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British Journal of Healthcare and Medical Research - Vol. 9, No. 2
Publication Date: April, 25, 2022
DOI:10.14738/jbemi.92.12194. Gianini, R. J., Santos, G. V. D., & Salvestro, G. (2022). Common Mental Disorders and Equity in Health Care Use: São Paulo-Capital
Health Survey. British Journal of Healthcare and Medical Research, 9(2). 139-152.
Services for Science and Education – United Kingdom
Common Mental Disorders and Equity in Health Care Use: São
Paulo-Capital Health Survey
Reinaldo José Gianini
Pontificia Universidade Católica de São Paulo
Gustavo Venâncio dos Santos
Pontificia Universidade Católica de São Paulo
Gabriel Salvestro
Pontificia Universidade Católica de São Paulo
ABSTRACT
Background: Common Mental Disorders (CMDs) compromise quality of life, thus
generating socioeconomic costs. Objectives: To analyze equity regarding use of the
services and health expenditures among individuals with CMDs, and their
relationships with sociodemographic variables. Methodology: The data are from
the 2015 São Paulo health survey, with application of SRQ-20. The participants have
given their consent for their data to be used in this research. Results: The sample
presented a CMD prevalence of 19.7% (95% CI=18.2%-21.4%). Higher CMD
prevalence values were found among users of the public health services (PR=1.49;
95% CI=1.25-1.76) and in groups with ≥ 33 dollars of health expenditures in the last
month (PR=1.28; 95% CI=1.08-1.52). For individuals with CMDs, the main variables
associated with “used the public health system” and “health expenditure
< 33 dollars” were lower schooling levels, lower per capita family income, and age
< 60 years old. There was an inverse relationship between use of the Unified Health
System (Sistema Único de Saúde, SUS) and health expenditure. Conclusion: Use of
the SUS by people with CMDs follows the principle of equity in that it assists groups
that are underprivileged in terms of schooling and family income, but not those over
60 years old.
BACKGROUND
Goldberg and Huxley (1) first defined Common Mental Disorders (CMDs) as encompassing a set
of symptoms, which, although not sufficient to determine a formal diagnosis of mental
disorders, compromises quality of life generating social and economic costs. Their global
prevalence varies from 17% to 35%, evidencing the need for studies on this subject matter (2),
especially in Brazil, where there are few studies capable of measuring the prevalence of CMDs,
and even more among individuals assisted by Primary Care (3) and those belonging to different
sociodemographic groups not frequently studied (4).
According to Monteiro (5), a number of studies show that people exposed to unfavorable social
and economic conditions have worse health status, reinforcing the existence of a risk pattern.
Thus, public health services emerge as a way to intervene in the health-disease process and to
compensate health discrepancies produced by society. For Travassos (6), equity in the use of
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British Journal of Healthcare and Medical Research (BJHMR) Vol 9, Issue 2, April - 2022
Services for Science and Education – United Kingdom
health services becomes an important, though not sufficient, condition to reduce inequalities in
contracting diseases and dying. This term includes all direct (medical consultations,
hospitalization) and indirect (preventive exams, diagnosis and medication) contacts with the
health services. Studying the use of health services is important to identify excluded population
groups and coverage levels, as well as to assist planning in health to ensure universal and equal
access (7, 8). In Brazil, immense socioeconomic and territorial inequalities mark the reality and
have repercussions on the distribution of health services, affecting the opportunity to remain
healthy (9, 10). Consequently, the concept of equity in health becomes fundamental to deal with
these inequalities; it means that it is necessary to address the unequal approach among
individuals, seeking to intensify measures for those who need it most (11, 12). The literature
states that there is a major difficulty on the part of the health services in the diagnosis and
treatment of CMDs. This favors the use of unnecessary tests and medications with high costs
from the public health point of view and the possibility of iatrogenic harms or side effects,
especially when there is insistence on treating only the physical repercussions, leaving aside
important care measures in the psychological and social dimensions (2, 3, 13). It also states that
this problem is greater in peripheral, disadvantaged and vulnerable populations, such as
women, non-white-skinned people, older adults, individuals with lower incomes and/or
schooling levels, widowers, people with chronic diseases, unemployed individuals and
practitioners of religious minorities that are marginalized (2, 4, 13).
A global and large systematic review (14) compiled the main trends of the relationship between
sociodemographic factors and use of the health services in individuals with CMDs. It observed
a hill-shaped relationship with age, use being higher by middle-aged individuals and lower by
young people and older adults. Female gender, Caucasian ethnicity and higher schooling levels
presented higher use rates. Married people and employed individuals showed lower utilization.
Income presented no association and immigration status showed no clear pattern, although
there was only one Brazilian study in this systematic review (15).
