Access to care and medication use among the ambulatory elderly in Rio de Janeiro, Brazil

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Title:
Access to care and medication use among the ambulatory elderly in Rio de Janeiro, Brazil
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x, 245 leaves : ill. ; 29 cm.
Language:
English
Creator:
Miralles, Maria Andrea
Publication Date:

Subjects

Subjects / Keywords:
Patient Compliance -- Aged -- Brazil   ( mesh )
Drug Therapy -- Aged -- Brazil   ( mesh )
Self Medication -- Aged -- Brazil   ( mesh )
Health Services Accessibility -- Brazil   ( mesh )
Genre:
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1992.
Bibliography:
Includes bibliographical references (leaves 232-244).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Maria Andrea Miralles.

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University of Florida
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Permission granted to the University of Florida to digitize, archive and distributed this item for non-profit and educational purposes only. Any reuse of this item in excess of fair use requires permission of the copyright holder.
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oclc - 50683545
ocm50683545
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AA00020015:00001

Table of Contents
    Title Page
        Page i
    Dedication
        Page ii
    Acknowledgement
        Page iii
        Page iv
        Page v
    Table of Contents
        Page vi
        Page vii
        Page viii
    Abstract
        Page ix
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    Chapter 1. Medication use and the elderly in Brazil
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    Chapter 2. Medical and pharmacy services in Brazil
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    Chapter 3. Methodology
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    Chapter 4. Results
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    Chapter 5. Discussion and conclusion
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    Appendix A. Item selection candidates
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    Appendix B. Instrument
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    Appendix C. Letter of introduction to study participants
        Page 223
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    Appendix D. Access to care and attitude measures
        Page 225
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    References
        Page 232
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    Biographical sketch
        Page 245
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Full Text











ACCESS TO CARE AND MEDICATION USE
AMONG THE AMBULATORY ELDERLY IN
RIO DE JANEIRO, BRAZIL















By


MARIA ANDREA MIRALLES


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1992














To

Naly G.













ACKNOWLEDGEMENTS

Several individuals and institutions are responsible

for the successful completion of this project. This project

would not have been possible without the support of the

Institute of Social Medicine at the State University of Rio

de Janeiro (IMS/UERJ). A special debt of gratitude is owed

to Dr. Renato P. Veras, coordinator of the Brazilian Old Age

Survey (BOAS), the first comprehensive survey of physical

and mental health of the Brazilian elderly, for his

generosity and encouragement. The present project on

medication use in the elderly was able to take advantage of

the extensive preliminary work of the BOAS team of

identifying the sample and training interviewers.

Especially appreciated are the efforts of Sidney Dutra

Silva, field coordinator on both projects. The continuity

provided by this was of immeasurable benefit.

Also at IMS/UERJ, special thanks are extended to Gerson

Noronha Filho, M.D., Ph.D., Director of the Department of

Planning, Antonio Cesar Lemme, M.D., and other members of

the Study Group on Quality of Care and Patient Satisfaction.

The receptivity and vitality of this group provided for a

stimulating intellectual exchange of ideas and research

experiences.







Many thanks are extended to the interviewers: Nelson

Lopes de Azevedo, Ana Lucia Barbosa, Marcelo Bessa, Marco

Aurdlio P. Carvalho, Vanderlei R. de Carvalho, Liane

Esteves, Edmeire 0. Exaltagdo, Angelica Fonseca, Ver6nica

Hamilton, Herminia Helena da Silva, Marta Cristina Nogueira,

Cristina A. M. Souza, and Eduardo Vilarin. Also, for help

with drug coding and data entry checking, thanks to Ligia M.

Soares, M.D., and Alexei Soares.

The elderly participants in this study who graciously

opened their doors to be interviewed provided a powerful

stimulus to completing the project, especially when train

trips and bus rides seemed tedious and interminable, and the

days too hot and dusty, or too hot and humid. Their

expressed interest in the subject and willingness to share

their thoughts and experiences, sometimes for hours at a

time, was extremely rewarding. In particular, there will

always be a special place in my heart for Dona Maria, Senhor

Ary, Dona Olinda, Dona Engragada, and Senhor Antonio.

An important source of professional and moral support

for this project was the Conselho Federal de Farmdcia, the

Brazilian national professional pharmacy association. I am

deeply grateful and honored to have had the opportunity to

participate in some very exciting discussions regarding the

future of community pharmacy practice in Brazil. For this,

I thank Luiz Italo Niero, Thiers Ferreira, M. Cristina F.

Rodrigues, Vicente T. de Araujo Junior, and other directors







of the various regional offices. I hope that this project

will help to guide the Conselho in its efforts to meet the

difficult challenges ahead.

For keeping their doors open, permitting countless

hours of extemporaneous teaching, special recognition is

extended to Dr. Charles H. Wood, sociologist/demographer,

Dr. Otto Von Mering, Director of the Center for

Gerontological Studies, Richard A. Angorn, J.D., R.Ph., and

Paul Doering, M.S.P., Director of the Drug Information

Center, at the University of Florida, and to Dr. Howard Eng,

at the University of Arizona, Health Sciences Center.

Through gestation to conclusion, this project was met

with encouragement and support from all of the faculty,

staff, and fellow students of the Department of Pharmacy

Health Care Administration at the University of Florida,

especially committee members Drs. Carole L. Kimberlin,

Charles D. Helper, and Donna Berardo. A great debt of

gratitude is due to Dr. Kimberlin. An exceptional mentor,

her unwavering patience, willingness to explore new ideas,

and high principles are to be emulated.

Finally, thanks to my husband, Glducio Ary Dill6n

Soares, friend and companheiro for more than a decade.














