Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults
Expanding delivery of primary healthcare to urban poor populations is a priority in many low- and middle-income countries. This remains a key challenge in Brazil despite expansion of the country's internationally recognized Family Health Strategy (FHS) over the past two decades. This study eval...
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| creator | Hone, Thomas Saraceni, Valeria Medina Coeli, Claudia Trajman, Anete Rasella, Davide Millett, Christopher Durovni, Betina |
| description | Expanding delivery of primary healthcare to urban poor populations is a priority in many low- and middle-income countries. This remains a key challenge in Brazil despite expansion of the country's internationally recognized Family Health Strategy (FHS) over the past two decades. This study evaluates the impact of an ambitious program to rapidly expand FHS coverage in the city of Rio de Janeiro, Brazil, since 2008.
A cohort of 1,241,351 low-income adults (observed January 2010-December 2016; total person-years 6,498,607) with linked FHS utilization and mortality records was analyzed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and nonusers. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA). The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education, whereas 102,899 (8%) had no formal education. Two thirds of individuals (827,250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analyzed, of which 8,765 (26%) were due to cardiovascular disease; 5,777 (17%) were due to neoplasms; 5,683 (17%) were due to external causes; 3,152 (9%) were due to respiratory diseases; and 3,115 (9%) were due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54-0.59, p < 0.001) and a 5-year risk reduction of 8.3 per 1,000 (95% CI 7.8-8.9, p < 0.001) compared with a non-FHS user. There were greater reductions in the risk of death for FHS users who were black (HR 0.50, 95% CI 0.46-0.54, p < 0.001) or pardo (HR 0.57, 95% CI 0.54-0.60, p < 0.001) compared with white (HR 0.59, 95% CI 0.56-0.63, p < 0.001); had lower educational attainment (HR 0.50, 95% CI 0.46-0.55, p < 0.001) for those with no education compared to no significant association for those with higher education (p = 0.758); or were in receipt of conditional cash transfers (Bolsa Família) (HR 0.51, 95% CI 0.49-0.54, p < 0.001) compared with nonrecipients (HR 0.63, 95% CI 0.60-0.67, p < 0.001). Key limitations in this study are potential unobserved confounding through selection into the program and linkage errors, although analytical approaches have minimized the potential for bias.
FHS utilization in urban poor p |
| doi_str_mv | 10.1371/journal.pmed.1003357 |
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A cohort of 1,241,351 low-income adults (observed January 2010-December 2016; total person-years 6,498,607) with linked FHS utilization and mortality records was analyzed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and nonusers. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA). The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education, whereas 102,899 (8%) had no formal education. Two thirds of individuals (827,250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analyzed, of which 8,765 (26%) were due to cardiovascular disease; 5,777 (17%) were due to neoplasms; 5,683 (17%) were due to external causes; 3,152 (9%) were due to respiratory diseases; and 3,115 (9%) were due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54-0.59, p < 0.001) and a 5-year risk reduction of 8.3 per 1,000 (95% CI 7.8-8.9, p < 0.001) compared with a non-FHS user. There were greater reductions in the risk of death for FHS users who were black (HR 0.50, 95% CI 0.46-0.54, p < 0.001) or pardo (HR 0.57, 95% CI 0.54-0.60, p < 0.001) compared with white (HR 0.59, 95% CI 0.56-0.63, p < 0.001); had lower educational attainment (HR 0.50, 95% CI 0.46-0.55, p < 0.001) for those with no education compared to no significant association for those with higher education (p = 0.758); or were in receipt of conditional cash transfers (Bolsa Família) (HR 0.51, 95% CI 0.49-0.54, p < 0.001) compared with nonrecipients (HR 0.63, 95% CI 0.60-0.67, p < 0.001). Key limitations in this study are potential unobserved confounding through selection into the program and linkage errors, although analytical approaches have minimized the potential for bias.