Concerning use of the SUS, Ribeiro et al (16) describe that it was lower for white-skinned
people, those aged 45 years old or more and groups with higher incomes and schooling levels.
The same authors describe health expenditures over 50 dollars (equivalent to 100 Reais in
2008) for individuals aged > 60 years old, white-skinned people, with incomes > 2.5 MWs
(1 MW = 415 Reais, equivalent to 207.5 dollars), married, and with higher education. There was
an inverse relationship between higher income or schooling levels and use of the SUS.
Figueroa (17) studied Medicare beneficiaries and reports a CMD prevalence equal to 7.5%, with
a per-year mental health expenditure 181% higher for individuals with CMDs when compared
to those without mental health diseases. For physical health problems, the difference in health
expenditure for individuals with CMDs was 118% higher when compared to those without
mental health problems. In general, the Medicare expenditures were 18.4% higher for
individuals with CMDs, 8.5% being indirectly related to mental health services and 4.2%
directly related to such services, adding up to 12.7%. This author observed higher prevalence
of CMDs in younger individuals, women, people with chronic multimorbidities, and black- skinned people. Individuals with CMDs presented 33% more hospital admissions and longer
hospitalization times; they also presented 40%-54% more need of rehabilitation, and more
need of emergency assistance; for them, the need of home health assistance was 27% higher.
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Gianini, R. J., Santos, G. V. D., & Salvestro, G. (2022). Common Mental Disorders and Equity in Health Care Use: São Paulo-Capital Health Survey.
British Journal of Healthcare and Medical Research, 9(2). 139-152.
URL: http://dx.doi.org/10.14738/jbemi.92.12194
OBJECTIVES
The studies about the populations most frequently affected by CMDs, as well as the
understanding of their relationship with the health services, are fundamental for the effective
response offered by the SUS. These studies can address important issues for those patients who
require multidisciplinary teams and trained managers (2, 4, 13, 18), problems that often
extrapolate direct contact with health care, as they demand governmental interventions in
fields such as education, social assistance and basic living conditions (3).
Given the above, and in view of the importance of CMDs in terms of public health and the
organization of the current health care system, this study set out to analyze equity in health
care for people with CMDs focusing on the use of health care services and health care
expenditures. The objectives are as follows: to analyze the prevalence of CMDs according to
sociodemographic variables; to analyze health expenditures and use of health services
according to presence of CMDs; to analyze health expenditure in individuals with CMDs
according to sociodemographic variables; to analyze the use of health health services by
individuals with CMDs according to sociodemographic variables; and to analyze the
relationship between health expenditure and use of health services by people with CMDs.
METHODOLOGY
The data from the 2015 São Paulo City Population Health Survey (ISA/SP-Capital 2015) are
used as the basis for this analysis (19). The sample of this population-based health survey
consisted in the residents of private households in the city urban area. The process to stratify
the probabilistic sampling of clusters in domains was in two levels, namely: census sectors with
four groups, and households with five groups. The sample domains were as follows: adolescents
aged from 12 to 19 years old, adult men aged from 20 to 59 years old, adult women aged from
20 to 59 years old, and men and women aged 60 years old or more (older adults). The city
stratification took into account the Regional Health Coordination Office (Coordenação Regional
de Saúde, CRS), including thirty census sectors in each CRS, and following the 2010
demographic census urban sectors register. The prevalence estimate from sample calculation
was 50% with an error of 0.10 at a 95% confidence interval and 1.5 design effect. The
population selected for this survey consisted of all the residents aged at least 15 years old who
answered emotional health Block E of the ISA/SP-Capital 2015 (19).
The Self-Reporting Questionnaire (SRQ-20), which refers to Block E, was the instrument used
to establish absence or presence of CMDs. The World Health Organization recommends using
this questionnaire in developing countries as a tool for screening psychiatric disorders (20).
Twenty yes/no questions about mental and physical symptoms make up the questionnaire. The
number of positive answers established as a cutoff point for the presence of CMDs was 6 or
more for men under 65 years old, 8 or more for women under 65 years old, and 5 or more for
men and women aged 65 or more. SRQ-20 has showed satisfactory performance as a diagnostic
test for CMDs, with 83% sensitivity and 80% specificity (2).
The sociodemographic variables included in this study were Gender, Age, Ethnicity/Race,
Religion, Marital Status, Place of Birth, Schooling, Occupation, and Per Capita Family Income in
minimum wages (MWs) in effect in 2015: 788 Reais or 262 dollars; the tables describe their
categories. The health care variables were Type of Health Service last sought, public or private;
and Health Expenditure in the last month, < 33 or ≥ 33 dollars, with the median as cutoff point.