TABLE OF CONTENTS


page

ACKNOWLEDGEMENTS ...................................... iii

ABSTRACT .............................................. viii

CHAPTERS

1 MEDICATION USE AND THE ELDERLY IN BRAZIL........ 1

Introduction.................... ..................... 1
Background: Medication Use in the Third World... 5
The Political and Economic-Infrastructural
Context...................................... ..... 6
The Social and Cultural Context.................. 10
Theoretical Framework ............................ 13
Health Services Utilization and Medication
Use......................................... ...... 13
Conceptualizing Access to Care................... 16
Access to Care and Medication Use.............. 20
Research Questions ............................... 23
Significance........................................ 24
Summary.......................................... ...... 28

2 MEDICAL AND PHARMACY SERVICES IN BRAZIL.......... 31

Health Care in Brazil ........................... 31
The Public Sector ............................. 32
The Private Sector ............................ 38
Health Services Utilization in Rio de Janeiro.... 41
The Pharmaceutical Industry in Brazil............. 46
The Private Sector ............................ 48
The Public Sector ............................. 51
Economic and Social Aspects of Drug Use........... 55
Pharmacies and Drugstores ........................ 58
Pharmacy Practice and Self-Medication............. 63
Conclusion.......................................... 65

3 METHODOLOGY ..................................... .. 65

Building a Medication Use Model for Brazil...... 65
Predisposing Variables ........................ 66
Enabling Variables ............................ 72
Need Variables................................. .. 75
Use Variables.................................. .. 77









Area .......................................... 78
Instrument Development........................... 78
Item Selection ................................ 78
Interviewer Training and Instrument Pilot..... 80
The Sample...................................... 83
Study Areas..................................... 86
Copacabana.................................... 86
Meier......................................... 89
Santa Cruz.................................... 89
Analysis Strategy................................ 91
Summary......................................... 92

4 RESULTS......................................... 94

Sample Characteristics........................... 94
Descriptive Results.............................. 97
Health Status.................................. 97
Medical and Medical Expenses................. 101
The Role of the Physician..................... 104
The Role of the Pharmacy...................... 108
The Role of the Pharmacist.................... 114
Medication Use................................. 119
Measures ........................................ 124
Access Measures............................... 125
Attitude Measures............................. 130
Correlates of Medication Use..................... 131
Modeling Medication Use.......................... 137
Prescription Medication Use.................. 137
Non-Physician Prescribed Medication Use...... 140
Correlates of Medication Use for Areas.......... 142
Modeling Medication Use for Areas............... 149
Prescription Medication Use for Areas........ 149
Non-Physician Prescribed Medication for
Areas .................................... 151
Summary......................................... 154

5 DISCUSSION AND CONCLUSION........................ 156

Medication Use Among the Brazilian Elderly..... 156
Health Services Utilization and Medication
Use......................................... 161
Patient Population Characterisitcs
and Medication Use......................... 162
Access to Care and Medication Use........... 164
Limitations...................................... 166
Policy Implications............................. 170
Health Care and Medication Use among the
Elderly................................... 173
Pharmacy Health Care......................... 177
Conclusion..................................... 181


vii









APPENDICES

A ITEM SELECTION CANDIDATES ...................... 184

B INSTRUMENT ............ .......................... .. 198

C LETTER OF INTRODUCTION TO STUDY PARTICIPANTS... 223

D ACCESS TO CARE AND ATTITUDE MEASURES............ 225

REFERENCES ............................................ 232

BIOGRAPHICAL SKETCH ................................... 245


viii













Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

ACCESS TO CARE AND MEDICATION USE
AMONG THE AMBULATORY ELDERLY IN
RIO DE JANEIRO, BRAZIL

By

Maria Andrea Miralles

August, 1992

Chairman: Carole L. Kimberlin, Ph.D.
Major Department: Pharmacy Health Care Administration

This study examines physician and non-physician

prescribed medication use of an increasingly important

segment of Brazilian society--the elderly. The elderly are

a rapidly growing segment in many developing countries,

including Brazil. Although the hazards associated with

medication use in the elderly have been well documented in

several developed countries, little is known about geriatric

drug use in the developing countries.

Medication use was modeled as a function of individual

and community level factors in the Municipio of Rio de

Janeiro, Brazil. The variables examined are based on a

behavioral model for health services utilization adapted to

medication use in the Brazilian context. Variables include

predisposing sociodemographic characteristics, enabling

variables reflecting aspects of access to care, and need for








care variables. Access to care was analyzed according to

the dimensions of perceived availability, affordability, and

acceptability of medical and pharmacy services. The

importance of these variables and their interrelationships

were examined for elderly residents in three socioeconomic

areas of Rio de Janeiro (N=436).

The rate of prescribed medication use in the sample was

found to approximate that of elderly populations in the

developing world, but self-medication was not as prevalent

as expected. Need variables were the most important

predictors of use in all areas. Age, gender, and income

were the most important predisposing variables in predicting

prescribed drug use. Household size and attitudes towards

lay advice about drugs were significant predictors of self-

medication.

Access to pharmacy services was not a significant

factor in predicting medication use. Although access to

medical care was not significant in predicting self-

medication, acceptability of medical services was the most

important access variable explaining prescribed drug use.

However, separate area analysis revealed that access to care

was not relevant for either prescribed or nonprescribed

medication use in the high SES area, and different

dimensions were important for each area. The value of

smaller area studies in understanding medication use is

borne out. Directions for further research and the role of

the pharmacy practice in Brazil are discussed.














CHAPTER 1
MEDICATION USE AND THE ELDERLY IN BRAZIL


Introduction

Medications play a significant, albeit somewhat

insidious, role in both the preventative and curative

spheres of health care: "properly" used, they may save lives

and contribute to an improved quality of life; misuse or

abuse, however, is associated with increased costs of care

and decreased quality of life. It is because of these

characteristics that the demand for modern medicines, their

availability, and their proper use are of global concern

(WHO, 1980).

The central issues of medication use in most developing

countries revolve around two related concerns about access

to medicines: the scarcity of "essential medicines"

(restricted access), and the popular use of a broad spectrum

of legend and non-legend medications outside the purview of

medical supervision (unsupervised access). In particular,

self-medication, the use of medicines without the

recommendation or guidance of a qualified health care

professional, often extends beyond the use of non-legend,

over-the-counter medications (OTCs) to include many legend

drugs that are designed to be taken under medical supervision.









The unsupervised access to medications is an indicator

of a larger set of factors that includes access to medical

and pharmacy services, as well as alternative sources of

medications. The receipt of a physician's prescription

implies access to medical services, whereas the relationship

is not so straightforward with self-medication. The

purchase of pharmaceuticals, with or without a prescription,

is dependent upon access to a commercial source of

medications, directly through pharmacies or drug peddlers,

or indirectly through another party.

The relationship between access to medical services,

commercial and alternative sources of medications, and

medication use is a crucial issue in many developing

countries (Van der Geest and Hardon, 1990). Where there are

significant barriers to medical care, pharmacies may

represent a significant alternative health care resource.