FHS utilization in urban poor populations in Brazil was associated with a lower risk of death, with greater reductions among more deprived race/ethnic and socioeconomic groups. Increased investment in primary healthcare is likely to improve health and reduce health inequalities in urban poor populations globally.]]></description><identifier>ISSN: 1549-1676</identifier><identifier>ISSN: 1549-1277</identifier><identifier>EISSN: 1549-1676</identifier><identifier>DOI: 10.1371/journal.pmed.1003357</identifier><identifier>PMID: 33125387</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Adult ; Biology and Life Sciences ; Brazil - epidemiology ; Cardiovascular diseases ; Cities ; Cohort analysis ; Cohort Studies ; Datasets ; Delivery of Health Care - methods ; Delivery of Health Care - trends ; Distribution ; Electronic medical records ; Evaluation ; Family Health ; Female ; Health aspects ; Health care rationing ; Health disparities ; Health Services ; Humans ; Infant mortality ; Life span ; Low income groups ; Male ; Management ; Medicine and Health Sciences ; People and places ; Physical Sciences ; Population ; Population studies ; Poverty ; Primary care ; Primary health care ; Primary Health Care - statistics & numerical data ; Primary Health Care - trends ; Research and Analysis Methods ; Risk factors ; Socioeconomic Factors ; Survival analysis ; Urban poor ; Urban Population ; Urban populations ; Vulnerable Populations</subject><ispartof>PLoS medicine, 2020-10, Vol.17 (10), p.e1003357-e1003357</ispartof><rights>COPYRIGHT 2020 Public Library of Science</rights><rights>2020 Hone et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2020 Hone et al 2020 Hone et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c764t-209726511c6320058aee8549033415846cda3a0356719cd3924bb6f3342a75693</citedby><cites>FETCH-LOGICAL-c764t-209726511c6320058aee8549033415846cda3a0356719cd3924bb6f3342a75693</cites><orcidid>0000-0001-7360-6490 ; 0000-0002-4000-4984 ; 0000-0003-0703-6973 ; 0000-0003-1757-3940 ; 0000-0002-7260-4386 ; 0000-0002-0793-9884</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598481/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598481/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,864,885,2100,2919,23857,27915,27916,53782,53784,79361,79362</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/33125387$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><contributor>Macinko, James</contributor><creatorcontrib>Hone, Thomas</creatorcontrib><creatorcontrib>Saraceni, Valeria</creatorcontrib><creatorcontrib>Medina Coeli, Claudia</creatorcontrib><creatorcontrib>Trajman, Anete</creatorcontrib><creatorcontrib>Rasella, Davide</creatorcontrib><creatorcontrib>Millett, Christopher</creatorcontrib><creatorcontrib>Durovni, Betina</creatorcontrib><title>Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults</title><title>PLoS medicine</title><addtitle>PLoS Med</addtitle><description><![CDATA[Expanding delivery of primary healthcare to urban poor populations is a priority in many low- and middle-income countries. This remains a key challenge in Brazil despite expansion of the country's internationally recognized Family Health Strategy (FHS) over the past two decades. This study evaluates the impact of an ambitious program to rapidly expand FHS coverage in the city of Rio de Janeiro, Brazil, since 2008.
A cohort of 1,241,351 low-income adults (observed January 2010-December 2016; total person-years 6,498,607) with linked FHS utilization and mortality records was analyzed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and nonusers. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA). The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education, whereas 102,899 (8%) had no formal education. Two thirds of individuals (827,250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analyzed, of which 8,765 (26%) were due to cardiovascular disease; 5,777 (17%) were due to neoplasms; 5,683 (17%) were due to external causes; 3,152 (9%) were due to respiratory diseases; and 3,115 (9%) were due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54-0.59, p < 0.001) and a 5-year risk reduction of 8.3 per 1,000 (95% CI 7.8-8.9, p < 0.001) compared with a non-FHS user. There were greater reductions in the risk of death for FHS users who were black (HR 0.50, 95% CI 0.46-0.54, p < 0.001) or pardo (HR 0.57, 95% CI 0.54-0.60, p < 0.001) compared with white (HR 0.59, 95% CI 0.56-0.63, p < 0.001); had lower educational attainment (HR 0.50, 95% CI 0.46-0.55, p < 0.001) for those with no education compared to no significant association for those with higher education (p = 0.758); or were in receipt of conditional cash transfers (Bolsa Família) (HR 0.51, 95% CI 0.49-0.54, p < 0.001) compared with nonrecipients (HR 0.63, 95% CI 0.60-0.67, p < 0.001). Key limitations in this study are potential unobserved confounding through selection into the program and linkage errors, although analytical approaches have minimized the potential for bias.
