Graduate Program in Public Health, Federal University of Santa Catarina, Campus Universitário Trindade, Florianópolis, Brazil.
Research Department of Epidemiology and Public Health, University College London, London, United Kingdom.
Ethn Health. 2023 May;28(4):488-502. doi: 10.1080/13557858.2022.2078483. Epub 2022 May 24.
Substantial research has shown that the population distribution of major depressive disorder (MDD) is strongly influenced by race, gender, and socioeconomic position. However, a deeper understanding of inequities in access to care for MDD according to these social markers is yet to be reached. We use data from the 2019 Brazilian National Health Survey, which includes 87,187 respondents aged 18 years and over, to test two hypotheses derived from the inverse care law: women, Black, and low-education respondents have higher frequencies of MDD, but lower access to each step of the depression care cascade, including diagnosis by a health professional, regular healthcare visits, and access to specialised treatment (H1); low-education Black women show the highest MDD frequency and the lowest access to care across the entire cascade (H2). Partially supporting H1 and H2, our results reveal a bottleneck in the first step of the depression care cascade. While no racial inequities were observed in the MDD prevalence, Black individuals were less likely than whites to be diagnosed by a health professional (OR 0.74). Women (OR 2.64) and low-education (OR 1.18) were more likely to have probable MDD in relation to men and high-education respondents, respectively, but only women (OR 1.58) were more likely to be diagnosed. Low-education Black women were equally more likely to have probable MDD (OR 3.11) than high-education white men. Conversely, high-education white women emerged as the most likely to be diagnosed with MDD (OR 1.63). Our findings suggest the inverse care law applies to the depression care cascade in Brazil through indication that its healthcare system perpetuates a multilayered system of oppression that overlooks multiply marginalised individuals. We also show that adequate screening by health care professionals should mitigate the complex patterns of inequity revealed by our study.
大量研究表明，主要抑郁症（MDD）的人口分布受到种族、性别和社会经济地位的强烈影响。然而，对于这些社会指标下 MDD 获得护理的不公平现象，我们还没有深入了解。我们使用了来自 2019 年巴西国家健康调查的数据，该调查包括 87187 名 18 岁及以上的受访者，以检验源自逆向护理定律的两个假设：女性、黑人、受教育程度低的人 MDD 发病率较高，但获得抑郁症护理各个环节的机会较低，包括由医疗保健专业人员诊断、定期接受医疗保健访问和获得专业治疗（H1）；低教育水平的黑人女性在整个护理链中表现出最高的 MDD 发病率和最低的护理机会（H2）。部分支持 H1 和 H2，我们的结果揭示了抑郁症护理链的第一步存在瓶颈。虽然在 MDD 患病率方面没有发现种族不平等现象，但与白人相比，黑人被医疗保健专业人员诊断的可能性较小（OR0.74）。与男性和高教育程度的受访者相比，女性（OR2.64）和受教育程度低的人（OR1.18）更有可能患有可能的 MDD，但只有女性（OR1.58）更有可能被诊断。受教育程度低的黑人女性与高教育程度的白人男性相比，更有可能患有可能的 MDD（OR3.11）。相反，高教育程度的白人女性被诊断为 MDD 的可能性最大（OR1.63）。我们的研究结果表明，逆向护理定律适用于巴西的抑郁症护理链，因为它表明其医疗保健系统延续了一个多层次的压迫制度，忽视了多重边缘化的个体。我们还表明，医疗保健专业人员的充分筛查应减轻我们研究揭示的复杂不平等模式。
