1 Student of the Doctoral I nter-units Program , Professor at the Medical School of São José do Rio Preto, Brazil, e-m ail: m lsperli@gm ail.com ; 2 PhD in Nursing in Public Health, Professor of the Medical School of São José do Rio Preto, Brazil, e-m ail: silviave@eerp.usp.br, claudiagazetta@yahoo.com .br; 3 Master Student in Nursing in Public Health, Professor of Medical School at São José do Rio Preto, Brazil, e-m ail: soniaoliveira@fam erp.br; 4 Associate Professor, e-m ail: tite@eerp.usp.br. University of São Paulo at Ribeirão Preto, College of Nursing, WHO Collaborating Center for Nursing Research Developm ent, Brazil
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae
POVERTY: SOCI OECONOMI C CHARACTERI ZATI ON AT TUBERCULOSI S
Mar ia de Lour des Sper li Ger aldes Sant os1 Silv ia Helena Figueir edo Vendr am ini2 Claudia Eli Gazet t a2 Sonia Apar ecida Cr uz Oliv eir a3 Ter eza Cr ist ina Scat ena Villa4
Sant os MLSG, Vendram ini SHF, Gazet t a CE, Oliveira SAC, Villa TCS. Povert y: socioeconom ic charact erizat ion at t uberculosis. Rev Lat ino- am Enferm agem 2007 set em bro- out ubro; 15( núm ero especial) : 762- 7.
This st udy aim ed t o evaluat e t he epidem iological st at us of Tuberculosis regarding t o t he socioeconom ic characteristics of São José do Rio Preto between 1998 and 2004. I ndexes estim ated for 432 urban census tracts from the dem ographic census of 2000, sorted system atically according to the values of socioeconom ic factors and grouped into quartiles were taken into account. The socioeconom ic characterization was outlined based on Schooling, I ncom e, and Num ber of Residents. The incidence rates were considered for 1998, 1999, 2003, and 2004. The socioeconom ic factor accounted for 87% of the total variation. The disease prevalence is higher in the poorest areas. The incidence rate and the risk of being infected by TB in the poorest areas declined in 2003 and 2004. The results confirm that TB is determ ined by the population’s living conditions in the city studied. I t strengthens the relevance of understanding the TB conditional social factors to transform the worrisom e scenario in which this population is inserted.
DESCRI PTORS: pov er t y ; t uber culosis; social condit ions
POBREZA: CARACTERI ZACI ÓN SOCI OECONÓMI CA DE LA TUBERCULOSI S
El obj et iv o fue analizar la sit uación epidem iológica de la Tuber culosis en r elación a las car act er íst icas socioeconóm icas de São José do Rio Preto entre 1998 e 2004. Fueron considerados indicadores estim ados para 432 sectores censales del área urbana, año censal 2000, ordenados según valores del factor socioeconóm ico, agrupados en quartiles. Caracterización socioeconóm ica delineada por la Escolaridad, Renta y Núm ero de personas. Coeficientes de incidencia fueron calculados para 1998, 1999, 2003 y 2004. El factor socioeconóm ico fue responsable por el 87% de la variación total. La enferm edad incide con m ás fuerza en las áreas m ás pobres. En 2003 y 2004, dism inuyó la incidencia y el riesgo de enferm ar por Tuberculosis en las áreas m ás pobres. Resultados confirm an la determ inación de la Tuberculosis, en el m unicipio, por las condiciones de vida de la población, fort aleciendo la im port ancia de la com prensión de los condicionantes sociales de la TB para transform ar el escenario preocupante en que está insertada.