FHS utilization in urban poor populations in Brazil was associated with a lower risk of death, with greater reductions among more deprived race/ethnic and socioeconomic groups. Increased investment in primary healthcare is likely to improve health and reduce health inequalities in urban poor populations globally.]]></description><subject>Adult</subject><subject>Biology and Life Sciences</subject><subject>Brazil - epidemiology</subject><subject>Cardiovascular diseases</subject><subject>Cities</subject><subject>Cohort analysis</subject><subject>Cohort Studies</subject><subject>Datasets</subject><subject>Delivery of Health Care - methods</subject><subject>Delivery of Health Care - trends</subject><subject>Distribution</subject><subject>Electronic medical records</subject><subject>Evaluation</subject><subject>Family Health</subject><subject>Female</subject><subject>Health aspects</subject><subject>Health care rationing</subject><subject>Health disparities</subject><subject>Health Services</subject><subject>Humans</subject><subject>Infant mortality</subject><subject>Life span</subject><subject>Low income groups</subject><subject>Male</subject><subject>Management</subject><subject>Medicine and Health Sciences</subject><subject>People and places</subject><subject>Physical Sciences</subject><subject>Population</subject><subject>Population studies</subject><subject>Poverty</subject><subject>Primary care</subject><subject>Primary health care</subject><subject>Primary Health Care - 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epidemiology</topic><topic>Cardiovascular diseases</topic><topic>Cities</topic><topic>Cohort analysis</topic><topic>Cohort Studies</topic><topic>Datasets</topic><topic>Delivery of Health Care - methods</topic><topic>Delivery of Health Care - trends</topic><topic>Distribution</topic><topic>Electronic medical records</topic><topic>Evaluation</topic><topic>Family Health</topic><topic>Female</topic><topic>Health aspects</topic><topic>Health care rationing</topic><topic>Health disparities</topic><topic>Health Services</topic><topic>Humans</topic><topic>Infant mortality</topic><topic>Life span</topic><topic>Low income groups</topic><topic>Male</topic><topic>Management</topic><topic>Medicine and Health Sciences</topic><topic>People and places</topic><topic>Physical Sciences</topic><topic>Population</topic><topic>Population studies</topic><topic>Poverty</topic><topic>Primary care</topic><topic>Primary health care</topic><topic>Primary Health Care - statistics & numerical data</topic><topic>Primary Health Care - trends</topic><topic>Research and Analysis Methods</topic><topic>Risk factors</topic><topic>Socioeconomic Factors</topic><topic>Survival analysis</topic><topic>Urban poor</topic><topic>Urban Population</topic><topic>Urban populations</topic><topic>Vulnerable Populations</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Hone, Thomas</creatorcontrib><creatorcontrib>Saraceni, Valeria</creatorcontrib><creatorcontrib>Medina Coeli, Claudia</creatorcontrib><creatorcontrib>Trajman, Anete</creatorcontrib><creatorcontrib>Rasella, Davide</creatorcontrib><creatorcontrib>Millett, Christopher</creatorcontrib><creatorcontrib>Durovni, Betina</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Gale In Context: Opposing Viewpoints</collection><collection>Gale In Context: Canada</collection><collection>Gale In Context: Science</collection><collection>ProQuest Central (Corporate)</collection><collection>Neurosciences Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Publicly Available Content Database</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><collection>PLoS Medicine</collection><jtitle>PLoS medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Hone, Thomas</au><au>Saraceni, Valeria</au><au>Medina Coeli, Claudia</au><au>Trajman, Anete</au><au>Rasella, Davide</au><au>Millett, Christopher</au><au>Durovni, Betina</au><au>Macinko, James</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults</atitle><jtitle>PLoS medicine</jtitle><addtitle>PLoS Med</addtitle><date>2020-10-30</date><risdate>2020</risdate><volume>17</volume><issue>10</issue><spage>e1003357</spage><epage>e1003357</epage><pages>e1003357-e1003357</pages><issn>1549-1676</issn><issn>1549-1277</issn><eissn>1549-1676</eissn><abstract><![CDATA[Expanding delivery of primary healthcare to urban poor populations is a priority in many low- and middle-income countries. This remains a key challenge in Brazil despite expansion of the country's internationally recognized Family Health Strategy (FHS) over the past two decades. This study evaluates the impact of an ambitious program to rapidly expand FHS coverage in the city of Rio de Janeiro, Brazil, since 2008.
