Contextual influence on poor self-rated health in patients with Chagas disease: multilevel study

Ferreira, Ariela Mota; Sabino, Ester Cerdeira; Silva, Léa Campos de Oliveira-da; Oliveira, Cláudia Di Lorenzo; Cardoso, Clareci Silva; Ribeiro, Antonio Luiz Pinho; Damasceno, Renata Fiúza; Leite, Sâmara Fernandes; Vieira, Thallyta Maria; Nunes, Maria do Carmo Pereira; Haikal, Desirée Sant’ Ana

doi:10.1590/1413-81232022277.01682022

Ariela Mota Ferreira

Programa de Pós-Graduação em Ciências da Saúde, Universidade Estadual de Montes Claros. Av. Prof. Rui Braga s/n, Vila Mauriceia. 39401-089 Montes Claros MG Brasil. arielamota@hotmail.com

https://orcid.org/0000-0002-2315-5318

Ester Cerdeira Sabino

LIM46, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. São Paulo SP Brasil.

https://orcid.org/0000-0003-2623-5126

Léa Campos de Oliveira-da Silva

LIM46, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. São Paulo SP Brasil.

https://orcid.org/0000-0002-7380-7548

Cláudia Di Lorenzo Oliveira

Grupo de Pesquisa em Epidemiologia e Novas Tecnologias em Saúde, Campus CCO, Universidade Federal de São João del-Rei. Divinópolis MG Brasil.

https://orcid.org/0000-0001-8533-8155

Clareci Silva Cardoso

Grupo de Pesquisa em Epidemiologia e Novas Tecnologias em Saúde, Campus CCO, Universidade Federal de São João del-Rei. Divinópolis MG Brasil.

https://orcid.org/0000-0003-0689-1644

Antonio Luiz Pinho Ribeiro

Departamento de Medicina Interna, Universidade Federal de Minas Gerais. Belo Horizonte MG Brasil.

https://orcid.org/0000-0002-2740-0042

Renata Fiúza Damasceno

Programa de Pós-Graduação em Ciências da Saúde, Universidade Estadual de Montes Claros. Av. Prof. Rui Braga s/n, Vila Mauriceia. 39401-089 Montes Claros MG Brasil. arielamota@hotmail.com

https://orcid.org/0000-0002-9525-8527

Sâmara Fernandes Leite

Programa de Pós-Graduação em Ciências da Saúde, Universidade Estadual de Montes Claros. Av. Prof. Rui Braga s/n, Vila Mauriceia. 39401-089 Montes Claros MG Brasil. arielamota@hotmail.com

https://orcid.org/0000-0001-7381-2454

Thallyta Maria Vieira

Programa de Pós-Graduação em Ciências da Saúde, Universidade Estadual de Montes Claros. Av. Prof. Rui Braga s/n, Vila Mauriceia. 39401-089 Montes Claros MG Brasil. arielamota@hotmail.com

https://orcid.org/0000-0002-1483-6234

Maria do Carmo Pereira Nunes

Departamento de Medicina Interna, Universidade Federal de Minas Gerais. Belo Horizonte MG Brasil.

https://orcid.org/0000-0001-8801-1828

Desirée Sant’ Ana Haikal

Programa de Pós-Graduação em Ciências da Saúde, Universidade Estadual de Montes Claros. Av. Prof. Rui Braga s/n, Vila Mauriceia. 39401-089 Montes Claros MG Brasil. arielamota@hotmail.com

https://orcid.org/0000-0002-0331-0747

Collaborations

AM Ferreira, EC Sabino, ALP Ribeiro, RF Damasceno, TM Vieira, MCP Nunes and DS Haikal made substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work. AM Ferreira, MCP Nunes and DS Haikal worked on drafting the work or revising it critically for important intellectual content. All authors read and approved the final manuscript.

