6	0.8	0.001
45–59	-0.3	1.0	0.429	1.1	1.1	0.619	-6.3	0.7	< 0.001
≥ 60	-6.4	0.9	0.002	-0.9	0.9	0.590	-7.2	0.7	0.012
Race/skin color
White	3.3	1.0	0.446	3.9	1.5	0.067	-5.1	0.7	0.011
Black	-15.7	0.8	< 0.001	-0.9	0.9	0.453	-4.9	0.6	0.036
Asian	-8.3	0.9	0.014	6.5	1.6	0.083	0.4	1.0	0.629
Brown	-1.2	1.0	0.005	4.3	1.6	< 0.001	-3.5	0.8	< 0.001
Indigenous	-11.3	0.9	0.012	-5.6	0.5	0.124	-10.6	0.5	0.016
Marital status
With partner	-3.9	1.0	< 0.001	1.2	1.2	0.329	-5.5	0.7	< 0.001
Without partner	-1.6	1.0	< 0.001	5.3	1.7	< 0.001	-2.8	0.8	< 0.001
Social class
A/B	-0.6	1.0	0.620	-1.1	0.9	0.402	0.4	1.0	0.912
C	-1.3	1.0	0.008	4.2	1.6	< 0.001	-5.1	0.7	< 0.001
D/E	-4.8	0.9	< 0.001	4.0	1.5	0.001	-3.8	0.8	0.001
Educational level
Higher education or above	5.1	1.1	0.203	-4.6	0.6	0.047	0.7	1.0	0.761
High school	-1.0	1.0	0.035	3.3	1.4	0.007	-2.1	0.8	0.002
Elementary school	-2.5	1.0	0.016	8.2	2.0	< 0.001	-2.1	0.8	0.061
Less than elementary school	-6.2	0.9	< 0.001	2.9	1.4	0.019	-7.6	0.6	< 0.001
Occupation
Formal job	-1.8	1.0	0.028	0.1	1.0	0.520	-1.0	0.9	0.236
Informal job	-1.6	1.0	0.086	4.4	1.9	< 0.001	-8.8	0.5	< 0.001
Retired	-2.7	1.0	0.363	1.2	1.1	0.658	-2.7	0.9	0.631
Student/housewife	1.0	1.0	0.918	4.8	1.5	0.001	-2.1	0.9	0.056
Unemployed	-9.3	0.9	< 0.001	5.7	1.9	< 0.001	-1.5	0.9	0.130
Health status
Good	-2.8	1.0	< 0.001	1.8	1.3	0.037	-3.3	0.7	< 0.001
Fair	-2.3	1.0	0.006	6.9	1.7	< 0.001	-6.7	0.7	< 0.001
Poor	1.2	1.0	0.831	5.0	1.3	0.067	3.5	1.1	0.274
Health insurance
No	-2.3	1.0	< 0.001	3.9	1.5	< 0.001	-4.2	0.7	< 0.001
Yes	-4.4	1.0	< 0.001	1.6	1.2	0.657	-1.6	0.9	0.158
Number of chronic diseases
0	-6.1	0.9	< 0.001	4.6	1.9	< 0.001	-3.9	0.6	< 0.001
1	-4.9	0.9	< 0.001	3.9	1.6	0.001	-3.6	0.7	0.003
≥ 2	4.0	1.0	0.008	2.5	1.2	0.033	-3.6	0.9	0.011
Total	-2.4	1.0	< 0.001	3.6	1.5	< 0.001	-3.8	0.8	< 0.001

Variables	PR (95%CI)	p	Adjusted PR (95%CI)	p
Year		0.036		0.063
2015	1.00		1.00
2019	0.97 (0.94–0.99)		0.97 (0.95–1.00)
Sex		< 0.001		< 0.001
Women	1.00		1.00
Men	0.85 (0.82–0.88)		0.87 (0.84–0.90)
Age group (years)		< 0.001		0.765
18–24	1.00		1.00
25–34	1.04 (1.00–1.09)		1.03 (0.98–1.08)
35–44	1.05 (1.00–1.10)		1.02 (0.97–1.07)
45–59	1.06 (1.01–1.11)		1.00 (0.96–1.06)
≥ 60	1.13 (1.08–1.19)		1.02 (0.96–1.09)
Race/skin color		0.072		0.371
White	1.00		1.00
Black	0.99 (0.93–1.06)		1.00 (0.94–1.06)
Asian	1.09 (1.01–1.17)		1.05 (0.97–1.13)
Brown	1.02 (0.97–1.06)		1.00 (0.96–1.04)
