WITH CRONIC MORBIDITY - THE EFFECT OF INCOME: A COMPARATIVE STUDY OF CERTAIN CAUSES OF MORBIDITY IN BRAZIL AND THE US Kaizô Iwakami Beltrão † Sonoe Sugahara ‡ † EBAPE/FGV, kaizo.beltrao@fgv.br ‡ ENCE/IBGE, sonoe.pinheiro@ibge.gov.br
ABSTRACT This study analyzes the prevalence of certain causes of chronic diseases morbidity conditions in Brazil and the US. Most conditions are highly correlated with socio-economic strata. Socio-economic strata boundaries, however, are quite difficult to define and different authors would have different definitions of what these strata boundaries are. Among the several options available we opted in this text to use per capita family income as a proxy for social strata. Given this, most information displayed here is also disaggregated by per capita family income (five strata). A comparison of similar statistics on self-reported morbidity in Brazil and the US are computed and analyzed. For reported morbidity, Brazilian data were drawn from PNS 2013. US information on the subject was drawn from NHIS 2012/13/14. In both surveys morbidity conditions are self-reported. To take into account age/sex distribution that can heavily influence such rates, standardization procedures were undertaken using the Brazilian and the American population. The relative position of the regions and of the social strata changed in some instances after the standardization. Age/sex specific rates were also analyzed, broken down as well by the five income brackets. Though the general shape of the curves corresponding to Brazil and the States are similar, they are not quite the same, varying in concavity and inflection points and, sometimes, even in the direction of the trend for some segments. ii
SUMMARY ABSTRACT ........................................................................................................................... ii I - Introduction ........................................................................................................................ 1 II - Concepts ........................................................................................................................... 2 III - Self-reported Brazilian prevalence of selected morbidity conditions by age/sex/income - Comparison to similar statistics in the US ........................................................................... 6 III.1 – Arthritis/Rheumatism ............................................................................................... 6 III.2 – Diabetes .................................................................................................................. 13 III.3 – Bronchitis/Asthma .................................................................................................. 20 III.4 – Hypertension .......................................................................................................... 26 III.5 - Heart Condition ....................................................................................................... 33 III. 6 - Stroke ..................................................................................................................... 40 III. 7 - COPD ..................................................................................................................... 47 II – Final Comments ............................................................................................................. 54 BIBLIOGRAPHY ............................................................................................................... 54 ANNEX A – MAIN CHARACTERISTICS OF THE SURVEYS ................................. 57 A.1 Main characteristics of PNS ....................................................................................... 57 A.2 Main characteristics of NHIS ..................................................................................... 57 ANNEX B – POPULATION DISTRIBUTION – BRAZIL ............................................ 59 ANNEX C – POPULATION DISTRIBUTION – USA ................................................... 63 ANNEX D – GRAPHS OF CRUDE AND STANDARDIZED RATES BRAZIL & THE US .......................................................................................... Erro! Indicador não definido. D 1 – Arthritis/Rheumatism ............................................ Erro! Indicador não definido. D 2 – Diabetes ................................................................. Erro! Indicador não definido. D 3 – Bronchitis/Asthma ................................................ Erro! Indicador não definido. D 4 – Hypertension ......................................................... Erro! Indicador não definido. D 5 - Heart Condition ..................................................... Erro! Indicador não definido. D 6 - Stroke ..................................................................... Erro! Indicador não definido. D 7 - COPD ..................................................................... Erro! Indicador não definido. iii
I - Introduction Although infectious diseases are important death causes, there is a significant growth of non-communicable chronic diseases: cardio-vascular, bronchitis/asthma, diabetes, cancer, mental problems, Chronic Obstructive Pulmonary Disease (COPD) etc. There is a vast literature showing health and death inequalities among social classes. For example, the Registrar General of England and Wales has been collecting data on occupational mortality related to every decennial census since 1851 (Coggon et al., 2009). They show that the social gap has been widening. The first documented study on mortality differentials seems to be due to Stevenson (1928). Other countries followed suit: Australia (AIHW 2005), Germany (GEYER and PETER. 1999), Finland (MARTIKAINEN, 1995), Korea (Lee et al., 2016). Mortality differentials are also due to differences in lifestyle such as smoking and obesity, between the socio-economic groups. Those in lower socio-economic groups are in disadvantage: smoke more and more often, follow a poorer diet with less fruits and greens, consume more alcohol, exercise less often and are more often overweight. This study analyzes the prevalence of certain causes of morbidity conditions in Brazil and the US. As seen in the literature, most conditions are highly correlated with socio-economic strata. Socio-economic strata boundaries, however, are quite difficult to define and different authors would have different definitions of what these strata boundaries are. Among the several options available, we opted in this text to use per capita family income as a proxy for social strata. Wilkinson and Pickett (2007) claim that relative deprivation is a core mechanism for why income inequality affects health in societies. Given this, most information displayed here is also disaggregated into five per capita family income brackets of equal size. Similar income brackets are used for the US. A comparison of statistics on self-reported morbidity in Brazil and the US are computed and analyzed. In the second chapter, we define the rates used in the comparisons and in the graphs analyzed in the study. In the third chapter, we tabulate and comment self-reported Brazilian prevalence of seven selected morbidity conditions by age/sex/income, namely: Arthritis/Rheumatism, Diabetes, Bronchitis/Asthma, Stroke, Hypertension, Heart condition 1
and COPD. A comparison to similar US statistics is also shown. Prevalence is reported on a crude and age-specific basis, as well as standardized both by Brazilian and by the US population distribution. Crude specific and standardized rates are present in tables in the main text and their corresponding graphs in Annex D. Data used for health conditions in the US are from the 2012, 2113 and 2014 NHIS - National Health Interview Survey. NHIS is a sample household survey conducted annually by the US Department of Health and Human Services. Corresponding data for Brazil are from PNS 2013. PNS is also a sample household survey and was conducted by IBGE (see Annex A for a brief description of these surveys). The authors made all tabulations using SPSS (Statistical Package for Social Sciences). Five-year age groups were used with an 80- year-and-over open-ended age interval. Both surveys consider morbidity solely for adults interviewees. As a proxy for socio-economic strata we used per capita family income. Income from all sources was used, there included: salary, pension benefits, rents, revenues from investments, etc. Since Brazilian income distribution is so biased and in a completely different level from that of the US, we decided to use quintiles as the grouping factor. Graphs with age/sex distribution of the Brazilian population disaggregated by per capita family income in the above-mentioned brackets are available in Annex B. We are supposing that poverty is a relative concept. Graphs with the age/sex distribution of the US population disaggregated into quintiles of per capita family income are in Annex C. II - Concepts Prevalence rates were computed as the ratio of persons of a given age group, sex and per capita family income bracket having declared to be suffering a specific morbidity condition and all persons in this same group: pop ( a , s , r , m ) i) ( , , , ) for age/sex/income specific morbidity rate; P a s r m ( , , ) pop a s r ( , , , ) pop a s r m a ii) ( , , , ) for crude morbidity rate by sex and income bracket; P s r m ( , , ) pop a s r a 2
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