Educational inequality in Rio de Janeiro and its impact on multimorbidity
evidence from the Pró-Saúde study. A cross-sectional analysis
Keywords:
Comorbidity, Health status disparities, Educational status, Cross-sectional studiesAbstract
BACKGROUND: Information about multimorbidity is scarce in developing countries. This study aimed to estimate the association of educational attainment with occurrences of multimorbidity in a population of public employees on university campuses in Rio de Janeiro. DESIGN AND SETTING: We conducted cross-sectional analyses on baseline data (1999-2001) from 3,253 participants in the Pró-Saúde study, conducted in Brazil. METHODS: The prevalence of multimorbidity, defined as a self-reported history of medical diagnoses of two or more chronic conditions, was estimated according to sex, age, smoking, obesity and educational level. The association between education and multimorbidity was estimated using odds ratios (OR) and the relative and slope indices of inequality, in order to quantify the degree of educational inequality among individuals with multimorbidity in this population. RESULTS: Greater age, female sex, smoking and obesity had direct associations with multimorbidity; and tobacco exposure and obesity also showed direct relationships with poorer educational level. There was a monotonic inverse linear trend between educational level and the presence of multimorbidity among women, with twice the odds (OR 2.47; 95% confidence interval, CI: 1.42-4.40) between extremities of schooling categories. There was excess multimorbidity of 22% at the lowest extremity of schooling, thus showing that women with worse educational status were more affected by the outcome. No trend and no excess multimorbidity was seen among men. CONCLUSIONS: Educational inequality is an important determinant for development of multimorbidity. Men and women experience its effect differently. Researchers need to consider that sex may be an effect modifier in multimorbidity studies.
Downloads
References
Valderas JM, Mercer SW, Fortin M. Research on patients with multiple health conditions: different constructs, different views, one voice. Journal of Comorbidity. 2011;1:1-3. Available from: Available from: http://www.jcomorbidity.com/index.php/test/article/download/11/15 Accessed in 2017 (Oct 5).
Valderas JM, Sibbald B, Salisbury C, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009;(7):357-63.
van Oostrom SH, Picavet HS, de Bruin SR, et al. Multimorbidity of chronic diseases and health care utilization in general practice. BMC Fam Pract. 2014;15:61.
Fortin M, Lapointe L, Hudon C, et al. Multimorbidity and quality of life in primary care: a systematic review. Health Qual Life Outcomes. 2004;2:51.
Calderón-Larrañaga A, Poblador-Plou B, González-Rubio F, et al. Multimorbidity, polypharmacy, referrals, and adverse drug events: are we doing things well? Br J Gen Pract. 2012;62(605):e821-6.
Marengoni A, von Strauss E, Rizzuto D, Winblad B, Fratiglioni L. The impact of chronic multimorbidity and disability on functional decline and survival in elderly persons. A community-based, longitudinal study. J Intern Med. 2009;265(2):288-95.
Salive ME. Multimorbidity in older adults. Epidemiol Rev. 2013;35:75-83.
France EF, Wyke S, Gunn JM, et al. Multimorbidity in primary care: a systematic review of prospective cohort studies. Br J Gen Pract. 2012;62(597):e297-307.
Nunes BP, Flores TR, Mielke GI, Thumé E, Facchini LA. Multimorbidity and mortality in older adults: A systematic review and meta-analysis. Arch Gerontol Geriatr. 2016;67:130-8.
Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition--multimorbidity. JAMA. 2012;307(23):2493-4.
Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43.
Orueta JF, Nuño-Solinís R, García-Alvarez A, Alonso-Morán E. Prevalence of multimorbidity according to the deprivation level among the elderly in the Basque Country. BMC Public Health. 2013;13:918.
Roberts KC, Rao DP, Bennett TL, Loukine L, Jayaraman GC. Prevalence and patterns of chronic disease multimorbidity and associated determinants in Canada. 2015;35(6):87-94.
Nagel G, Peter R, Braig S, et al. The impact of education on risk factors and the occurrence of multimorbidity in the EPIC-Heidelberg cohort. BMC Public Health. 2008;8:384.
Booth HP, Prevost AT, Gulliford MC. Impact of body mass index on prevalence of multimorbidity in primary care: cohort study. Fam Pract. 2014;31(1):38-43.
Fortin M, Haggerty J, Almirall J, et al. Lifestyle factors and multimorbidity: a cross sectional study. BMC Public Health. 2014;14:686.
Frenk J, Frejka T, Bobadilla J, et al. La transición epidemiológica en América Latina. Bol Of Sanit Panam. 1991;111(6):485-96.
Duarte EC, Barreto SM. Transição demográfica e epidemiológica: a Epidemiologia e Serviços de Saúde revisita e atualiza o tema. Epidemiol Serv Saúde. 2012;21(4):529-32.
Alaba O, Chola L. The social determinants of multimorbidity in South Africa. Int J Equity Health. 2013;12:63.
Chung RY, Mercer S, Lai FT, et al. Socioeconomic Determinants of Multimorbidity: A Population-Based Household Survey of Hong Kong Chinese. PLoS One. 2015;10(10):e0140040.
Ha NT, Le NH, Khanal V, Moorin R. Multimorbidity and its social determinants among older people in southern provinces, Vietnam. Int J Equity Health. 2015;14:50.
Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. 1971. Milbank Q. 2005;83(4):731-57.