Indigenous	0.91 (0.80–1.04)		0.91 (0.80–1.03)
Marital status		0.010		0.114
With partner	1.00		1.00
Without partner	0.96 (0.94–0.99)		0.98 (0.95–1.01)
Social class		0.128		0.066
A/B	1.00		1.00
C	0.96 (0.92–1.00)		0.96 (0.92–1.00)
D/E	0.96 (0.92–1.01)		0.95 (0.91–1.00)
Educational level		0.139		0.710
Higher education or above	1.00		1.00
High school	0.94 (0.89–1.00)		1.00 (0.94–1.06)
Elementary school	0.95 (0.89–1.01)		1.02 (0.95–1.09)
Less than elementary school	0.97 (0.91–1.03)		0.99 (0.93–1.06)
Occupation		< 0.001		< 0.001
Formal job	1.00		1.00
Informal job	0.90 (0.86–0.94)		0.91 (0.87–0.95)
Retired	1.07 (1.02–1.13)		1.00 (0.94–1.06)
Student/housewife	1.01 (0.97–1.05)		0.96 (0.92–1.00)
Unemployed	0.97 (0.93–1.02)		0.97 (0.93–1.02)
Health status		< 0.001		< 0.001
Good	1.00		1.00
Fair	1.14 (1.11–1.18)		1.09 (1.06–1.12)
Poor	1.13 (1.07–1.19)		1.05 (1.00–1.11)
Health insurance		< 0.001		< 0.001
No	1.00		1.00
Yes	1.15 (1.11–1.18)		1.13 (1.09–1.17)
Number of chronic diseases		< 0.001		< 0.001
0	1.00		1.00
1	1.11 (1.07–1.16)		1.10 (1.06–1.14)
≥ 2	1.23 (1.19–1.27)		1.17 (1.13–1.22)

Variables	PR (95%CI)	p	Adjusted PR (95%CI)	p
Year		< 0.001		< 0.001
2015	1.00		1.00
2019	1.46 (1.23–1.73)		1.55 (1.30–1.85)
Sex		< 0.001		< 0.001
Women	1.00		1.00
Men	0.45 (0.37–0.55)		0.55 (0.44–0.68)
Age group (years)		0.041		< 0.001
18–24	1.00		1.00
25–34	0.93 (0.73–1.18)		0.98 (0.77–1.24)
35–44	0.77 (0.60–1.00)		0.73 (0.56–0.95)
45–59	0.72 (0.55–0.94)		0.57 (0.43–0.77)
≥ 60	0.69 (0.49–0.97)		0.41 (0.27–0.63)
Race/skin color		0.642		0.481
White	1.00		1.00
Black	0.91 (0.61–1.34)		0.86 (0.58–1.27)
Asian	1.32 (0.84–2.07)		1.18 (0.75–1.84)
Brown	0.99 (0.78–1.27)		0.88 (0.69–1.12)
Indigenous	0.84 (0.41–1.73)		0.69 (0.34–1.42)
Marital status		0.018		0.012
With partner	1.00		1.00
Without partner	1.25 (1.04–1.49)		1.27 (1.05–1.53)
Social class		0.074		0.599
A/B	1.00		1.00
C	1.17 (0.89–1.54)		1.06 (0.81–1.39)
D/E	1.37 (1.02–1.82)		1.15 (0.85–1.55)
Educational level		0.114		0.334
Higher education or above	1.00		1.00
High school	0.95 (0.63–1.43)		1.01 (0.66–1.54)
Elementary school	1.24 (0.80–1.91)		1.23 (0.78–1.94)
Less than elementary school	0.98 (0.64–1.50)		1.03 (0.65–1.64)
Occupation		< 0.001		0.012
Formal job	1.00		1.00
Informal job	0.71 (0.53–0.94)		0.67 (0.51–0.89)
Retired	0.96 (0.66–1.41)		0.97 (0.63–1.51)
Student/housewife	1.34 (1.05–1.71)		0.93 (0.72–1.22)