However, for the same reasons, the ill-prepared or

irresponsible pharmacy may pose a serious potential health

threat through the promotion of inappropriate self-

medication with potent pharmaceuticals.

The primary goal of this study was to examine physician

and non-physician prescribed medication use of an

increasingly important segment of Brazilian society--the

elderly. The populations typically targeted as being at

high risk for hazardous self-medication in developing

countries are pregnant women and young children. However,









the elderly are a rapidly growing segment of many Third

World populations, including Brazil (Kinsella, 1988; Ramos

et al., 1987). The hazards associated with the use of

medications (prescribed and non-prescribed) in the elderly

have been well documented in several developed countries

(Beadsley, 1988; Chapron, 1988; Johnson and Pope, 1983;

Moore and Teal, 1985; Simonson, 1984). However, little is

known about geriatric drug use in the "aging" developing

countries.

In this investigation, medication use was modeled as a

function of various individual and community level factors

which were related to access to medical and pharmacy

services in the Municipio (county) of Rio de Janeiro,

Brazil. Self-medication was defined as the use of a

pharmaceutical or other medicinal product (including home

remedies) not prescribed or recommended by a physician for

the patient. The variables examined in the model are based

on the Andersen and Newman (1973) behavioral model for

health services utilization (HSU) and adapted to medication

use in the Brazilian context. Variables include

predisposing sociodemographic characteristics, enabling

variables reflecting aspects of access to care, and need for

care variables.

In this study, access to medical and pharmacy services

are analyzed according to their component dimensions of

perceived availability, perceived affordability, and the









sociocultural acceptability of services. Typically, access

to services is evaluated with secondary data and use

indicators such as the distribution or number of hospital

beds or physician offices as indices of the availability of

services. Similarly, the affordability of services is often

evaluated by measures such as regular source of care, income

and insurance status. However, the assumptions implicit in

these traditional measures fail to capture other dimensions

of access that may be of particular relevance to some

patient subgroups such as the elderly or patients with

particular illnesses. Given the special socioeconomic,

psychosocial, and health status considerations of the

elderly patient, an understanding of the patient's

perceptions of access to needed services may be useful in

understanding behavior. The relative importance of these

variables and their interrelationships were examined for

elderly residents in three socioeconomic areas of the

Municipio of Rio de Janeiro.

A secondary goal of this project was to begin to

describe medication use in the Brazilian elderly. Such a

description not only provides the foundation for future

evaluations of drug therapies, particularly of the extent of

inappropriateness or potential danger in self-medication,

but also allows for cross-cultural comparisons of geriatric

drug use.









Background:Medication Use in the Third World

Both the restricted access to essential medications and

the unsupervised access to legend medications in developing

countries have provoked a great deal of controversy world-

wide, at least since the 1970s (Silverman, 1976, 1977;

Melrose, 1982; Silverman et al., 1982, 1986; Landmann,

1982). Over-medication, under-medication, use of the wrong

drug, and unnecessary medication use are always important

considerations in promoting effective drug therapy anywhere,

anytime. However, these considerations acquire a greater

prominence in many developing countries, especially for the

case of self-medication.

Whereas in the more developed countries self-medication

may be considered a luxury, in many developing countries,

self-medication may be a necessity (Van de Geest and Hardon,

1990). The tendency to by-pass a physician's prescription

may be considered a necessary adaptation to a situation

characterized by an ineffective or non-functioning official

drug distribution system and the relative dearth of medical

personnel. The lack of control over the distribution and

use of medications gives multinational pharmaceutical

corporations greater latitude, especially for the marketing

of suspect medications, thereby exacerbating the already

precarious conditions for self-medication. The types of

medications made available to these populations, and the

undue expense of inappropriate treatment for impoverished









patients assigns a particularly ardent bent to the issue of

self-medication in the developing world.

A global perspective is imperative for an understanding

of the local economic-infrastructural and cultural context

of medication use. This necessarily includes an

appreciation of the role of the international pharmaceutical

industry in providing medications, and the role of retail

pharmacy in promoting pharmaceuticals as an accepted form of

therapy.

The Political and Economic-Infrastructural Context

The international pharmaceutical industry, unlike other

industries, faces a particular scrutiny because the products

involved are health products, many of which hold the balance

between life and death. Since the 1970s, industry behavior

has been severely criticized for failing to uphold the

mandate to responsibly provide pharmaceuticals, particularly

in the developing countries, with respect to questionable,

if not unethical, production and marketing practices. These

multinational corporations (MNCs) have been accused of

compromising their mandate in order to pursue the incentives

that drive any other industry "hungry for profits" (Ledogar,

1975).

The relationship between the international

pharmaceutical industry and developing countries has been

described as characterized by dependency (CEPAL, 1987;

Evans, 1979; Gereffi, 1983; Jenkins, 1984). This dependency









refers to the control by a small number of large

multinational corporations (MNCs) of the means of

production, research and development of most pharmaceuticals

throughout the world. The dependency perspective argues

that this control translates into political and economic

power which, in turn, may be used to manipulate domestic and

foreign policies of countries without a strong domestic

industry. Because they depend on MNCs to provide their

populations with needed medications, other national economic

and health interests may be compromised. On the other hand,

however, there can be no doubt that MNCs do play a vital,

positive role in meeting medication needs in situations

where no one else can do so. Many developing countries may

never be able to sustain a viable national pharmaceutical

industry and must rely on imported products, or products

produced by local MNC subsidiaries. From the industry's

perspective, the problems of providing "the right

medications at the right price" stem from public rather than

private sector inconsistencies and inadequacies (Peretz,

1983).

During the late 1950s and early 1960s, the

pharmaceutical industry world-wide experienced radical

changes in the research and development of new drugs. With

the introduction of expensive and time consuming clinical

trials and new laboratory techniques in drug development,

there was a decline in the rate of innovation, traditionally









the backbone to profits in the industry. This, together

with new regulatory restraints regarding the marketing of

pharmaceuticals (especially in the United States with the

passing of the 1962 Kefauver-Harris Amendment), encouraged

pharmaceutical firms to look to developing countries without

such rigid controls, either de facto or de jure, as

potential markets. This is particularly true for unapproved

new and old products (CEPAL, 1987:17-29).