DESCRI PTORES: pobr eza; t u ber cu losis; con dicion es sociales
POBREZA: CARACTERI ZAÇÃO SOCI OECONÔMI CA DA TUBERCULOSE
O obj et iv o f oi an alisar a sit u ação epidem iológica da t u ber cu lose ( TB) em r elação às car act er íst icas socioeconôm icas de São José do Rio Pret o, SP, ent re 1998 e 2004. Considerou- se indicadores est im ados para 432 set ores censit ários da área urbana, ano censit ário 2000, ordenados segundo valores do fat or socioeconôm ico e agrupados em quartis. A caracterização socioeconôm ica foi delineada com base em escolaridade, renda e núm ero de m oradores. Os coeficientes de incidência foram calculados para 1998, 1999, 2003 e 2004. O fator socioeconôm ico foi responsável por 87% da variação t ot al. A doença incide com m ais força nas áreas m ais pobres. Em 2003 e 2004 dim inuíram a taxa de incidência e o risco de adoecer por tuberculose nas áreas m ais pobres. Os resultados confirm am a determ inação da tuberculose, no m unicípio estudado, pelas condições de vida da população, fortalecendo a im portância da com preensão dos condicionant es sociais da TB para t ransform ar o cenário preocupant e em que est á inserida.
I NTRODUCTI ON
T
uberculosis ( TB) , supposedly a disease of t he past , is found t o be in cont inuous expansion all over the world, bringing concerns to health authorities, scient ific com m unit ies and civ il societ y. I n spit e of advances and incent ives like t he DOTS st rat egy and efficien t , affor dable dr u g t h er apy, TB poses as an unbearable burden of suffering and a large obst acle for socioeconom ic dev elopm ent all ov er t he w or ld. The global incidence of the disease increases 1% every year, wit h 9 m illion new cases and 2 m illion deat hs b ein g r eg ist er ed an n u ally in t h e w or ld( 1 - 2 ), w h ich r epr esent s an incidence of 136 cases per 100, 000 inhabit ant s.Sev er al au t h or s h av e at t r ibu t ed t h e qu ick propagat ion of TB t o povert y and low socioeconom ic developm ent . Alt hough t he over all healt h of people has im proved in recent decades, it is easy to see that t h is sit u at ion is a pr iv ilege of gr ou ps w it h bet t er i n co m e . Po o r e r, so ci a l l y d i sa d v a n t a g e d a n d m ar ginalized populat ions ar e dispr opor t ionat ely and dr am at ically st r u ck by diseases, am on g t h em TB, w h i ch h a s t e r r i f y i n g l y e n t r e n ch e d i t se l f i n t o disadv ant aged count r ies.
TB and pov er t y ar e par t of a bidir ect ional r elat ion, for eit her pov er t y m ay be r elat ed t o poor h ea l t h co n d i t i o n s o r t h ese p o o r co n d i t i o n s m a y induce pov er t y, r educing oppor t unit ies of w or k and subsist ence, t hus for m ing a v icious cir cle t hat only t ends t o w or sen. The sev er it y and negat iv e im pact of t he disease v ar ies at an inv er se r at e t o t he HDI ( Hum an Dev elopm ent I ndex ) , and it s non- unifor m dist r ibu t ion is in flu en ced by fact or s lik e t er r it or ial ex t en sion , d isor d er ed p op u lat ion g r ow t h an d t h e concent r at ion of people in t he poor er ar eas of t he cit ies, w h ich h av e been dr aggin g alon g for y ear s. Th e r elat ion sh ip bet w een pov er t y an d TB is w ell-d ocu m en t eell-d r eg ar ell-d in g r isk s r elat eell-d t o in ell-d icat or s o f so ci o eco n o m i c st at u s, su ch as o v er cr o w d i n g , p o v e r t y a n d u n e m p l o y m e n t , b u t n o e f f e c t i v e s o l u t i o n h a s b e e n f o u n d , a l t h o u g h m a n y i n v e s t m e n t s a r e b e i n g m a d e . H o w e v e r, s u c h m easur es focus on t r eat m ent inst ead of pr ev ent ion. Pr ev en t ion is n ot in ex ist en t - t h er e ar e act ion s for pr ev en t ion an d con t r ol, st r at egies lik e DOTS t h at a r e i n n o v a t i v e a n d e f f e c t i v e , b u t p o l i t i c a l in v olv em en t an d f u n d in g is u n sat isf act or y in t h is m at t er( 2- 3).