Chief editors:

Romeu Gomes, Antônio Augusto Moura da Silva

Contextual variables	Year of collection	Source	Concept	Cut off point adopted
1. Total population	2010	Atlas of Human Development in Brazil¹	Number of people residing in the municipality.	75^th percentile=31,003 inhabitants.
2. % of the rural population	2010	Atlas of Human Development in Brazil¹	Percentage of people residing in the area outside urban limits.	25^th percentile=33.11%
3. Municipal Human Development Index (MHDI)	2010	Atlas of Human Development in Brazil¹	Geometric average of the indices of the dimensions Income, Education and Longevity, with equal weights. This varies from 0 to 1, with higher values indicating a better situation.	Categorized by international standard and dichotomized as low (<0,550) vs. high (>0,700) /medium (0,551-0,699)
4. Gini index	2010	Atlas of Human Development in Brazil¹	Measures the degree of inequality in the distribution of household income per capita. Its value ranges from 0, when there is no inequality, to 1 when the inequality is maximum.	25^th percentile=0.4642
5. Average wage of formal workers	2015	IBGE²	Average wage of formal workers, measured in number of minimum wages.	75^th percentile=1.7 minimum wages
6. Illiteracy rate	2010	DATASUS³	Percentage of illiterates in the population of the municipality	25^th percentile=17.1%
7. % of the population with running water	2010	Atlas of Human Development in Brazil¹	Percentage of the population of the municipality with access to running water	25^th percentile=85.4%
8. % of the population with adequate sewerage	2010	Atlas of Human Development in Brazil¹	Percentage of the population of the municipality with access to adequate sewerage	25^th percentile=49.5%
9. % of the population with electricity	2010	Atlas of Human Development in Brazil¹	Percentage of the population of the municipality with access to electricity	25^th percentile=98.8%
10. SUS Performance Index (IDSUS)	2010	Performance Index of the Public Health System⁴	Assesses the municipal performance of the SUS* regarding: universality of access, integrality, equality, resolvability and equity of care, decentralization with a single command by management level, tripartite responsibility, regionalization and hierarchy of the health service network.	Categorized by national standard and dichotomized as 0.500-0.599 (low) vs. 0.600-0.699/0.700-0.799 (high/medium)
11. Total health expenditure per inhabitant	2016	SIOPS - Public Health Budget Information System⁵	Measures the dimension of total public health expenditure per inhabitant	75^th percentile=R$ 610.72
12. Number of doctors per thousand inhabitants	2017	CNES - National Health Establishment Register⁶	Number of doctors per thousand inhabitants present in the municipality hired by the SUS	75^th percentile=0.79
13. % of the population with health insurance	2017	Department of Primary Care - Ministry of Health⁷	Proportion of population of the municipality with health insurance	75^th percentile=3.03%
14. FHS coverage	2017	Department of Primary Care - Ministry of Health⁷	Percentage of coverage of the population of the municipality by teams of the family health strategy (FHS).	75^th percentile=100%

Contextual variables		Descriptive		Bivariate
		n municipalities	n individuals	Self-rated health
		n municipalities	n individuals	Poor n (%)	95%CI
Total population
	<31,003 inhabitants	16	902	196 (21.7%)	19.6-23.77
	>31,003 inhabitants	5	611	139 (22.7%)	20.58-24.81
% of the rural population
	<33.11%	5	529	104 (19.7%)	17.69-21.70
	>33.12%	16	984	231(23.5%)	21.36-25.63
Municipal Human Development Index. (MHDI)
	Low	4	1,256	61 (23.7%)	21.55-25.84
	High/medium	17	257	274 (21.8%)	19.71-23.88
Gini index
	<0.4642	5	229	286 (22.3%)	20.20-24.39
	>0.4643	16	1,284	49 (21.4%)	19.71-23.88
Average wage of formal workers
	<1.7 minimum wages	12	780	172 (22.1%)	20.00-14.19
	>1.8 minimum wages	9	733	163 (22.2%)	20.10-24.19
Illiteracy rate
	<17.1%	5	667	139 (20.8%)	18.75-22.84
	>17.2%	16	846	196 (23.2%)	21.07-25.32
% of the population with running water
	<85.4%	16	1,136	254 (22.4%)	20.29-24.50
	>85.5%	5	377	81 (21.5%)	19.42-23.57
% of the population with adequate sewerage
	<49.5%	16	1,100	263 (23.9%)	21.75-26.04
	>49.6%	5	413	72 (17.4%)	15.48-19.31
% of the population with electricity
	<98.8%	16	1,209	274 (22.7%)	20.58-24.81
	>98.8%	5	304	61 (20.1%)	18.08-22.11
SUS Performance Index (IDSUS)
	0.500-0.599	7	604	152 (25.2%)	23.01-27.38
	0.600-0.799	14	909	183 (20.1%)	18.08-22.11
Total health expenditure per inhabitant
	<R$ 610.72	16	1,142	269 (23.6%)	21.65-25.94
	>R$ 610.73	5	371	66 (17.8%)	15.87-19.72
Number of doctors per thousand inhabitants
	<0.79	16	1,100	262 (23.8%)	21.65-25.94
	>0.80	5	413	73 (17.7%)	15.87-19.72
% of the population with health insurance
	<3.03%	16	978	225 (23%)	20.87-25.12
	>3.04%	5	535	110 (20.6%)	18.56-22.63
FHS coverage
	<99%	4	587	202 (21.8%)	19.71-23.88
	100%	17	926	133 (22.7%)	20.58-24.81

