Desigualdades sociais no uso de serviços odontológicos: comparação entre a assistência prestada pelo SUS e por outros serviços

Abstract

The Brazilian Single Health System (SUS) presents as doctrinal propositions to universality, equity and integrality, which aim to provide access to individual and collective services with actions of promotion, prevention and assistance. The aim was to analyze the use of dental services among adolescents, adults and elderly in a sample of the Brazilian population, and their association by means of multilevel approach, with individual and contextual information. It was an analytical cross-sectional prevalence study, with individual data, from the project SB BRAZIL - National Survey of Oral Health 2010 and aggregated data of 177 municipalities investigated, obtained in public databases (DATE SUS, IBGE and Atlas Brazil). The theoretical model used was based on the contextual determinants of health of the WHO, (Solin and Irwin, 2007) and in previous theoretical models that analyzed the use (Andersen & Davidson, 1997), the quality (Donabedian, 1988) and the subjective questions (Gift et al,1998) related to health. Four dimensions were defined in the model: contextual, individual, behavioral, oral health condition and assessment of care. A cross-sectional study was conducted with the multilevel samples of adolescents (n= 5445), adults (n= 9779) and elderly patients (n= 7619).The analyzed outcome: use of dental services in the SUS and in other types of services, was originated by the question: Where was his last consultation (dental)? The independent variables were classified as contextual and individual and relate to individual primary determinants (changeable and immutable), behaviors and related to oral health conditions and to the evaluation of the consultation.The multilevel analysis used the schematic of fixed effects and random intersection, for the estimation of the adjustment between the outcome (use of dental services at SUS) and the explanatory variables of the first (participating cities) and second (individuals examined) levels of analysis. Among the three age groups assessed adolescents had a greater prevalence of use of dental services in the SUS (46.8%), being adults with 37.9% and elderly 30%. Among the thirteen contextual variables tested, six (IDHM, access to the bathroom and àgua piped, access to garbage collection, average of supervised brushing, coverage of oral health teams and index of dental care) were associated with the use of health services in the SUS in some of the age ranges studied, but none was common to the three strata. Meanwhile in individual variables, only years of study and family income of individuals was commonly associated to adolescents, adults and elderly. The seventeen individual variables tested, fourteen have proved significant association to the public use of dental services (years of study, age, skin color, income, time of last query, reason for consultation, tooth decay component, tooth lost, missing tooth obturated, toothache, satisfaction with teeth and mouth, self-perception of the need for treatment, selfperception of need for prosthesis and assessment of consultation). The principle of universality still presents fragilities, because in the three age groups there were people who had never used dental services. The challenge is to make this fairness accessible to the majority of the population and add efforts in the conquest of an ideal use for all.