The fact that Brazil holds the 16th place in a list of 22 countries with the highest incidence of TB is a r ef lex of t h e d ist r essin g socioecon om ic sit u at ion , poverty and inability of the governm ent to act, due to in ef f ect iv e gov er n m en t al in v olv em en t , in su f f icien t governm ental com m itm ent and inconsistent application of the program s to control the disease in the country. This sit uat ion of pov er t y and suffer ing has been a source of concern for international, governm ental and n o n - g o v e r n m e n t a l o r g a n i za t i o n s d e v o t e d t o dev elopm en t an d cooper at ion . I n r espon se t o t h e appeal of the World Health Assem bly in May/ 2000, the Global Part nership t o St op TB was form ed, m ade up by a network of over 400 organizations, countries and represent at ives from t he public and privat e sect or.
This Part nership result ed in t he Global Plan t o st op TB, prom ot ed and coordinat ed by t he World Healt h Or gan izat ion ( WHO) an d su ppor t ed by t h e World Bank, having t he elim inat ion of TB as one of t he obj ect ives t o reduce povert y all over t he world.
Th e f ir st Wor ld Plan ( 2 0 0 1 - 2 0 0 5 ) br ou gh t advances in t erm s of new allies, research incent ives and m ore im pact on t he places m ost affect ed by t he epidem ic. The am ount of patients treated by the DOTS strategy rose to 2 m illion in 2004 and to 4 m illion in 2005.
The goals of t he 2nd Global Plan against TB for 2015 aim t o m eet t he Millennium Dev elopm ent Goals( 6), as it proposes strategic action to reduce the burden of TB in t he world, decreasing t he incidence of the disease and halving its prevalence and m ortality when com pared to the rates of 1990( 1).
D i f f i cu l t i e s f o u n d a l l o v e r t h e w o r l d , part icularly in disadvant aged count ries, have povert y as a det erm ining or worsening fact or when it com es to falling ill to TB.
The present study aim s to urge reflection on t he necessit y for a new out look of TB, consider ing t he im pact of t he socioeconom ic condit ions on t he w o r sen i n g o f t h e ep i d em i o l o g i c si t u a t i o n o f t h e disease. The m agnit ude of t he problem causes grief an d d eat h , in sp it e of t h e av ailab ilit y of con t r ol st r at egies, by show ing an alar m ing scenar io, ev en t hough t here is a presence of inst it ut ions responsible f o r t h e sch o o l i n g o f h u m a n r eso u r ces i n h ea l t h sciences, and also t he need for m ore invest m ent in clinical, epidem iologic and operat ional research in a TB cont ext .
METHODOLOGY
Th i s i s a n e x p l o r a t o r y - d e scr i p t i v e , epidem iologic study, perform ed in the city of São José do Rio Pr et o, in t he st at e of São Paulo, Br azil - an urban area wit h 400 t housand inhabit ant s. Rat ed as one of the cities with higher quality of life, it shows a Hu m a n D ev el o p m en t I n d ex ( HD I ) o f 0 . 8 3 4 ; l i f e ex pect ancy at bir t h of 71.5 y ear s; Gr oss Dom est ic Pr oduct ( GDP) at ar ound US$ 2.3 m illion. The cit y features specific problem s, particularly in its peripheral area, due to extrem e poverty in 4% of its population. I t is con sid er ed a p r ior it y b y t h e Em er g en cy TB Cont r ol Plan because of a high r at e of TB/ HI V co-infect ion( 7- 8).
The study population was delim ited as all new cases geo- referenced for t he 432 census t ract levels o f t h e u r b a n a r e a o f Sã o Jo sé d o Ri o Pr e t o . I nform ation from the TB Notification System ( EPI TB) , t h e St a t e Sy st e m f o r D a t a An a l y si s Fo u n d a t i o n ( SEADE)( 9) and t he I nfor m at ion Depar t m ent of t he Brazilian Health Ministry ( DATASUS)( 10) was also used in the study.