The pharmaceutical industry typically creates a demand

for products through intensive drug promotion. Both the

real medical need and popular demand for modern medicines in

Third World countries can be easily exploited. Drug

promotion has been documented to include deceptive and

misleading practices which involve some form of

misinformation and/or error (Silverman, 1977; Silverman et

al., 1982, 1986). Errors of omission include neglecting to

mention potential adverse reactions and other warnings, and

errors of commission include listing inappropriate

indications for use and providing fictitious clinical data

on drug effectiveness and other forms of "statistical

malpractice" (Victora, 1982). Physicians, influenced by the

information presented to them, become "irrational"

prescribers (Melrose, 1982).

The capability to monitor the quality of products and

their marketing is generally beyond the means of many

developing countries. As such, government agencies must







9

rely on the good faith of the producers and distributors, at

least to maintain the standards of the countries of origin.

The dangers of relying on the industry to uphold such

standards is exemplified by the case of chloramphenicol, an

antibiotic widely dispensed in many developing countries

during the 1970s. In the United States, the indications for

chloramphenicol included only a few life-threatening

infections. Physicians were warned of the risk of inducing

aplastic anemia and other blood disorders with the use of

the drug. In Latin America, however, few warnings regarding

adverse reactions were provided, and indications included

many relatively trivial conditions, such as tonsillitis and

whooping cough (Silverman, 1976:13-150). The combination of

the dangers of the drug and the inappropriate conditions for

which it was being used was a lethal one for the populations

in Latin America.1

The high social and economic costs to many developing

countries of the production, distribution and promotional

practices of MNCs, in both the public and private sector,

prompted many countries to seek alternative means of

providing needed pharmaceuticals to their populations. In


I In 1977, after the publication of these findings,
the International Federation of Pharmaceutical Manufacturer's
Association (IFPMA) established standards for its members
regarding the provision of correct product information.
Despite concerns regarding the IFPMA's ability to enforce
itself, follow-up studies have indicated some improvement
(c.f., Silverman et al., 1982, 1986).









the 1970s, the notion of "rational drug systems" was

developed (WHO, 1975). Developing countries have been

encouraged, with the assistance of the World Health

Organization, to design national formularies that would

guide the public sector procurement of so-called "essential"

low-priced products considered appropriate for the

particular health needs of individual countries. Emphasis is

also placed on developing or expanding the role of the state

and local private pharmaceutical industries to produce these

products so as to break the cycle of dependency on MNCs (Von

Wartensleben, 1983).

The Social and Cultural Context

The relationship between the presence of a national

essential drugs formulary, physician prescribing, and self-

medication is not irrelevant. Because regulations regarding

the sale of legend medications are either very relaxed or

not well enforced in many situations, consumers can purchase

almost any medication without presenting a prescription from

a physician. Nonetheless, self-medication in many

developing countries appears to parallel the prescribing

habits of physicians, especially in the preference for brand

name products (cf., Hardon, 1987; Fergusen, 1981; Loyola,

1983; Logan, 1983). Drug merchants and consumers learn what

medications are prescribed for various conditions from

previous prescriptions (their own or others'), or drug

promotion literature and package inserts. In Brazil, for







11

example, lay individuals who make a hobby of collecting and

studying package inserts (bula) are called "bulistas".

Indeed, some researchers have suggested that, based on

existing international mortality data, there is no evidence

to date to support the claim that requiring a prescription

renders medication use any safer than self-medication

(Pelztman, 1987). Therefore, the concern regarding

irrational physician prescribing and developing national

formularies is necessarily extended to self-medication

practices.

Fergusen (1981) suggests that the medicalization of

illness, the definition and treatment of certain illnesses

as medical problems, is different in developing countries

than in the more developed countries and that this accounts

for differences in self-medication behavior. The way in

which modern pharmaceuticals are integrated into self-care

practices in these societies reveals a reliance on a type of

therapy which is based on the notion that the solution to

illness resides in the consumption of medications rather

than on the consult with a medical professional. The

"commerciogenisis" of pharmaceuticals has been described for

several developing countries (cf., Hardon, 1987; Greenhalgh,

1987; Igun, 1987; Logan, 1983), including Brazil (Tempordo,

1986).

In this schema, pharmacists often play a crucial role.

Pharmacies tend to have a less centralized distribution than









physician offices and hospitals and are, therefore,

relatively accessible (Knox, 1981). In various developing

country contexts, pharmacists and other pharmacy personnel,

whether formally trained or not, are often called upon to

play the role of a culture broker, interpreting and

mediating modern medicine and alternative or popular care

traditions (Woods, 1977; Press, 1969; Fergusen, 1983; Logan,

1983). Because of the relative accessibility of

pharmacists, in those societies where resources for medical

care compete with those for other pressing development

needs, pharmacies may represent an untapped resource by

health care planners in promoting informed self-medication.

Although the potential for pharmacists to serve as

primary providers and health care advocates in countries

like Brazil is apparently great, there are significant

barriers to overcome. Primarily, often, the vendor of

pharmaceuticals is not a pharmacist. Although the need for

a trained pharmacist in the community setting is open to

debate, some reorientation within the profession which re-

emphasizes professional responsibilities in the community

pharmacy is clearly required (Cunha, 1987). If a minimum

standard for trained, informed pharmacy assistance for

patients could be established and enforced, the abuses

arising from the precedence of commercial interests over

patient welfare may be curbed.









Theoretical Framework

Health Services Utilization and Medication Use

Medication use may be considered a subset of health

services utilization. However, there is an important

distinction between utilization of pharmaceuticals and

utilization of other health care services. Pharmaceuticals

are a market commodity, and many drugs are available to the

general public in a relatively uncontrolled environment.

Therefore, consumers are allowed greater leeway in terms of

personal decision-making about drug use than patients

seeking care in treatment facilities (Kloos et al.,

1986:670). Individuals may chose to self-medicate, to use

only prescribed medications, or to be "non-compliant" with a

physician's prescription. The latitude for action is

subject to certain constraints on access to care imposed by

various individual and local factors. These constraints may

include, for example, legal constraints, financial

limitations and other barriers to care, beliefs and

perceptions of health and illness, and access to alternative

sources for care.