Characteristics		Descriptive	Bivariate		P-value
		Descriptive	Self-rated health
		n	Poor n (%)	95%CI
Individual
Gender
	Female	1,028	241 (23.4%)	21.2-25.5	0.076
	Male	485	94 (19.4%)	17.4-21.39
Age
	60 years or older	667	137 (20.5%)	18.46-22.53	0.183
	Up to 60 years	846	198 (23.4%)	21.26-25.53
Self-reported skin color*
	White	321	236 (73.5%)	71.27-75.72	0.424
	Brown	891	650 (73%)	70.76-75.23
	Black	270	209 (77.4%)	75.29-79.50
	Others	26	21 (80.8%)	78.81-82.78
Marital status*
	Single. widowed or divorced	526	116 (22.1%)	20.00-24.19	0.956
	Married or cohabiting	983	218 (22.2%)	20.10-24.29
Literacy*
	No	645	157 (24.3%)	22.13-26.46	0.076
	Yes	863	177 (20.5%)	18.46-22.53
Family income*
	Up to R$ 727.00	800	200 (25%)	22.81-27.18	0.004
	Above R$ 728.00	709	134 (18.9%)	16.92-20.87
Distance from the Health Unit*
	Over 100 km	61	27 (44.3%)	41.79-46.80	<0.001
	6 to 99 km	322	71 (22%)	19.91-24.08
	0 to 5 km	736	151 (20.5%)	18.46-22.53
Health service used*
	None	132	39 (29.5%)	27.02-31.79	0.090
	Public	1,013	214 (21.1%)	19.04-23.15
	Private/health insurance	368	82 (22.3%)	20.20-24.39
Examination frequency*
	Rarely or never	758	190 (25.1%)	22.91-27.28	0.004
	Regularly/frequently	648	132 (20.4%)	18.36-22.43
	Always	107	13 (12.1%)	10.45-13.74
Frequency of access to medicines*
	Rarely or never	665	153 (23%)	20.87-25.12	0.056
	Regularly/frequently	421	97 (23%)	20.87-25.12
	Always	317	53 (16.7%)	14.82-18.57
Medical monitoring by the FHS*
	Not monitored	675	138 (20.4%)	18.36-22.43	<0.001
	Monitored irregularly	435	123 (28.3%)	26.03-30.56
	Monitored regularly	349	56 (16%)	14.15-17.84
Monitoring by specialist *
	Not monitored	905	184 (20.3%)	18.27-22.32	0.092
	Monitored irregularly	304	80 (26.3%)	24.08-28.51
	Monitored regularly	237	52 (21.9%)	19.81-23.98
Diabetes mellitus
	Yes	176	47 (26.7%)	24.47-28.92	0.121
	No	1,337	288 (21.5%)	19.42-23.57
Arterial hypertension
	Yes	982	233 (23.7%)	21.55-25.84	0.043
	No	531	102 (19.2%)	17.21-21.18
BMI*
	Overweight	796	174 (21.9%)	19.81-23.98	0.802
	Normal weight	692	155 (22.4%)	20.29-24.50
Benznidazole use in the last 2 years*
	No	1,403	303 (21.6%)	19.52-23.67	0.152
	Yes	93	26 (28%)	25.73-30.26
Functional class*
	With limitations	629	179 (28.5%)	26.22-30.77	<0.001
	No limitations	870	151(17.4%)	15.48-19.31
QRS wave duration*
	Greater than or equal to 120 m/s	590	137 (23.2%)	21.07-25.32	0.516
	Up to 119 m/s	886	193 (21.8%)	19.71-23.88
NT-pro BNP level*
	Changed	178	61 (34.3%)	31.90-36.69	<0.001
	Not changed	1,277	255 (20%)	17.98-22.01
Health behavior
Physical activity
	No	1,153	287 (24.9%)	22.72-27.07	<0.001
	Yes	360	48 (13.3%)	11.58-15.01
Alcohol*
	Frequent alcohol use	29	5 (17.2%)	15.29-19.10	0.524
	Infrequent alcohol use	1,482	329 (22.2%)	20.10-24.29
Smoking*
	Smoker	89	33 (37.1%)	34.66-39.53	<0.001
	Never smoked or ex-smoker	1,423	301 (21.2%)	19.14-23.25
Understanding CD*
	Do not understand enough	707	200 (28.3%)	26.03-30.56	<0.001
	Reasonable understanding	473	67 (14.2)	12.44-15.95
	Understands well	193	21 (10.9%)	9.32-12.47
Time since the last CD consultation*
	More than a year	272	43 (15.8%)	13.96-17.63	0.003
	One year or less	881	215 (24.4%)	22.23-26.56