The socioeconom ic indicat ors for each of t he 432 census t ract levels were est im at ed based on t he c e n s u s y e a r 2 0 0 0 . Th e s o c i o e c o n o m i c char act er izat ion of t he populat ion in t hese census t r a c t l e v e l s w a s o u t l i n e d o n t h e b a s i s o f t h e d em o g r a p h i c cen su s, i n a d d i t i o n t o t h e cen su a l sect or ’s lev el, b ased on t h e f ollow in g v ar iab les: Av er ag e y ear s of sch oolin g of p eop le r esp on sib le
for each household; Av er age y ear s of schooling of t he wom en responsible for each household; Average in com e ( in Reais) of p eop le r esp on sib le f or each household; Average incom e ( in Reais) of t he wom en r esp on sib le f or each h ou seh old ; Rat e of illit er at e people over 5 years of age; Rat e of illit erat e wom en over 5 years of age; Rat e of households wit h m ore t han 5 inhabit ant s.
The 432 census t r act lev els w er e ar r anged according to the value of their socioeconom ic factors, and arranged in four quart ers. The group of census tract levels defined as the first quarter was rated as a socioeconom ic level I ( lowest ) ; t he second and t hird quar t er s w er e r at ed as socioeconom ic levels I I and I I I ( int erm ediat e) ; and t he fourt h quart er was rat ed as socioeconom ic level I V ( highest ) .
Th e n ew cases of TB w er e en t er ed in t o a Microsoft Excel dat abase, so t hat t he coefficient s of TB incidence ( new cases of t he disease per ev er y 1 0 0 , 0 0 0 in h ab it an t s) cou ld b e calcu lat ed f or t h e per iods of 1998/ 1999 and 2003/ 2004, accor ding t o t he areas under analysis for t he t ot al populat ion of São José do Rio Preto in 2003.
The socioeconom ic v ar iables w er e analy zed i n STATA so f t w a r e a cco r d i n g t o t h e Pr i n ci p a l Co m p o n en t An al y si s st at i st i cal t ech n i q u e, w h i ch p r o d u ces n o n - co r r el at i v e f act o r s an d r ep r esen t s im por t ant aspect s char act er ized by t he cor r elat ion bet ween variables( 11).
RESULTS
Table 1 - Socioeconom ic charact er ist ics of t he four cen su al sect or gr ou pin gs, São José do Rio Pr et o, 2000
DI SCUSSI ON
Assum ing t hat t he healt h sit uat ion of people infect ed by TB has povert y as it s det erm ining fact or, t h i s st u d y p r esen t s a f ew t o p i cs f o r d i scu ssi o n , considering t he obt ained result s.
By look in g at t h e socioecon om ic v ar iables ident ified in t he principal com ponent analysis in t his st udy, fact or s such as y ear s of schooling/ illit eracy, incom e of t he people responsible for each household an d am ou n t of in h abit an t s per h ou seh old becam e ev i d en t . Th i s f act h as b een m en t i o n ed b y o t h er r esea r ch er s w h o cl a i m t h a t t h e m o st i m p o r t a n t i n d i cat o r s t o d et er m i n e t h e so ci o eco n o m i c l ev el a sso ci a t ed t o p o p u l a t i o n h ea l t h i n cl u d e l ev el o f inst ruct ion, incom e and occupat ion( 12), alt hough t he latter was not significant in the present study.
Th e ev i d en ce o f so ci al st r at i f i cat i o n i s a com m on factor am ong these variables. The individuals fill niches in t he social hier ar chy accor ding t o t heir occupat ion, incom e and level of educat ion, and each of t hese indicat ors covers a different aspect of social st r a t i f i ca t i o n . Th e l e v e l o f e d u ca t i o n sh o w s t h e d i f f er en ces am o n g p eo p l e i n t er m s o f access t o infor m at ion and t he possibilit y and per spect iv es of ben ef it in g f r om n ew k n ow ledge; I n co m e, at f ir st , represents access to consum er goods, including health ser v ices; an d o ccu p at i o n al st at u s com p r ises b ot h asp ect s, alon g w it h b en ef it s r eceiv ed f r om som e occupat ions, such as prest ige, privileges and power. I n Brazil, the influence of education on health condit ions was m ade evident t hrough t he result s of t h e Re se a r ch a b o u t St a n d a r d s o f Li v i n g ( PPV) , perform ed in 1996/ 1997 by the Brazilian I nstitute for Geogr aphy and St at ist ics ( I BGE) . By analy zing t he im port ance of t he socioeconom ic variables, regarding t he healt h st at us of individuals over t went y years of ag e, su ch as y ear s of sch oolin g , occu p at ion an d m ont hly incom e, it can be at t est ed t hat t he variable “ years of schooling” was second in relevance only t o “ age”( 13).