A number of national and cross-national studies of

medication use have examined the bivariate relationships

between patient sociodemographic variables and medication

use in primarily Western societies in Europe and North

America (see review by Blum and Kreitman, 1981). Cross-

national medication use studies generally do not take into









account the various social, economic, and cultural

dimensions of access to care that are likely to influence

behavior differently in different places (Rabin, 1977).

In order to address some of these aspects of access to

care, some researchers have found it useful to incorporate a

multivariate approach to understanding medication behavior

in smaller populations. One such approach is based on the

health services utilization (HSU) model, originally

developed by Andersen and Newman (1973) and expanded by

colleagues (Aday and Shortell, 1988). The HSU model has

been widely used to analyze use of different kinds of

physician and hospital services by various populations,

including the elderly (Evashwick et al., 1984; Eve and

Friedsam, 1980; Wan and Soifer, 1974; Wolinsky, 1978;

Wolinsky et al., 1983; Wolinsky et al., 1989). Variations

of the health services utilization model have also been

applied to studying factors related to prescribed and non-

prescribed medication use for urban adult samples (Bush and

Osterweis, 1978; Segal and Goldstein, 1989), including the

urban elderly in particular (Stoller, 1988), and a rural

sample (Sharpe et al., 1985).

The HSU model focuses on the unique characteristics of

the population at risk, and the resources of the health care

system. The characteristics of the population at risk

include predisposing, enabling, and need variables.

Predisposing variables include social and demographic









characteristics, health care beliefs and attitudes.

Enabling variables typically encompass various measures of

access to services and are selected to identify potential

barriers to seeking care when care is needed. Need

variables describe the extent to which the individual feels

the need for a given service and is frequently measured by

actual or perceived morbidity. Resources include the

distribution, volume and organization of the health care

system. Utilization may be measured in terms of the type,

site and quantity of health services used, and the time

interval separating use or the frequency of services used.

The HSU behavioral model has become a significant

paradigm for studying the health and health care seeking

behavior, even of the elderly patient population (Wolinsky

et al., 1990). However, this is not to say that the model

is not without its limitations. In a review of the utility

of the application of the HSU model, Wolinsky and Arnold

(1988) point out that need variables are consistently the

most significant determinants of health services

utilization, and that the contribution of predisposing and

enabling characteristics are often insignificant.

Furthermore, the total amount of variance explained by the

model is usually minimal.

Often, studies employing the HSU paradigm are

constrained by the type of data available. Traditional

models that provide measures of existing services employ







16

measures of availability and cost of services as proxies for

access to care. Service characteristics (enabling

variables) typically include measures of hospital bed

supply, physician supply, and so on, for a given area.

While these are practical measures for many policy

development concerns, it has been suggested that they may

not be best suited for the elderly and that a more

psychosocial approach to conceptualizing and measuring these

constructs may be more appropriate for this population

(Wolinsky and Arnold, 1988; Wolinsky, et al., 1990). Such

an approach would acknowledge the role of other important

aspects of care seeking among the elderly, such as social

networks and other emotive aspects of illness behavior

(Stoller, 1988). Furthermore, there is an implicit

assumption of a close correspondence of "actual"

availability and cost of services with perceived

availability and cost. Such assumptions may not always be

valid, particularly under abnormal situations, as in the

case of illness and other physical and psychological

impairments. They also do not take into considerations the

availability of alternative sources of care .

Conceptualizing Access to Care

In its broadest sense, the health services utilization

model addresses the relationship between the accessibility

and use or non-use of health care services. As a general

model, it serves as a guide for the development of more







17

specific models of utilization for specific populations and

services. Indeed, access is a relative term which may be

conceptualized to acknowledge socioeconomic, cultural,

physical, psychological and organizational aspects of

access. At the very least, it incorporates the aspects of

the availability, affordability of health care, as well as

the acceptability, in terms of patient satisfaction and

trust, of care (Fosu, 1989).

Medical geographers are often concerned with access to

care in terms of physical distance. Spatial analytic

studies examine actual distance and the effects of distance

decay on service utilization. Spatially discrete

concentrations of health care services inevitably make

physical access an important issue in more rural developing

countries (Kroeger, 1983), as well as inner city areas

everywhere (Shannon et al., 1973; Kloos, 1986; Igun, 1987).

The underlying assumption in this approach is that physical

accessibility to services implies minimal time and cost

involved in travel, thereby releasing a greater proportion

of household income for expenditure on consumption and

making a greater amount of time available for other

activities.

Health care economists often operationally define

access to care to include the affordability of care in

addition to the availability of health care facilities.

Common indicators for affordability of care that have been







18

used in the United States include health insurance coverage

and family income. The assumption is that having health

insurance coverage or higher incomes enable a person to

receive services. Results have suggested that insurance

status, including public programs such as Medicaid, may have

reduced the financial barriers to care for poor patients

(Wan, 1982; Wolinsky et al., 1989).

Accessibility also implies the more qualitative aspects

of opportunity and choice in use so that physical distance

and price may not always be meaningful factors in and of

itself. The combined effect of perceived distance, the

perceived availability of transportation, costs, and

facility characteristics, has been found to affect health

care services utilization (Joseph and Reynolds, 1984; Knox,

1979). Indeed, distance may not be a relevant factor at all

for some groups of patients (von Mering et al., 1976), or it

may only be relative to all other available health care

alternatives or options (Gesler and Meade, 1988). Cross-

cultural studies confirm that greater utilization of health

care services correlates with higher socioeconomic status,

but only when such services operate on a fee-for-service

basis (Kleinman, 1980). Some studies indicate that lower

socioeconomic status patients are more likely than higher

status patients to utilize a greater number of health care

sectors (popular and professional), and a broader range of

health care practitioners so that increased income and









higher education may actually restrict rather than broaden

the patient's range of health care options (Low, 1981).

Perceived options in health care is also a reflection

of patient preference for, and expectations of, particular

services or treatment modalities. Attitudes towards medical

and pharmaceutical services, as well as alternative healing

strategies, are essentially historical in nature. They are

not only historical with respect to an individual's personal

experiences (so that elderly patients are likely to have

different views about medical care than younger patients),

but encompass a broader social and cultural experience.

