Education-related health inequities in noncommunicable diseases: an analysis of the <i>Brazilian National Health Survey</i>, 2013 and 2019

Macinko, James; Mullachery, Pricila H.

doi:10.1590/0102-311X00137721

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DEBATE • Cad. Saúde Pública 38 (Suppl 1) • 2022 • https://doi.org/10.1590/0102-311X00137721 linkcopy

Education-related health inequities in noncommunicable diseases: an analysis of the Brazilian National Health Survey, 2013 and 2019

Inequidades relacionadas à escolaridade na prevalência de doenças crônicas não transmissíveis: uma análise da Pesquisa Nacional de Saúde, 2013 e 2019

Inequidades de salud relacionadas con la educación en enfermedades no transmisibles: un análisis de la Encuesta Nacional de Salud brasileña, 2013 y 2019

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstracts

This study assesses changes in the prevalence and distribution of noncommunicable diseases (NCDs) and related risk factors among Brazilian adults from the 2013 and 2019 Brazilian National Health Surveys (PNS). It is based on the hypothesis that deteriorating socioeconomic conditions over this period would lead to increased NCDs among the least advantaged populations. We estimated adjusted prevalence ratios by education category and three inequality measures - the slope index of inequality (SII), the relative index of inequality (RII), and population attributable fraction (PAF) - for obesity, hypertension, arthritis, asthma, cancer, depression, diabetes, heart disease, having any chronic condition, and multimorbidity by survey year. We also estimated the 27 Brazilian Federative Units RII and prevalence rates for diabetes and multimorbidity per year and plotted the RII against prevalence by year. Results showed that all NCDs increased over the period observed, ranging from an 8% increase in the adjusted prevalence of arthritis to a 24% increase in the adjusted prevalence of obesity. Measures of inequality showed that most conditions exhibited significant educational inequities in both 2013 and 2019. However, on average, education-based inequities did not significantly change between the two periods. Considering the deterioration of the socioeconomic conditions of most Brazilians, the erosion of social protections, and the continuing economic, political, and health crises occurring in the nation, we observed an urgent need for discussion about the best way to adopt equity-promoting health policies and programs and action to reduce socioeconomic and geographic inequalities in NCDs throughout the country.

Keywords:
Health Status Disparities; Noncommunicable Diseases; Education; Socieconomic Factors

Characteristc	2013 (N = 60,202)		2019 (N = 88,509)		Change		Test for difference (2019-2013)
Characteristc	Mean	95%CI or SD	Mean	95%CI or SD	Mean	95%CI or SD
Age	42.9	0.14	44.9	0.12	2.01	0.18	p < 0.0001
Female (%)	52.9	52.1, 53.7	53.2	52.6, 53.8	0.3	-1.1, 1.7	p = 0.598
Education
Less than primary	39.0	38.1, 40.0	34.8	34.1, 35.4	-4.2	-5.9, -2.7
Primary complete	15.5	15.0, 16.1	14.5	14.1, 14.9	-1.0	-2.0, -0.1	p < 0.0001
High school complete	28.1	27.4, 28.8	28.8	29.2, 30.4	0.7	0.4, 3.0
Higher education or more	17.4	16.6, 18.2	20.9	20.2, 21.7	3.5	2.0, 5.1
Income	BRL 1,177	24.7	BRL 1,618	24.7	BRL 441	35.0	p < 0.0001
Obesity (%)	20.8	20.2, 21.4	26.5	23.6, 29.7	5.7	2.2, 9.5	p = 0.0001
Hypertension	22.0	21.4, 22.7	25.9	25.4, 26.4	3.9	2.7, 5.0	p < 0.0001
Arthritis	6.4	6.1, 6.8	7.6	7.2, 7.9	1.2	0.4, 1.8	p < 0.0001
Asthma	4.4	4.1, 4.7	5.3	5.0, 5.5	0.9	0.3, 1.4	p < 0.0001
Cancer	1.8	1.6, 2.1	2.6	2.4, 2.7	0.8	0.3, 1.1	p < 0.0001
Depression	7.6	7.2, 8.1	10.2	9.8, 10.6	2.6	1.7, 3.4	p < 0.0001
Diabetes	7.0	6.7, 7.4	8.2	7.9, 8.6	1.2	0.5, 1.9	p < 0.0001
Heart disease	4.1	3.8, 4.49	5.3	5.0, 5.6	1.2	0.51, 1.8	p < 0.0001
Any chronic condition	35.3	34.6, 36.0	41.8	41.2, 42.4	6.5	5.2, 7.8	p < 0.0001
Multimorbidity	12.7	12.2, 13.2	16.1	15.6, 16.5	3.4	2.4, 4.3	p < 0.0001