Afshar S, Roderick PJ, Kowal P, Dimitrov BD, Hill AG. Multimorbidity and the inequalities of global ageing: a cross-sectional study of 28 countries using the World Health Surveys. BMC Public Health. 2015;15:776.
Sousa-Muñoz RL, Ronconi DE, Dantas GC, Lucena DMS, Silva IBA. Impacto de multimorbidade sobre mortalidade em idosos: estudo de coorte pós-hospitalização [Impact of multimorbidity on mortality in elderly: a post-hospitalization cohort study]. Rev Bras Geriatr Gerontol. 2013;16(3):579-89.
de S Santos Machado V, Valadares AL, Costa-Paiva LH, et al. Aging, obesity, and multimorbidity in women 50 years or older: a population-based study. Menopause. 2013;20(8):818-24.
de Souza Santos Machado V, Valadares AL, da Costa-Paiva LS, Moraes SS, Pinto-Neto AM. Multimorbidity and associated factors in Brazilian women aged 40 to 65 years: a population-based study. Menopause. 2012;19(5):569-75.
Nunes BP, Thumé E, Facchini LA. Multimorbidity in older adults: magnitude and challenges for the Brazilian health system. BMC Public Health. 2015;15(1):1172.
Diederichs C, Berger K, Bartels DB. The measurement of multiple chronic diseases--a systematic review on existing multimorbidity indices. J Gerontol A Biol Sci Med Sci. 2011;66(3):301-11.
Diederichs CP, Wellmann J, Bartels DB, et al. How to weight chronic diseases in multimorbidity indices? Development of a new method on the basis of individual data from five population-based studies. J Clin Epidemiol. 2012;65(6):679-85.
van den Bussche H, Koller D, Kolonko T, et al. Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health. 2011;11:101.
Verbrugge LM. Gender and health: an update on hypotheses and evidence. J Health Soc Behav. 1985;26(3):156-82.
Faerstein E, Chor D, Lopes CS, Werneck GL. Estudo Pró-Saúde: características gerais e aspectos metodológicos [The Pro-Saude Study: general characteristics and methodological aspects]. Rev Bras Epidemiol. 2005;8(4):454-66.
Chor D, Faerstein E, Alves MG, de Souza Lopes C. How reproducible is self-reported information on exposure to smoking, drinking, and dietary patterns? Evidence among Brazilian adults in the Pró-Saúde Study. Sao Paulo Med J. 2003;121(2):63-6.
World Health Organization. Waist Circumference and Waist-Hip Ratio. Report of a WHO Expert Consultation. Geneva: World Health Oorganization; 2008. Available from: Available from: http://apps.who.int/iris/bitstream/10665/44583/1/9789241501491_eng.pdf Accessed in 2017 (Oct 5).
Alves RFS, Faerstein E. Desigualdade educacional na ocorrência de obesidade abdominal: Estudo Pró-Saúde [Educational inequality in the occurrence of abdominal obesity: Pró-Saúde Study]. Rev Saúde Pública. 2015;49:65.
Moreno-Betancur M, Latouche A, Menvielle G, Kunst AE, Rey G. Relative index of inequality and slope index of inequality: a structured regression framework for estimation. Epidemiology. 2015;26(4):518-27.
World Health Organization. Handbook on Health Inequality Monitoring: with a special focus on low- and middle-income countries. Geneva: World Health Organization; 2013. Available from: Available from: http://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.pdf Accessed in 2017 (Oct 5).
Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med. 2005;3(3):223-8.
van den Akker M, Buntix F, Metsemakers JF, Roos S, Knottnerus JA. Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol. 1998;51(5):367-75.
Britt HC, Harrison CM, Miller GC, Knox SA. Prevalence and patterns of multimorbidity in Australia. Med J Aust. 2008;189(2):72-7.
Galobardes B, Smith GD, Lynch JW. Systematic review of the influence of childhood socioeconomic circumstances on risk for cardiovascular disease in adulthood. Ann Epidemiol. 2006;16(2):91-104.
World Health Organization. Commission on Social Determinants of Health. Health equity through action on the social determinants of health. Geneva: World Health Organization ; 2008. Available from: Available from: http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf Accessed in 2017 (Oct 5).
Schäfer I, Hansen H, Schön G, et al. The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. First results from the multicare cohort study. BMC Health Serv Res. 2012;12(1):89.
Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43.
Hudon C, Fortin M, Poitras M-E, Almirall J. The relationship between literacy and multimorbidity in a primary care setting. BMC Fam Pract. 2012;13(1):33.
Reforma da Atenção Primária à Saúde na cidade do Rio de Janeiro - avaliação dos primeiros três anos de Clínicas da Família. Pesquisa avaliativa sobre aspectos de implantação, estrutura, processos e resultados das Clínicas da Família na cidade do Rio de Janeiro. Porto Alegre: OPAS; 2013. Available from: Available from: http://www.sbmfc.org.br/media/file/reforma_atencao.pdf Accessed in 2017 (Oct 5).
Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002. Available from: Available from: http://bvsms.saude.gov.br/bvs/publicacoes/atencao_primaria_p1.pdf Accessed in 2017 (Oct 5).
Macinko J, Harris MJ. Brazil’s family health strategy--delivering community-based primary care in a universal health system. N Engl J Med. 2015;372(23):2177-81.
Promoting health and development: closing the implementation gap. Proceedings of the 7th Global Conference on Health Promotion. October 26-30, 2009. Nairobi, Kenya. Glob Health Promot. 2010;17(2):3-95.
