Inequidades no acesso ao rastreamento por mamografia no Brasil

Nogueira, Mário Círio; Fayer, Vívian Assis; Corrêa, Camila Soares Lima; Guerra, Maximiliano Ribeiro; Stavola, Bianca De; dos-Santos-Silva, Isabel; Bustamante-Teixeira, Maria Teresa; Silva, Gulnar Azevedo e

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Brasil

Cadernos de Saúde Pública

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Sumário

ARTICLE • Cad. Saúde Pública 35 (6) • 2019 • https://doi.org/10.1590/0102-311X00099817 copiar

Inequidades no acesso ao rastreamento por mamografia no Brasil

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo:

O estudo teve como objetivos descrever a distribuição espacial do rastreamento por mamografia entre áreas geográficas pequenas (microrregiões) no Brasil, além de investigar se as diferenças observadas estavam associadas a inequidades espaciais nas condições socioeconômicas, na prestação de assistência à saúde e no uso de serviços de saúde. Este foi um estudo ecológico de base territorial, comparando a cobertura do rastreamento por mamografia em 2010-2011 com fatores socioeconômicos e de cuidados de saúde. O estudo usou 438 microrregiões sanitárias brasileiras como as unidades analíticas. Foram utilizados modelos de regressão espacial para estudar as associações. Houve uma importante variabilidade na cobertura por mamografia entre microrregiões (mediana = 21,6%; variação interquartil: 8,1%-37,9%). A análise multivariada identificou: forte desigualdade na renda familiar, número baixo de radiologistas/100 mil habitantes, número baixo de aparelhos de mamografia/10 mil habitantes e número baixo de mamografias realizadas com cada aparelho enquanto correlatos independentes da baixa cobertura mamográfica no nível microrregional. Houve evidência de forte dependência espacial nessas associações, em que as mudanças em uma microrregião afetavam as microrregiões vizinhas, além de heterogeneidade geográfica. O estudo revelou importantes inequidades no acesso ao exame de mamografia entre microrregiões brasileiras em 2010-2011, com cobertura mais alta nas microrregiões com menor desigualdade de renda e melhor acesso geral aos cuidados de saúde.

Palavras-chave:
Iniquidade em Saúde; Neoplasias da Mama; Acesso aos Serviços de Saúde

