Failure to use health services by people with Chagas disease: Multilevel analysis of endemic area in Brazil

This study aimed to assess the prevalence of non-use of health services in the last year by people with Chagas disease (CD) in an endemic area in Brazil and the contextual and individual factors associated with this non-use. This is a multilevel study that considered contextual and individual data. Contextual data were collected from official publicly accessible databases of the Brazilian government, at the municipal level. The individual data came from the first follow-up of a Brazilian cohort that assessed patients with CD in 21 municipalities in endemic area for the disease. The sample consisted of 1,160 individuals with CD. The dependent variable “use of health services in the last year” was categorized as yes vs. no. The analysis was performed using Poisson regression with robust variance. The prevalence of non-use of health services in the last year was 23.5% (IC95%: 21.1–25.9). The contextual factor “larger population” (PR: 1.6; 95% CI = 1.2–2.0) and individual factors related to the lower severity of the disease as a functional class without limitations (PR: 1.6; 95% CI = 1.2–2.1) and unaltered N-terminal pro b-type natriuretic peptide levels (PR: 2.2; 95% CI = 1.3–3.6) increased the prevalence of non-use of the health service in the last year by people with CD. The results of this study showed that individual determinants are not isolated protagonists of the non-use of health services in the last year by people with CD, which reinforces the need for public policies that consider the contextual determinants of the use of health services by populations affected by the disease.Author summary: Chagas disease (CD) is a parasitic infection caused by Trypanosoma cruzi (T. cruzi) that predominantly affects poor and vulnerable populations. It is estimated that around six million people are infected with T. cruzi, most of them in endemic areas of Latin American countries. It is recommended that individuals with CD be followed up by health services through one to two medical consultations per year. Identifying groups of people with CD who are more vulnerable in relation to their health status, whether due to the unavailability of health services or the types of behavior that lead to the non-use of available services, can contribute to reducing morbidity and mortality from the disease. Our study evaluated the prevalence of non-use of health services in the last year by 1,160 people with CD in an endemic area in Brazil and the contextual and individual factors associated with this non-use. The study results showed that almost a quarter of these patients had not had a medical appointment in the last year. “Living in cities with a larger population” and “having a lower severity of the disease” influenced the non-use of the health service in the last year by these patients. These results reinforce the need for public policies that consider the contextual determinants of the use of health services by populations affected by the disease.