Ferezin Letícia Perticarrara, Rosa Rander Junior, Moura Heriederson Sávio Dias, de Campos Mônica Chiodi Toscano, Delpino Felipe Mendes, Nascimento Murilo César do, Araújo Juliana Soares Tenório de, Pinto Ione Carvalho, Arcêncio Ricardo Alexandre
Department of Maternal and Child Nursing and Public Health, School of Nursing, University of São Paulo at Ribeirão Preto, São Paulo 05508-220, Brazil.
Department of Nursing, School of Health Sciences, University of Brasília, Brasília 70910-900, Brazil.
Int J Environ Res Public Health. 2025 May 25;22(6):831. doi: 10.3390/ijerph22060831.
Brazil's Unified Health System (Sistema Único de Saúde-SUS) has played a crucial role in reducing health disparities by providing universal and free healthcare to a diverse population. However, the COVID-19 pandemic exposed significant barriers to healthcare access among vulnerable groups, particularly due to the intersection of multiple vulnerabilities. This study aimed to examine how intersectionality-specifically sex/gender, race/ethnicity, and education level-has influenced inequalities in healthcare service utilization among vulnerable populations during the COVID-19 pandemic in Brazil.
This cross-sectional study is part of the "COVID-19 Social Thermometer in Brazil" project, conducted between May 2022 and October 2023 in Brazil's state capitals and the Federal District, focusing on populations considered socially vulnerable during the pandemic. Participants were selected using sequential sampling and completed a structured questionnaire. Statistical analyses-performed using Excel, RStudio (version 4.3.2), and ArcGIS-included sociodemographic profiling, the construction of the Jeopardy Index (a measure of social vulnerability), and binary logistic regression to explore associations between Jeopardy Index and healthcare service utilization.
3406 participants, the majority were men (60%), aged 30 to 59 years (65.1%), and identified as Black or Brown (72.2%). Most participants were concentrated in the Northeast (26.6%) and North (22.3%) macroregions. A high reliance on public healthcare services (SUS) was observed, particularly in the Southeast (96%). According to the Jeopardy Index, the most socially vulnerable groups-such as women, transgender individuals, Black people, and those with no formal education-were significantly more likely to rely on SUS (OR = 3.14; 95% CI: 1.34-7.35) and less likely to use private healthcare (OR = 0.07; 95% CI: 0.02-0.20), reflecting a 214% higher likelihood of SUS use and a 93% lower likelihood of private service utilization compared to the most privileged group.
Our findings reveal that individuals experiencing intersecting social vulnerabilities face marked inequalities in healthcare access. Without SUS, these populations would likely have been excluded from essential care. Strengthening SUS and implementing inclusive public policies are critical to reducing disparities and ensuring equitable healthcare access for historically marginalized groups.
巴西的统一卫生系统（Sistema Único de Saúde - SUS）通过为多样化的人群提供普遍且免费的医疗保健，在减少健康差距方面发挥了关键作用。然而，新冠疫情暴露了弱势群体在获得医疗保健方面的重大障碍，特别是由于多种脆弱性因素相互交织所致。本研究旨在探讨在巴西新冠疫情期间，交叉性因素——具体而言是性别、种族/民族和教育水平——如何影响了弱势群体在医疗服务利用方面的不平等现象。
这项横断面研究是“巴西新冠社会温度计”项目的一部分，于2022年5月至2023年10月在巴西的州首府和联邦区开展，重点关注疫情期间被视为社会弱势群体的人群。采用序贯抽样法选取参与者，并让他们完成一份结构化问卷。使用Excel、RStudio（版本4.3.2）和ArcGIS进行统计分析，包括社会人口统计学特征分析、危险指数（一种衡量社会脆弱性的指标）的构建以及二元逻辑回归分析，以探究危险指数与医疗服务利用之间的关联。
3406名参与者中，大多数为男性（60%），年龄在30至59岁之间（65.1%），且自认为是黑人或棕色人种（72.2%）。大多数参与者集中在东北部（26.6%）和北部（22.3%）大区。观察到对公共医疗服务（SUS）的高度依赖，尤其是在东南部（96%）。根据危险指数，社会最脆弱的群体，如女性、跨性别者、黑人以及未接受过正规教育的人，明显更有可能依赖SUS（优势比 = 3.14；95%置信区间：1.34 - 7.35），而使用私人医疗服务的可能性较小（优势比 = 0.07；95%置信区间：0.02 - 0.20），这表明与最具优势的群体相比，使用SUS的可能性高出214%，使用私人医疗服务的可能性低93%。
我们的研究结果表明，经历多重社会脆弱性的个体在获得医疗保健方面面临显著不平等。如果没有SUS，这些人群很可能会被排除在基本医疗之外。加强SUS并实施包容性公共政策对于减少差距以及确保历史上被边缘化群体获得公平的医疗保健至关重要。