Variable /Brazilian regions *	Number of health micro-regions	Variable distribution per health micro-regions
Variable /Brazilian regions *	Number of health micro-regions	Mean	SD	Minimum value	Q1	Median	Q3	Maximum value
Outcome variable
Mammography ratio (per 100 women, %), 2010-2011
Brazil	438	24.15	17.96	0.05	8.06	21.58	37.87	84.15
Southeast	153	37.04	14.81	2.19	27.72	37.26	44.66	84.15
South	68	37.19	12.81	13.95	27.92	36.52	43.02	73.58
Northeast	133	13.40	10.70	0.05	5.94	12.15	17.48	51.55
Central	39	8.55	8.57	0.19	2.82	5.03	12.32	32.56
North	45	5.95	6.72	0.20	0.80	4.20	9.68	30.31
Socioeconomic conditions (distal variables)
Population size (x 1,000), 2010
Brazil	438	435.52	846.80	21.47	152.19	250.12	396.32	11253.50
Southeast	153	525.26	1272.24	44.27	128.29	236.19	393.43	11253.50
South	68	402.75	466.20	94.96	182.14	271.87	397.34	3223.84
Northeast	133	399.11	501.23	44.66	187.46	277.16	400.62	3908.76
Central	39	360.46	507.38	21.47	102.66	161.29	354.36	2570.16
North	45	352.54	421.38	41.34	137.53	214.88	377.47	2119.74
GDP per capita (x 1,000 BRL), 2010
Brazil	438	14.62	9.48	3.15	6.73	13.04	19.17	59.22
Southeast	153	19.01	10.35	4.48	12.15	17.76	23.43	59.22
South	68	20.08	6.55	10.04	15.53	18.84	22.89	43.10
Northeast	133	7.14	4.19	3.15	4.77	5.80	8.08	39.49
Central	39	18.01	8.81	7.08	12.99	15.59	21.86	58.33
North	45	10.61	5.40	3.18	6.07	10.39	12.45	30.83
Gini index of per capita household income (%), 2010
Brazil	438	50.92	5.11	38.00	48.00	51.00	54.00	71.00
Southeast	153	47.85	3.47	40.00	45.00	48.00	50.00	65.00
South	68	47.00	4.00	38.00	44.00	47.50	50.00	54.00
Northeast	133	53.68	2.92	48.00	51.00	54.00	56.00	63.00
Central	39	51.69	3.77	46.00	49.00	51.00	54.00	64.00
North	45	58.40	4.28	50.00	55.00	58.00	61.00	71.00
Population with secondary or higher education (%), 2010
Brazil	438	46.11	10.22	20.54	36.91	46.69	53.74	70.75
Southeast	153	51.11	8.94	26.63	46.57	52.90	57.87	66.90
South	68	51.38	6.10	39.79	47.66	50.08	54.66	67.74
Northeast	133	37.91	8.28	26.35	32.43	35.70	40.54	70.15
Central	39	48.76	6.96	38.30	43.80	46.88	52.13	70.75
North	45	43.08	10.41	20.54	36.11	40.35	48.84	65.79
Urbanization rate (%), 2010
Brazil	438	75.16	15.43	40.00	63.00	77.00	89.00	100.00
Southeast	153	84.86	12.30	42.00	80.00	89.00	94.00	100.00
South	68	78.68	10.94	55.00	70.50	80.00	85.25	99.00
Northeast	133	63.47	13.18	40.00	54.00	62.00	70.00	100.00
Central	39	79.87	10.91	58.00	69.00	81.00	89.50	98.00
North	45	67.31	13.95	43.00	57.00	65.00	77.00	98.00
Provision of health care (intermediate variables)
FHS coverage (%)
Brazil	438	78.42	22.65	13.01	64.92	86.50	98.11	100.00
Southeast	153	66.89	25.23	13.01	47.02	68.06	90.33	100.00
South	68	69.14	22.52	20.70	57.06	71.06	84.93	100.00
Northeast	133	94.53	9.62	40.63	92.76	98.13	100.00	100.00
Central	39	80.66	17.12	27.69	71.97	85.84	93.33	100.00
North	45	82.10	14.02	43.20	75.13	83.80	91.80	100.00
Physician ratio (per 1,000), 2010
Brazil	438	1.00	0.62	0.12	0.54	0.85	1.31	3.64
Southeast	153	1.35	0.63	0.30	0.93	1.24	1.64	3.64
South	68	1.27	0.54	0.63	0.87	1.14	1.44	2.99
Northeast	133	0.64	0.40	0.26	0.42	0.53	0.68	2.69
Central	39	0.92	0.54	0.42	0.58	0.85	0.96	2.73
North	45	0.59	0.38	0.12	0.33	0.47	0.72	1.47
Radiologist ratio (per 100,000), 2010
Brazil	438	2.93	2.59	0.00	1.00	2.00	4.00	20.00
Southeast	153	3.94	2.92	0.00	2.00	3.00	5.00	20.00
South	68	3.91	2.28	1.00	2.00	3.50	5.00	10.00
Northeast	133	1.79	1.85	0.00	1.00	1.00	2.00	11.00
Central	39	2.87	2.48	0.00	1.00	2.00	4.00	11.00
North	45	1.38	1.51	0.00	0.00	1.00	2.00	5.00
Mammography machines ratio (per 10,000), 2010
Brazil	438	1.19	0.86	0.00	0.63	1.14	1.66	7.70
Southeast	153	1.44	0.78	0.00	0.89	1.43	1.86	3.87
South	68	1.38	0.59	0.39	0.89	1.32	1.76	3.29
Northeast	133	0.84	0.70	0.00	0.43	0.71	1.18	3.31
Central	39	1.31	0.96	0.00	0.66	1.38	1.95	3.67
North	45	0.95	1.31	0.00	0.00	0.73	1.36	7.70
Healthcare services utilization (proximal variable)
Mammographic examinations per machine (x 100), 2010
Brazil	438	7.14	6.86	0.00	1.43	6.03	10.30	52.06
Southeast	153	9.66	6.58	0.00	5.38	8.21	12.48	30.39
South	68	11.94	6.42	3.80	7.89	9.75	13.79	34.33
Northeast	133	5.02	6.28	0.00	0.14	3.87	7.78	52.06
Central	39	2.24	2.66	0.00	0.11	1.59	3.67	10.52
North	45	1.82	3.06	0.00	0.00	0.22	2.41	12.42