Unemployed	0.95 (0.70–1.27)		0.72 (0.53–0.97)
Health status		< 0.001		< 0.001
Good	1.00		1.00
Fair	1.78 (1.48–2.13)		1.65 (1.36–1.99)
Poor	2.35 (1.80–3.07)		2.15 (1.63–2.84)
Health insurance		0.399		0.137
No	1.00		1.00
Yes	1.11 (0.87–1.41)		1.20 (0.94–1.52)
Number of chronic diseases		< 0.001		< 0.001
0	1.00		1.00
1	1.22 (0.97–1.54)		1.19 (0.94–1.50)
≥ 2	1.77 (1.45–2.18)		1.68 (1.33–2.12)

Variables	PR (95%CI)	p	Adjusted PR (95%CI)	p
Year		< 0.001		< 0.001
2015	1.00		1.00
2019	0.76 (0.66–0.88)		0.75 (0.65–0.86)
Sex		< 0.001		< 0.001
Women	1.00		1.00
Men	0.68 (0.59–0.78)		0.76 (0.65–0.88)
Age group (years)		< 0.001		< 0.001
18–24	1.00		1.00
25–34	1.48 (1.13–1.92)		1.28 (0.99–1.67)
35–44	2.32 (1.80–2.98)		1.78 (1.38–2.31)
45–59	2.43 (1.89–3.12)		1.54 (1.18–2.01)
≥ 60	2.63 (1.99–3.46)		1.29 (0.92–1.81)
Race/skin color		0.150		0.360
White	1.00		1.00
Black	0.84 (0.60–1.16)		0.86 (0.62–1.19)
Asian	1.09 (0.72–1.64)		0.93 (0.62–1.41)
Brown	1.15 (0.94–1.40)		1.08 (0.89–1.32)
Indigenous	0.91 (0.51–1.61)		0.84 (0.50–1.40)
Marital status		0.034		0.511
With partner	1.00		1.00
Without partner	0.86 (0.76–0.99)		0.96 (0.84–1.09)
Social class		0.032		0.144
A/B	1.00		1.00
C	1.29 (1.04–1.61)		1.24 (1.01–1.55)
D/E	1.36 (1.08–1.71)		1.20 (0.94–1.52)
Educational level		< 0.001		0.334
Higher education or above	1.00		1.00
High school	0.74 (0.55–0.98)		0.77 (0.58–1.02)
Elementary school	0.74 (0.54–1.02)		0.77 (0.56–1.06)
Less than elementary school	1.07 (0.80–1.43)		0.79 (0.58–1.06)
Occupation		< 0.001		0.135
Formal job	1.00		1.00
Informal job	1.15 (0.93–1.41)		0.97 (0.79–1.21)
Retired	1.73 (1.35–2.21)		1.11 (0.81–1.50)
Student/housewife	1.13 (0.92–1.39)		0.89 (0.71–1.12)
Unemployed	0.85 (0.66–1.10)		0.77 (0.60–1.00)
Health status		< 0.001		< 0.001
Good	1.00		1.00
Fair	2.26 (1.96–2.60)		1.70 (1.45–1.98)
Poor	2.77 (2.26–3.38)		1.82 (1.46–2.28)
Health insurance		0.150		0.427
No	1.00		1.00
Yes	0.89 (0.73–1.09)		0.92 (0.74–1.14)
Number of chronic diseases		< 0.001		< 0.001
0	1.00		1.00
1	1.57 (1.28–1.93)		1.38 (1.12–1.69)
≥ 2	3.12 (2.62–3.72)		2.16 (1.76–2.64)

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[1] Correspondence: Gustavo Magno Baldin Tiguman Universidade Estadual de Campinas Faculdade de Ciências Farmacêuticas Rua Cândido Portinari, 200 – Cidade Universitária 13083-871 Campinas, São Paulo, Brasil E-mail: gustavo.tiguman@gmail.com