Su ch f act can b e clear ly an aly zed in t h e socioeconom ic m ap of t he cit y ( Figure 1) , where t he disease affects the poorer groups m ore strongly, and, as m ore investm ent in public policies was directed to t he social issues of t he cit y, t her e has also been a less- w idespr ead dist r ibut ion of t he incidence of TB b e t w e e n l e v e l s I V a n d I . Th e se r e su l t s a r e i n con cor d an ce w i t h ot h er st u d i es t h at d i scu ss t h e influence of social inequalit ies on healt h result s.
* As of Septem ber/ 2000
The values for the coefficient of TB influence obt ained accor ding t o t he socioeconom ic lev els for t h e p e r i o d s o f 1 9 9 8 / 1 9 9 9 a n d 2 0 0 3 / 2 0 0 4 a r e present ed in Table 2:
Table 2 - New TB cases for every 100,000 inhabitants, accor din g t o t h e socioecon om ic lev el an d y ear of occu r r en ce
Accor ding t o Table 2 , im pr ov em ent s in t h e i n ci d en ce i n d i ca t o r s ca n b e i d en t i f i ed w h en t h e p e r i o d s o f 1 9 9 8 / 1 9 9 9 a n d 2 0 0 3 / 2 0 0 4 a r e com par ed r egar din g socioecon om ic lev el, w it h t h e d ecr eased in cid en ce at t h e w or st lev el ( Lev el I ) b ein g m ost ex p r essiv e. I t cou ld also b e v er if ied t hat , fr om 1 9 9 8 t o 1 9 9 9 , t he r isk of falling ill du e t o TB w as t w ice as high in t he ar eas w it h t he w or st socioecon om ic lev els. Fr om 2 0 0 3 t o 2 0 0 4 , t h er e w as an i m p r ov em en t i n t h e i n ci d en ce i n d i cat or s and a decr eased differ ence in t he r isk of falling ill a m o n g t h e a r ea s w i t h t h e w o r st so ci o e co n o m i c lev el s. No si g n if ican t d if f er en ces w er e i d en t i f i ed i n t h e r i s k o f f a l l i n g i l l d u e t o TB a m o n g t h e gr oupings t hat cor r espond t o lev els I I , I I I and I V, in b ot h p er iod s.
e l b a i r a V t c a r t s u s n e c f o s g n i p u o r G s l e v e l
I II III IV
e l p o e p f o g n il o o h c s f o s r a e y e g a r e v A d l o h e s u o h h c a e r o f e l b i s n o p s e
r 5.3 6.5 7.9 10.8
n e m o w e h t f o g n il o o h c s f o s r a e y e g a r e v A d l o h e s u o h h c a e r o f e l b i s n o p s e
r 4.6 5.8 7.2 10.0
e l p o e p f o ) * s i a e R n i( e m o c n i e g a r e v A d l o h e s u o h h c a e r o f e l b i s n o p s e
r 465.20690.031046.92401.42
n e m o w f o ) * s i a e R n i( e m o c n i e g a r e v A d l o h e s u o h h c a e r o f e l b i s n o p s e
r 298.50453.60687.201510.40
f o s r a e y 5 r e v o e l p o e p e t a r e ti ll i f o e t a R ) % ( e g
a 11.3 8.1 5.8 3.2
f o s r a e y 5 r e v o n e m o w e t a r e ti ll i f o e t a R ) % ( e g
a 12.4 9.2 6.6 3.6
5 n a h t e r o m h ti w s d l o h e s u o h f o e t a R ) % ( s t n a ti b a h n
i 23.5 17.2 15.5 13.7
l e v e l c i m o n o c e o i c o
S Year
9 9 9 1 / 8 9 9
1 2003/2004
I 51.7 37.7
II 36.2 31.1
II
I 30.1 30.0
V
Figure 1 - Map of São José do Rio Preto, according to socioecon om ic ar eas an d TB in ciden ce coef f icien t , 1998/ 1999 and 2003/ 2004.