Variables *	Step 1			Step 2			Step 3
	Impacts (p-value)			Impacts (p-value)			Impacts (p-value)
	Direct	Indirect	Total	Direct	Indirect	Total	Direct	Indirect	Total
Regions **
Southeast	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
South	0.263 (0.859)	0.166 (0.863)	0.429 (0.860)	-0.103 (0.850)	-0.065 (0.859)	-0.167 (0.853)	-2.006 (0.100)	-0.859 (0.142)	-2.865 (0.108)
Northeast	-6.732 (0.001)	-4.241 (0.001)	-10.972 (< 0.001)	-6.793 (< 0.001)	-4.274 (< 0.001)	-11.067 (< 0.001)	-2.676 (0.078)	-1.145 (0.089)	-3.820 (0.075)
Central	-14.693 (< 0.001)	-9.257 (< 0.001)	-23.951 (< 0.001)	-14.811 (< 0.001)	-9.319 (< 0.001)	-24.130 (< 0.001)	-9.846 (< 0.001)	-4.214 (< 0.001)	-14.060 (< 0.001)
North	-8.500 (0.001)	-5.355 (0.002)	-13.856 (0.001)	-7.831 (0.001)	-4.927 (0.001)	-12.758 (0.000)	-2.641 (0.237)	-1.131 (0.261)	-3.772 (0.237)
Population (x 1,000, log)	1.985 (0.005)	1.251 (0.016)	3.236 (0.006)	1.668 (0.039)	1.050 (0.058)	2.718 (0.042)	-0.278 (0.734)	-0.119 (0.738)	-0.396 (0.734)
GDP per capita (x 1,000 BRL)	0.102 (0.106)	0.064 (0.115)	0.166 (0.106)	0.101 (0.144)	0.064 (0.150)	0.165 (0.142)	0.112 (0.152)	0.048 (0.188)	0.160 (0.156)
Gini index (%)	-0.648 (< 0.001)	-0.408 (0.002)	-1.056 (0.000)	-0.600 (0.000)	-0.378 (0.000)	-0.978 (0.000)	-0.562 (< 0.001)	-0.241 (< 0.001)	-0.803 (< 0.001)
Urbanization rate (%)	0.158 (0.002)	0.099 (0.009)	0.257 (0.002)	0.074 (0.363)	0.046 (0.382)	0.120 (0.368)	0.037 (0.421)	0.016 (0.457)	0.052 (0.429)
FHS coverage (%)				0.049 (0.120)	0.031 (0.126)	0.080 (0.117)	-0.004 (0.805)	-0.002 (0.815)	-0.006 (0.807)
Radiologists ratio per 100,000 inhabitants				0.870 (0.001)	0.548 (0.011)	1.418 (0.002)	0.919 (< 0.001)	0.393 (0.001)	1.312 (< 0.001)
Mammography machines ratio per 10,000 inhabitants				2.451 (< 0.001)	1.542 (0.001)	3.993 (< 0.001)	3.715 (< 0.001)	1.590 (< 0.001)	5.305 (< 0.001)
Mammograms per mammography machine (x 100)							0.948 (< 0.001)	0.406 (< 0.001)	1.353 (< 0.001)
Model diagnostics
AIC	3302.700			3278.900			3140.200
Breusch-Pagan test heterocedasticity	0.106			0.167			0.290
Test for residual autocorrelation	0.396			0.460			0.072