The effect of the social distance between client and

professional on patient satisfaction with different forms of

health care has been researched by medical sociologists and

anthropologists for many years, in many situations in

various cultural and multicultural settings (c.f., Simmons,

1958; Koos, 1954, 1958; Clark, 1970; Low, 1983; Loyola,

1983). Patient dissatisfaction may arise from the conflict

between the social equalitarian ideology behind public

services (such as health care) and the realities of

socioeconomic inequalities and cultural conflicts regarding

the interpretation of appropriate therapies and outcomes.

The more overt examples of this interaction include the

reserved attitudes of ethnic enclaves toward "mainstream"

medical care for certain conditions and complaints, but not

others (Clark, 1970). Patients unsatisfied with a given









medical treatment may seek to supplement or substitute a

physician's treatment with the advice of another, more

"acceptable" health professional, or other alternative.

Along these lines, Loyola (1983), in her ethnography of

health care services utilization in the city of Nova Iguazu

(Rio de Janeiro), suggests that an individual's attitudes

towards health care alternatives are influenced not only by

the physical environment, but also by the social environment

in which the drama of health and illness takes place.

Through what Loyolla calls the "efeito do bairro," or,

neighborhood effect, attitudes toward services are shaped by

a kind of dialectic interaction between the relative and

absolute poverty (or wealth) of the community and the

internal and external social cohesion of the community.

Access to Care and Medication Use

Several studies have incorporated some aspects of the

HSU framework for examining different kinds of medication

use (for a review see Sharpe et al., 1985). However, few of

these have incorporated measures of perceived access to

care. Bush and Osterweis (1978) included in their model of

medication use behavior for American adults in Baltimore a

measure for perceived availability of care. Although

measured by only one item on a four point ordinal scale, the

results indicate that the more people perceived care as

available, the more likely they were to use a prescribed

medication and less likely to use a non-prescribed









medication. People were more likely to self-medicate if

care was perceived as less available. Furthermore, in this

study, perceived availability of medical care was not

related to the travel time to the site of care.

In another model developed by Sharpe et al. (1985) for

medication use among the rural elderly in Mississippi, a

measure for perceived availability of physician services and

one for perceived availability of pharmacy services were

included. These measures represented indices of the

summated scores for various items. Results showed that

perceived availability of pharmacy services exerted a

significant negative effect on both prescription and non-

prescription (OTC only) drug use, while perceived

availability of physician services was not a significant

factor in the analysis. The unexpected, counterintuitive

finding of a negative effect of the perceived availability

of pharmacy services on medication use may have been due to

the operationalization of the construct, and/or the

inclusion of the ordinal variable in a regression model.

The present study builds upon this previous research by

focussing on the relationship between perceived access to

medical and pharmacy services and medication use. It adapts

the behavioral HSU model to include three dimensions of

perceptions of access to care (acceptability, availability,

and affordability) as the enabling variables of interest.

These measures complement more traditional measures, and









offer a reasonable alternative in the absence of complete

data on actual service availability.

The current investigation adopts the perspective that

geographical area is more than a simple measure of location

and spatial discreetness. In this sense, the approach taken

in this study approximates the traditional approach of the

sociology and anthropology of community study (Stein, 1972;

Arensbery and Kimball, 1965). However, in recognition of

the limitations of the usefulness of community studies as a

source of information about broader regional or national

experiences, this study examines a larger geographic unit of

analysis (groups of communities sharing significant

characteristics) in order to enhance the representativeness

of the sample. The investigator concurs with other studies

that recognize the limitations of the distance variable in

assessing access to care (Gesler and Meade, 1988:460). In

addition, the investigator agrees with and builds upon the

work of other health services utilization studies that

acknowledge the possibility of a significant influence of

social structure on perceived access to care for various

subpopulations in a society (Wolinsky, et al., 1989).

Furthermore, she suggests that an independent examination of

smaller geographical areas within the larger areas may

reveal relationships of various predictor variables and

access to care that might otherwise be obscured in studies

of larger aggregate populations. Specifically, in this









research, predictors of medications use for the different

SES areas were examined both collectively and for each area

individually.

Research Questions

In order to address the stated goals of this study, the

following specific research questions were investigated:

1) Which variables of the hypothesized medication use

model (predisposing, enabling, and need) emphasizing

perceived access to medical and pharmacy services are most

important in explaining prescribed medication use, and which

are most important in explaining self-medication in the

sample of Brazilian urban elderly in the Municipio of Rio de

Janeiro? Do residential areas with different socioeconomic

characteristics affect these interrelationships, and if so,

in what ways?

2) How well does the conceptual model fit the

utilization of physician and non-physician prescribed

medication in the low, medium, and high socioeconomic status

areas in the municipio of Rio de Janeiro? What variables

are the best predictors of self-prescribed and physician

prescribed medication use in these areas?

3) What proportion of medications being taken are

prescribed by a physician and what proportion are self-

prescribed?









4) Which therapeutic classes of medications are most

frequently used by the elderly in the sample? How

frequently are different classes self-prescribed?

Significance

In 1985, the World Health Organization published Drucs

for the Elderly, a concise report on issues in geriatric

drug therapy. These include high rates of medication use

relative to other age groups, and the increased risks for

clinical and non-clinical drug-related problems.

Nonetheless, as a treatment modality, the cost-benefit ratio

of pharmaceuticals is often favorable relative to other

modalities for many of the conditions that typically afflict

the elderly. The timeliness of the WHO publication for

developing countries derives from by the fact that large

elderly populations are no longer confined to the developed

Western world (Kalache et al., 1987; Kinsella, 1988) and

there is relatively little known about geriatric drug use in

less developed countries.

The health care needs of the elderly have demanded the

attention of policy makers in the more developed countries

for many years. Of increasing importance is the widespread

use of both prescribed and non-prescribed medications.

Indeed, in many Western, developed nations, medication use

has been found to be more the rule than the exception among

the elderly (cf. Rabin, 1977; Simonson, 1984; Lipton and

Lee, 1987; Cartwright and Smith, 1988), and consequently,









the elderly may be identified as a high risk group for

experiencing serious drug-related problems (Strand, et al.,

1990). In the United States, for example, the elderly made

up approximately 12% of the population in 1986, but received

32% of all prescription medications (Baum et al., 1987). In

addition, it has been estimated that roughly one-third of

all medications taken by the aged are over-the-counter (OTC)

products, and as many as 75% or more of the elderly in the

United States use at least one OTC at any time (Simonson,

1984:14-15).