The assessm ent and planning of PCT act ions r e q u i r e a m o d e l o f a n a l y s i s o f c o l l e c t i v e r i s k sit uat ions t o r eplace t he m odel of indiv idual r isk s, by using t he land/ t errit ory as a reference. This view brings t o light t he inequalit ies t hat exist w it hin t he cit ies, m ak in g t h e p lan n in g of in t er v en t ion s an d select iv e m onit or ing possible, accor ding t o t he r eal needs of sm aller areas. I t also allows t he redirect ing of public policies, aim ing for a bet t er adequacy of p u b l i c i n v e s t m e n t i n a r e a s t h a t l a c k u r b a n in f r ast r u ct u r e, by m ean s of of f er in g bet t er pu blic ser v ices an d t h e im plem en t at ion of specific social program s( 8). Wit h t he result s obt ained, t he proposed reflect ions aim t o widen t he approach of st udies about TB, by incor por at ing epidem iologic indicat or s, and ot h er in st r u m en t s lik e g eo- p r ocessin g , w h ich w ill al l o w t h e u n d er st an d i n g o f t h e d y n am i cs o f t h e d i sea se b y co n si d er i n g t h e co m p o n en t o f so ci a l inequalit y.
Ev en t h ou g h t h e cit y u n d er st u d y sh ow s in d icat or s t h at in d icat e g ood st an d ar d s of liv in g , t her e is a t w ice- higher incidence of TB am ong t he popu lat ion w it h t h e w or st lev els of socioecon om ic d e v e l o p m e n t , w h i c h c o n f i r m s t h e p r o p o s e d
reflect ion on t he burden of TB for t he underst anding o f so ci a l co n d i t i o n e r s o f t h e TB h e a l t h - d i se a se p r o cess.
The analy sis of t he liv ing condit ions of t he population points to the fact that the risk of falling ill t o TB is t w ice as high in t he ar eas w it h t he w or st socioeconom ic lev els, com par ed t o t hose of bet t er levels. From 2003 t o 2004, an im provem ent can be observed in t he incidence indicat ors and a decreased difference in the risk of falling ill in the areas with the w or st socioeconom ic lev els w hen com par ed t o t he area wit h bet t er levels. I t m ust be not ed, howev er, that there have been investm ent in the change of the cit y’s public policies in t his period, direct ed t o social issues.
CONCLUSI ON
I n t h e cit y of São José do Rio Pr et o, t h e dist ribut ion of t he populat ion across t he urban space follows practically the sam e inequality patterns of large cent ers, wit h groups wit h fewer privileges ( regarding incom e and healt h condit ions) living on t he out skirt s of the city.
Th e f i n d i n g s o f t h i s st u d y co n f i r m t h e pr ev iously - st at ed hy pot hesis, w her e t he pat t er n of TB m or bidit y in t he populat ion of São José do Rio Pret o is influenced by it s living condit ions.
By con sid er in g t h e m ag n it u d e of TB as a socially - pr odu ced disease, alon g w it h it s n egat iv e im pact on collect ive healt h, t here is an evident need for a great er involvem ent of healt h professionals and the scientific com m unity, regarding the im plem entation of oper at ional act ion and r elev ant inv est igat ion t o underst and t he social condit ioners of t he TB healt h-disease pr ocess an d, con sequ en t ly, t o ch an ge t h e dist ressing scenario it is insert ed in. Hopefully, t his st u d y h as p r o v i d ed su ch u n d er st an d i n g an d t h e inform at ion obt ained herein m ay prove useful t o t he t ask of out lining successful st rat egies of act ions for TB co n t r o l , t h u s e n su r i n g t h e e st a b l i sh m e n t o f co o p e r a t i o n b e t w e e n t h e a ca d e m y a n d h e a l t h ser v ices.
ACKNOW LEDGEMENTS
Th e au t h or s t h an k CNPQ an d FAPESP f or funding t he proj ect s.
Cases of tuberculosis per 100.000 inhabitants/year
anos 1998/1999 51,7
2003/2007
36,2 30,1 25,5
37,7 31,1 30,0 22,4 Socioeconomic level I
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