Regions/Variables	Step 1			Step 2			Step 3
	Impacts (p-value)			Impacts (p-value)			Impacts (p-value)
	Direct	Indirect	Total	Direct	Indirect	Total	Direct	Indirect	Total
Souheast
Population (x 1,000, log)	0.848 (0.395)	0.450 (0.408)	1.298 (0.394)	0.878 (0.562)	0.444 (0.569)	1.323 (0.561)	-1.566 (0.114)	-0.489 (0.154)	-2.055 (0.115)
GDP per capita (x 1,000 BRL)	0.146 (0.229)	0.077 (0.296)	0.224 (0.247)	0.153 (0.137)	0.077 (0.191)	0.231 (0.147)	0.144 (0.129)	0.045 (0.162)	0.189 (0.127)
Gini index (%)	-1.416 (< 0.001)	-0.751 (< 0.001)	-2.168 (< 0.001)	-1.373 (< 0.001)	-0.695 (0.001)	-2.067 (< 0.001)	-0.914 (< 0.001)	-0.285 (0.003)	-1.199 (< 0.001)
Urbanization rate (%)	-0.052 (0.230)	0.071 (0.250)	0.205 (0.230)	0.030 (0.614)	0.015 (0.675)	0.045 (0.632)	0.030 (0.919)	0.009 (0.924)	0.039 (0.919)
FHS coverage (%)				0.008 (0.906)	0.004 (0.900)	0.013 (0.903)	-0.061 (0.048)	-0.019 (0.083)	-0.080 (0.050)
Radiologists ratio per 100,000 inhabitants				0.598 (0.063)	0.303 (0.089)	0.901 (0.064)	0.692 (0.014)	0.216 (0.049)	0.908 (0.015)
Mammography machines ratio per 10,000 inhabitants				2.300 (0.008)	1.432 (0.031)	4.262 (0.011)	5.510 (< 0.001)	1.719 (0.001)	7.229 (< 0.001)
Mammograms per mammography machine (x 100)							0.965 (< 0.001)	0.301 (0.001)	1.266 (< 0.001)
South
Population (x 1,000, log)	9.210 (0.000)	4.885 (0.011)	14.095 (0.000)	7.710 (0.004)	3.902 (0.027)	11.613 (0.006)	5.946 (< 0.001)	1.856 (0.012)	7.802 (< 0.001)
GDP per capita (x 1,000 BRL)	-0.018 (0.975)	-0.010 (0.966)	-0.027 (0.972)	0.025 (0.991)	0.013 (1.000)	0.038 (0.994)	0.101 (0.698)	0.031 (0.726)	0.132 (0.703)
Gini index (%)	-1.275 (0.000)	-0.676 (0.006)	-1.951 (0.000)	-0.872 (0.011)	-0.441 (0.028)	-1.313 (0.012)	-0.899 (0.002)	-0.280 (0.008)	-1.179 (0.001)
Urbanization rate (%)	-0.223 (0.158)	-0.118 (0.216)	-0.341 (0.169)	-0.058 (0.737)	-0.029 (0.734)	-0.088 (0.734)	-0.114 (0.417)	-0.035 (0.442)	-0.149 (0.418)
FHS coverage (%)				0.203 (0.002)	0.103 (0.012)	0.306 (0.002)	0.072 (0.167)	0.022 (0.220)	0.094 (0.173)
Radiologists ratio per 100,000 inhabitants				1.259 (0.072)	0.637 (0.117)	1.896 (0.080)	1.127 (0.037)	0.352 (0.101)	1.478 (0.043)
Mammography machines ratio per 10,000 inhabitants				3.871 (0.071)	1.959 (0.115)	5.830 (0.078)	13.215 (< 0.001)	4.124 (0.001)	17.339 (< 0.001)
Mammograms per mammography machine (x 100)							1.311 (< 0.001)	0.409 (0.002)	1.720 (< 0.001)
Northeast
Population (x 1,000, log)	3.572 (0.012)	1.895 (0.027)	5.467 (0.013)	2.744 (0.049)	1.389 (0.059)	4.133 (0.047)	0.332 (0.741)	0.104 (0.740)	0.436 (0.739)
GDP per capita (x 1,000 BRL)	0.345 (0.156)	0.183 (0.207)	0.528 (0.167)	0.265 (0.272)	0.134 (0.301)	0.097 (0.276)	0.032 (0.956)	0.010 (0.958)	0.042 (0.956)
Gini index (%)	0.154 (0.557)	0.082 (0.599)	0.236 (0.569)	0.106 (0.586)	0.054 (0.604)	0.160 (0.588)	0.079 (0.885)	0.025 (0.891)	0.103 (0.886)
Urbanization rate (%)	0.096 (0.299)	0.051 (0.307)	0.148 (0.295)	0.020 (0.762)	0.010 (0.776)	0.030 (0.765)	0.094 (0.347)	0.029 (0.379)	0.123 (0.350)