	Obesity	Hypertension	Arthritis	Asthma	Cancer	Depression	Diabetes	Heart disease	Any chronic	Multimorbidity
Male (95%CI)	0.69 * (0.65, 0.73)	0.77 * (0.75, 0.80)	0.38 * (0.35, 0.42)	0.71 * (0.65, 0.77)	0.81 * (0.71, 0.91)	0.36 * (0.33, 0.39)	0.89 * (0.83, 0.95)	0.96 (0.89, 1.04)	0.75 * (0.73, 0.76)	0.56 * (0.54, 0.59)
Age [years] (95%CI)	1.08 * (1.07, 1.09)	1.15 * (1.15, 1.16)	1.17 * (1.15, 1.18)	0.97 * (0.96, 0.98)	1.15 * (1.12, 1.18)	1.08 * (1.07, 1.10)	1.22 * (1.20, 1.24)	1.09 * (1.07, 1.11)	1.08 * (1.07, 1.08)	1.16 * (1.15, 1.17)
Primary complete [vs. less] (95%CI)	0.98 (0.90, 1.07)	0.98 (0.93, 1.03)	1.04 (0.94, 1.16)	0.99 (0.87, 1.14)	0.98 (0.80, 1.21)	0.95 (0.86, 1.05)	0.97 (0.87, 1.08)	0.98 (0.85, 1.12)	0.98 (0.95, 1.02)	1.01 (0.94, 1.08)
High school complete (95%CI)	0.93 ** (0.87, 1.00)	0.87 * (0.83, 0.91)	0.93 (0.84, 1.03)	0.90 (0.79, 1.02)	1.07 (0.91, 1.27)	0.83 * (0.76, 0.90)	0.79 * (0.72, 0.88)	0.84 *** (0.73, 0.96)	0.89 * (0.87, 0.92)	0.86 * (0.81, 0.91)
Higher education and more (95%CI)	0.81 * (0.74, 0.90)	0.77 * (0.73, 0.81)	0.80 * (0.71, 0.90)	1.08 (0.94, 1.23)	1.45 (1.20, 1.76)	0.99 (0.90, 1.10)	0.60 * (0.53, 0.68)	0.81 *** (0.70, 0.94)	0.92 * (0.88, 0.95)	0.76 * (0.71, 0.83)
2019 [vs. 2013] (95%CI)	1.24 * (1.11, 1.39)	1.09 * (1.05, 1.12)	1.08 ** (1.00, 1.16)	1.19 * (1.09,1.29)	1.21 *** (1.06, 1.38)	1.30 * (1.22, 1.40)	1.11 * (1.04, 1.19)	1.17 *** (1.07, 1.29)	1.11 *** (1.09, 1.14)	1.15 * (1.10, 1.21)
N	60,839	139,322	139,322	139,322	139,322	139,322	127,509	139,322	139,322	139,322

	2013			2019
	RII ** (95%CI)	SII ** (95%CI)	PAF *** (95%CI)	RII ** (95%CI)	SII ** (95%CI)	PAF *** (95%CI)
Obesity	1.00	-0.02	5.54	1.07	0.01	4.55
	(0.91, 1.11)	(-0.15, 0.11)	(1.95, 9.01)	(0.79, 1.45)	(-0.42, 0.45)	(-4.13, 12.50)
Hypertension	1.30 ^#	0.40 ^#	10.93	1.40 ^#	0.60 ^#	10.85
	(1.18, 1.43)	(0.26, 0.55)	(6.71, 14.96)	(1.31, 1.49)	(0.50, 0.71)	(8.36, 13.28)
Arthritis	1.31 ^##	0.32 ^##	8.98	1.30 ^##	0.33 ^#	9.90
	(1.07, 1.60)	(0.09, 0.54)	(0.24, 16.95)	(1.11, 1.52)	(0.15, 0.52)	(3.53, 15.85)
Asthma	0.76 ^###	-0.28 ^###	1.37	0.69 ^#	-0.39 ^#	2.55
	(0.60, 0.97)	(-0.54, -0.03)	(-6.79, 8.90)	(0.57, 0.84)	(-0.60, -0.18)	(-3.17, 7.95)
Cancer	0.36 ^#	-1.08 ^#	-26.00	0.48 ^#	-0.77 ^#	-6.49
	(0.25, 0.52)	(-1.46, -0.69)	(-47.14, -7.89)	(0.38, 0.61)	(-1.02, -0.51)	(-17.97, 3.87)
Depression	1.05	0.05	9.58	0.84 *	-0.21 **	4.24
	(0.87, 1.27)	(-0.16, 0.27)	(3.03, 15.69)	(0.74, 0.96)	(-0.37, -0.06)	(0.22, 8.10)
Diabetes	1.61 ^#	0.55 ^#	21.72	1.86 ^#	0.73 ^#	18.88
	(1.31, 1.99)	(0.31, 0.78)	(12.51, 29.96)	(1.61, 2.15)	(0.57, 0.90)	(12.79, 24.54)
Heart disease	1.35 ^###	0.32 ^###	15.38	1.19 ^###	0.20 ^###	10.51
	(1.03, 1.78)	(0.03, 0.61)	(3.29, 25.95)	(1.00, 1.42)	(0.01, 0.39)	(2.22, 18.11)
Any chronic conditions	1.02 ^#	0.16 ^###	7.34	1.01 ^#	0.15 ^##	5.03
	-	(0.03, 0.28)	(4.63, 9.98)	-	(0.05, 0.24)	(3.30, 6.73)
Multi-morbidity	1.22 ^##	0.25 ^##	12.84	1.31 ^#	0.38 ^#	12.62
	(1.07, 1.39)	(0.07, 0.42)	(6.96, 18.35)	(1.20, 1.42)	(0.25, 0.50)	(9.04, 16.05)

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Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rua Leopoldo Bulhões, 1480 , 21041-210 Rio de Janeiro RJ Brazil, Tel.:+55 21 2598-2511, Fax: +55 21 2598-2737 / +55 21 2598-2514 - Rio de Janeiro - RJ - Brazil
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[TFN1] 95%CI: 95% confidence interval; SD: standard deviation.

[TFN2] Source: PNS 2013 and 2019.

[TFN3] Notes: weighted proportions, means, and 95% confidence intervals are adjusted for survey design. Health conditions were self-reported based on the question: “Have you been told by a health care provider that you have (insert condition)?”. Obesity was defined as BMI larger than 30kg/m². Measures of weight and height were obtained from all respondents in 2013 and a subsample of respondents (n = 6,571) in 2019.