One of the most consistent findings in geriatric drug

use research is the increase in the number of medicines used

with increasing age. Between 1977 and 1985, prescribing for

the elderly in Great Britain increased 27% compared to a

decrease of 6% among the non-elderly population (Cartwright

and Smith, 1988:1-2). In a longitudinal study of ambulatory

elderly in Florida, the average number of medications used

increased significantly from 3.22 in 1978-9 to 3.94 in 1987-

9 (Stewart et al., 1991). The absolute number of

medications used not only increases with age, but the nature

of the medications most commonly used also changes. These

changes would appear to follow the nosological alterations

accompanying the aging process (Knoben and Wertheimer,

1976).

The elderly are more likely to suffer from chronic,

degenerative, and disabling conditions than younger adults,









and these conditions often entail long-term medication use

(Verbrugge, 1984). Many treatments involve complex drug

therapies, such that the elderly who use medications are

also likely to use more than one medication. Polypharmacy

(the use of multiple drugs) has been associated with

multiple prescribers, particularly for patients suffering

from several ailments and who are under the care of more

than one physician. Lack of coordination in drug therapy,

confusion about drug use, and non-compliance are often

associated with more complex drug regimens (German and

Burton, 1989).

With polypharmacy, the likelihood of the occurrence of

an adverse drug reaction (ADR) and drug-drug interaction, as

well as drug duplication, increases. However, many ADRs are

considered to be predictable and, therefore, preventable.

Yet, because many ADRs manifest differently in the elderly

than in younger patients, a vicious cycle may result as

medications are prescribed for treating the symptoms of the

side effects of a previous medication. Some side effects

manifest as behavioral disorders which may be misdiagnosed

as senile dementia by an untrained physician (Beardsley,

1988; Miller and Elliot, 1976). The costs of ADRs

associated with hospitalizations, prolonged

hospitalizations, and heroic life-saving measures may be

high, the preventable loss of life unmeasurable (Manasse,

1989; Grymonpre et al., 1988; Gurwitz and Avorn, 1991;









Melmon, 1971; Tinetti et al., 1988; Hallas et al., 1990;

Hepler and Strand, 1990).

There are several nonmedical drug-related problems that

elderly people may be likely to experience. The elderly are

often unemployed and typically rely on restricted incomes,

factors associated with decreased access to medical services

(Fredman and Haynes, 1985). Patients on chronic

medications, needing several different medications, or

expensive medications, may compromise their drug regimen in

order to economize.

The developing countries may anticipate similar but

more acute difficulties than the developed countries in

meeting the health needs of their elderly (Tout, 1989). It

is widely recognized that many developing countries have

overburdened, inadequate health infrastructures unable to

meet the persistent primary care needs of a younger and

poorer population. Competition for scarce resources may

result in difficult prioritization in resource allocation

(Bicknell and Parks, 1989).

Brazil has been described as a young country growing

old (Veras, 1988). In 1980, eight percent of the population

was 60 years old or more, and nearly 70% of these lived in

urban areas (IBGE, 1987). The elderly have been the fastest

growing age group in Brazil since the 1940s and it is

estimated that by 2025, Brazil will have the sixth largest

elderly population in the world. Between 1980 to 2000, the









proportion of the population over 60 years old is expected

to increase 107% in contrast to that proportion of the

population 15 years old and less, which is expected to

increase only 14%. Brazilian gerontologists are concerned

that Brazilian authorities are already facing the problem of

an aging population comparable to that experienced by the

developed countries with all its implications for the health

and social care system (Ramos et al., 1987).

Summary

Brazil shares with other developing countries the

problems regarding access to needed essential medications

and the inappropriate use of medications (Allen, 1989;

Soares, 1989). Medications, whether in the form of

vaccines, antibiotics, or analgesics, are an integral

element of public health and primary care as well as in the

management of chronic and degenerative diseases. An

understanding of the factors that influence access to and

the appropriate use of medications is of extreme relevance

for all patient/client groups, including the elderly.

The purpose of evaluating perceived access to care in

the study of health care services utilization is to identify

barriers to care, or, conversely, facilitating factors.

Access to care necessarily incorporates dimensions of

acceptability, availability, and affordability of care. In

the study of medication use, both with physician prescribed

and non-physician prescribed drugs, it is meaningful to









investigate the relative importance of perceived access to

medical and pharmacy services. In the context of

uncontrolled commercialization of medications characteristic

of many developing countries, including Brazil, where the

risks associated with self-medication are increased, this

relationship assumes particular interest. The specific case

of Brazil, including the health care system, pharmaceutical

industry, and retail pharmacy in this nation, is discussed

in Chapter 2.

The determination of the extent to which the dimensions

of perceived access influence medication use behavior in

different areas within an urban setting is also a focus of

this study. Areas may be distinguished by locational,

socioeconomic and cultural factors. Areas are not only

composed of groups of individuals, but they may also be

understood as in themselves influencing individual

attitudes, and exerting some influence on perceived access

to care.

The specific population of interest in this study is

the urban, noninstitutionalized elderly. The elderly

represent a segment of the population in developing

countries which will be commanding increased attention. The

economic, social, and political impact of the health and

illness of a growing elderly population will need to be

considered in assessing the relative value of competing

health policies. Changing demographics will force countries









like Brazil, accustomed to being concerned about the

expanding bottom of their population pyramids, to look up

and refocus.

The methodology employed for the development of a model

to describe medication use for the urban Brazilian elderly

is presented in Chapter 3, including the operational

definitions of variables and their measurement, selection of

the sample and data collection techniques. Descriptive

results are presented in Chapter 4, along with the results

of analysis modeling medication use. Conclusions and

recommendations for future research are presented in Chapter

5.













CHAPTER 2
MEDICAL AND PHARMACY SERVICES IN BRAZIL


Introduction

This chapter presents the health care context in which

medication use takes place in Brazil. The discussion begins

with an overview of the formal health care system, the

principal public and private institutions that provide

services, and how they are utilized. National formularies,

regulations that define legend and non-legend drug

categories, who may prescribe legend medications, and the

mode of distribution and commercialization of medications

are all aspects of a formal health care system.

The discussion of the informal health care system, for

the purpose of this study, is limited to the role of the

pharmacy and pharmacy personnel. Commercial pharmacies are

at once marginal to the formal health care system and an

essential element. They also represent an avenue for

recourse in self-help in general, and self-medication in

particular.