FHS coverage (%)				-0.078 (0.570)	-0.040 (0.555)	-0.118 (0.562)	-0.069 (0.476)	-0.022 (0.489)	-0.091 (0.476)
Radiologists ratio per 100,000 inhabitants				0.514 (0.490)	0.260 (0.519)	0.774 (0.496)	0.757 (0.191)	0.236 (0.228)	0.994 (0.193)
Mammography machines ratio per 10,000 inhabitants				1.547 (0.192)	0.783 (0.202)	2.330 (0.188)	0.951 (0.336)	0.297 (0.382)	1.248 (0.340)
Mammograms per mammography machine (x 100)							1.036 (0.000)	0.323 (0.001)	1.360 (0.000)
Central
Population (x 1,000, log)	4.946 (0.049)	2.623 (0.103)	7.569 (0.059)	1.574 (0.644)	0.797 (0.676)	2.371 (0.652)	0.575 (0.712)	0.180 (0.726)	0.755 (0.714)
GDP per capita (x 1,000 BRL)	-0.008 (0.852)	-0.004 (0.877)	-0.012 (0.859)	-0.218 (0.284)	-0.110 (0.314)	-0.328 (0.288)	-0.277 (0.231)	-0.087 (0.265)	-0.364 (0.233)
Gini index (%)	-0.036 (0.895)	-0.019 (0.884)	-0.056 (0.891)	-0.110 (0.852)	-0.056 (0.855)	-0.166 (0.852)	-0.123 (0.647)	-0.038 (0.661)	-0.161 (0.648)
Urbanization rate (%)	-0.052 (0.883)	-0.028 (0.876)	-0.079 (0.880)	0.024 (0.869)	0.012 (0.865)	0.035 (0.867)	-0.122 (0.536)	-0.038 (0.541)	-0.160 (0.534)
FHS coverage (%)				0.107 (0.425)	0.054 (0.441)	0.161 (0.427)	0.050 (0.690)	0.015 (0.672)	0.062 (0.683)
Radiologists ratio per 100,000 inhabitants				2.767 (0.003)	1.400 (0.020)	4.167 (0.004)	2.293 (0.018)	0.716 (0.074)	3.008 (0.024)
Mammography machines ratio per 10,000 inhabitants				0.624 (0.810)	0.316 (0.797)	0.940 (0.805)	0.968 (0.434)	0.302 (0.434)	1.270 (0.430)
Mammograms per mammography machine (x 100)							1.848 (0.009)	0.577 (0.033)	2.425 (0.009)
North
Population (x 1,000, log)	1.912 (0.394)	1.014 (0.413)	2.926 (0.396)	1.122 (0.584)	0.568 (0.635)	1.690 (0.599)	-0.320 (0.803)	-0.100 (0.808)	-0.420 (0.803)
GDP per capita (x 1,000 BRL)	0.153 (0.629)	0.081 (0.654)	0.234 (0.635)	0.065 (0.791)	0.033 (0.785)	0.097 (0.788)	0.052 (0.883)	0.016 (0.900)	0.068 (0.886)
Gini index (%)	-0.063 (0.942)	-0.034 (0.982)	-0.097 (0.956)	0.012 (0.997)	0.006 (0.966)	0.018 (0.987)	-0.124 (0.810)	-0.039 (0.835)	-0.162 (0.815)
Urbanization rate (%)	0.246 (0.075)	0.130 (0.108)	0.376 (0.080)	0.152 (0.383)	0.077 (0.411)	0.230 (0.390)	0.036 (0.742)	0.011 (0.756)	0.047 (0.743)
FHS coverage (%)				-0.021 (0.938)	-0.011 (0.903)	-0.032 (0.925)	-0.069 (0.474)	-0.021 (0.526)	-0.090 (0.482)
Radiologists ratio per 100,000 inhabitants				0.777 (0.641)	0.393 (0.648)	1.170 (0.641)	0.672 (0.671)	0.210 (0.665)	0.881 (0.667)
Mammography machines ratio per 10,000 inhabitants				1.663 (0.135)	0.842 (0.171)	2.505 (0.140)	2.089 (0.037)	0.652 (0.091)	2.741 (0.040)
Mammograms per mammography machine (x 100)							1.148 (0.014)	0.358 (0.041)	1.507 (0.014)

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[1] Correspondence M. C. Nogueira Faculdade de Medicina, Universidade Federal de Juiz de Fora. Rua Alberto Vieira Lima 357, Juiz de Fora, MG 36050-070, Brasil. mario.cirio.nogueira@gmail.com