Models	Variables		Gross OR (95%CI)	Gross P-value	Adjusted OR (95%CI)	P-value
Model 1 Contextual Characteristics	Population
		Larger population	1		1
		Smaller population	0.333 (0.141-0.786)	0.012	0.600 (0.379-0.949)	0.029
	Illiteracy rate
		Lower illiteracy rate	1		1
		Higher illiteracy rate	4.871 (1.506-15.751)	0.008	1.558 (1.004-2.417)	0.048
	Number of doctors per thousand inhabitants
		Higher number of doctors	1		1
		Lower number of doctors	1.388 (0.878-2.194)	0.160	1.512 (1.004-2.417)	0.019
Deviance (-2log Log likelihood )=1.586
Model 2 Contextual Characteristics Individual Characteristics	Income
		Greater than one wage	1		1
		Less than/lower one wage	1.401 (0.984-1.995)	0.055	1.523 (1.158-2.003)	0.003
	Distance from the BHU
		0 to 5 km	1		1
		6 to 99 km	1.0032 (0.705-1.509)	0.733	1.050 (0.736-1.496)	0.787
		Above 100 km	2.482 (1.286-4.791)	0.005	2.529 (1.394-4.590)	0.002
	FHS monitoring
		Regularly	1		1
		Irregularly	1.612 (1.012-2.568)	0.038	1.752 (1.148-2.674)	0.009
		Not monitored	1.367 (0.835-2.238)	0.210	1.368 (0.901-2.079)	0.141
	Arterial hypertension
		Absent	1		1
		Present	1.504 (1.022-2.215)	0.031	1.500 (1.057-2.131)	0.023
	Functional class
		Without limitations	1		1
		With limitations	1.861(1.331-2.601)	<0.001	2.000 (1.468-2.725)	<0.001
	NT-pro BNP level
		Not changed	1		1
		Changed	1.985 (1.244-3.165)	0.003	1.911 (1.256-2.906)	0.002
Deviance (-2log Log likelihood )=1.017
Model 3 Contextual Characteristics Individual Characteristics Health Behaviors	Physical activity practice
		Yes	1		1
		No	1.863 (1.205-2.882)	0.002	1.853 (1.231-2.789)	0.003
	Smoking
		No	1		1
		Yes	3.303 (1.564-5.766)	0.002	2.621 (1.461-4.702)	0.001
Deviance (-2log Log likelihood )=996.725

[1] Collaborations

AM Ferreira, EC Sabino, ALP Ribeiro, RF Damasceno, TM Vieira, MCP Nunes and DS Haikal made substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work. AM Ferreira, MCP Nunes and DS Haikal worked on drafting the work or revising it critically for important intellectual content. All authors read and approved the final manuscript.

Brasil

Brasil

Contextual influence on poor self-rated health in patients with Chagas disease: multilevel study

Influência contextual na pior autopercepção em saúde de portadores de Doença de Chagas: estudo multinível

Abstract