A cohort of 1,241,351 low-income adults (observed January 2010-December 2016; total person-years 6,498,607) with linked FHS utilization and mortality records was analyzed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and nonusers. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA). The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education, whereas 102,899 (8%) had no formal education. Two thirds of individuals (827,250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analyzed, of which 8,765 (26%) were due to cardiovascular disease; 5,777 (17%) were due to neoplasms; 5,683 (17%) were due to external causes; 3,152 (9%) were due to respiratory diseases; and 3,115 (9%) were due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54-0.59, p < 0.001) and a 5-year risk reduction of 8.3 per 1,000 (95% CI 7.8-8.9, p < 0.001) compared with a non-FHS user. There were greater reductions in the risk of death for FHS users who were black (HR 0.50, 95% CI 0.46-0.54, p < 0.001) or pardo (HR 0.57, 95% CI 0.54-0.60, p < 0.001) compared with white (HR 0.59, 95% CI 0.56-0.63, p < 0.001); had lower educational attainment (HR 0.50, 95% CI 0.46-0.55, p < 0.001) for those with no education compared to no significant association for those with higher education (p = 0.758); or were in receipt of conditional cash transfers (Bolsa Família) (HR 0.51, 95% CI 0.49-0.54, p < 0.001) compared with nonrecipients (HR 0.63, 95% CI 0.60-0.67, p < 0.001). Key limitations in this study are potential unobserved confounding through selection into the program and linkage errors, although analytical approaches have minimized the potential for bias.
FHS utilization in urban poor populations in Brazil was associated with a lower risk of death, with greater reductions among more deprived race/ethnic and socioeconomic groups. Increased investment in primary healthcare is likely to improve health and reduce health inequalities in urban poor populations globally.]]></abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>33125387</pmid><doi>10.1371/journal.pmed.1003357</doi><orcidid>https://orcid.org/0000-0001-7360-6490</orcidid><orcidid>https://orcid.org/0000-0002-4000-4984</orcidid><orcidid>https://orcid.org/0000-0003-0703-6973</orcidid><orcidid>https://orcid.org/0000-0003-1757-3940</orcidid><orcidid>https://orcid.org/0000-0002-7260-4386</orcidid><orcidid>https://orcid.org/0000-0002-0793-9884</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1549-1676 |
| ispartof | PLoS medicine, 2020-10, Vol.17 (10), p.e1003357-e1003357 |
| issn | 1549-1676 1549-1277 1549-1676 |
| language | eng |
| recordid | cdi_plos_journals_2479468588 |
| source | MEDLINE; DOAJ Directory of Open Access Journals; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; Public Library of Science (PLoS); PubMed Central |
| subjects | Adult Biology and Life Sciences Brazil - epidemiology Cardiovascular diseases Cities Cohort analysis Cohort Studies Datasets Delivery of Health Care - methods Delivery of Health Care - trends Distribution Electronic medical records Evaluation Family Health Female Health aspects Health care rationing Health disparities Health Services Humans Infant mortality Life span Low income groups Male Management Medicine and Health Sciences People and places Physical Sciences Population Population studies Poverty Primary care Primary health care Primary Health Care - statistics & numerical data Primary Health Care - trends Research and Analysis Methods Risk factors Socioeconomic Factors Survival analysis Urban poor Urban Population Urban populations Vulnerable Populations |
| title | Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-15T04%3A37%3A50IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_plos_&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Primary%20healthcare%20expansion%20and%20mortality%20in%20Brazil's%20urban%20poor:%20A%20cohort%20analysis%20of%201.2%20million%20adults&rft.jtitle=PLoS%20medicine&rft.au=Hone,%20Thomas&rft.date=2020-10-30&rft.volume=17&rft.issue=10&rft.spage=e1003357&rft.epage=e1003357&rft.pages=e1003357-e1003357&rft.issn=1549-1676&rft.eissn=1549-1676&rft_id=info:doi/10.1371/journal.pmed.1003357&rft_dat=%3Cgale_plos_%3EA642236044%3C/gale_plos_%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2479468588&rft_id=info:pmid/33125387&rft_galeid=A642236044&rft_doaj_id=oai_doaj_org_article_fa8e15f3721b449cb65951c8b1d6b9c4&rfr_iscdi=true |