Health Care in Brazil

The character of the Brazilian health care system is

fragmented, offering disparate levels of care. The level of

technological sophistication and "completeness" of services









rivals that of the more developing countries. Indeed, the

costs of care also approximate those of some of the more

developed countries: in 1987, total public plus private

expenditures on health care in Brazil exceeded US$10 billion

per annum, more than 5% of the Gross Domestic Product, which

is approximately the same percent as the United Kingdom

(World Bank, 1988a:19). However, health care in Brazil is

marked by sharp disparities on the regional and local levels

such that the "marginal", poorer populations have limited

access to even the most basic of public health services,

including medications.

The health care system is also constantly evolving.

Health care is provided by public institutions (federal,

state, and municipal) and private institutions. These are

not totally independent, but they are not well coordinated

either. Decades of bureaucratic reforms gave rise to a

large centralized public sector which became notorious for

its inefficiencies in service delivery at all levels. More

recent reforms, however, call for the decentralization of

the system.

The Public Sector

The Brazilian public health care sector consists of two

major agencies: the Ministry of Health and INAMPS (Instituto

Nacional de Assistdncia Medica), the social security

institution. The Ministry of Health, which is financed

through general government revenues, is responsible for the








33

national public health programs, such as maternal and child

health and nutrition programs as well as vaccinations.

Financed through federal payroll tax revenues, INAMPS, until

recently, has been primarily responsible for providing

curative, hospital-based services to its beneficiaries.

Since the 1940s, and until 1975, the public health and

social security curative care subsystems had little to do

with each other. The Ministry of Health held low political

priority and struggled with limited budget resources to deal

with the major public health problems, whereas social

security programs were politically far more important to a

rapidly industrializing country. As social security

benefits were extended to more individuals, revenues

increased. The curative hospital-based system of the social

security medical benefits program grew at a cumulative

average annual rate of almost 20 percent for more than a

quarter of a century, while public health programs

floundered (Braga and Paula, 1980: 101).

The growth in social security medical care was directed

primarily to very costly medical treatments that were so

concentrated that they benefitted only a relatively few

patients. This style of health care delivery, which began

as a deliberate strategy of the populist political figures

to woo the emerging urban working and middle classes,

ultimately evolved to reflect the tastes of the military

technocrats for modern science and large, centralized









bureaucracies (Horn, 1985; Luz, 1986). By 1974, however,

pressure was put on political leaders to address the dearth

of public health services and the rising costs of health

care to specific needy populations not covered by social

security, such as nonsalaried urban workers and rural

workers (Malloy, 1977; Mesa-Lago, 1978).

In 1975, the Sistema Nacional de Saude (SNS) was

created as the first attempt at a unified, coordinated

national health care system. The new system

administratively linked the three ministries already

involved in some aspect of health care: the Ministry of

Labor was to oversee occupational health and safety

programs; the Ministry of Health was to be responsible for

health planning and for environmental and collective

preventative health care; the Ministry of Social Security

and Social Assistance (MPAS) was to be responsible for the

provision of personal health services. The newly created

INAMPS was to be directly responsible for the reorganization

and expansion to the poor of certain services previously

reserved for beneficiaries.

The role of the social security program in providing

medical services increased with the growing pool of social

security beneficiaries. Between 1970 and 1980, the

proportion of all workers covered by Social Security in

Brazil increased from 27 percent to 47 percent (Isuani,

1984:195). In the urban areas, 86.3 percent of all









employees and 50.4 of all self-employed individuals were

covered to some extent by 1980, with the highest proportion

residing in the more industrialized southern regions (IBGE,

1980).

There has been a direct cost associated with this trend

which has become the nemesis of the system. As mentioned

previously, the curative, hospital-based care INAMPS

provides is expensive. However, INAMPS also pays for

services rendered in non-INAMPS facilities on a fee-for-

service basis. Patients with a choice of facilities tended

to select the higher cost private care, invoking a version

of the "moral hazard" associated with certain health

insurance schemes. Since insurance lowers the price of care

to individuals, they will consume more care than if they had

to pay the entire price themselves, and "too much" medical

care is consumed (Feldstein, 1988:128-129).

The physicians also had a direct role in promoting this

behavior by means of what Brazilians call "duDla

militancia", referring to a conflict of interest that arises

when physicians work as part-time employees at several jobs,

as many do, in both public and private facilities. Under

dupla militancia, physicians recruit patients from the

public facility, where they are salaried and work with

patient quotas, into the private facility where (it is

assumed) the physician believes s/he can offer better

quality services. This is also a lucrative business move








36

for the physician because s/he can then charge on a fee-for-

service basis, even when INAMPS reimburses (Cordeiro, 1984;

World Bank, 1988:44-45).

This unanticipated abuse of the system was not the only

problem with the SNS. There were serious problems with

meeting some of the other reform mandates to provide care to

the needy. Although the SNS promised to give a boost to

traditional public health programs, there was no

administrative mechanism that permitted coordination to take

place between the various agencies, especially the Ministry

of Health and INAMPS. The Ministry of Health actually did

experience a 35.7% budget increase between 1974 and 1975,

but the positive impact of the new reform on the Ministry of

Health was short-lived. New programs were forced to operate

under severe limitations as promised resources never fully

materialized (Braga and Paula, 1980: 97-98). Since the

ministries could not resolve their ideological differences

about health care priorities and coordinate activities, an

informal geographical division grew up between them, with

the Ministry of Health focusing on the Northern regions and

rural hinterlands, and INAMPS on the Southern regions and

industrialized centers. In 1977, a reform within SNS aimed

to resolve the administrative barriers between the

ministries. However, despite these reforms and the

expansion of free-to-patient INAMPS emergency medical









services, private health care expenditure did not decrease

(Musgrove, 1983).

The mid-1980s marked the beginning of the return of

democracy to Brazil. With it came a flood of proposals for

a more democratic health care system which resulted in the

creation of the new Unified System for Services (Sistema

Unificado de Saude, or SUS). In sharp contrast to previous

efforts, SUS aims to improve the efficiency of the public

sector by decentralizing its administration and allowing

states and local municipalities to take on a larger role in

administrating and coordinating local health care services.

It is too soon to evaluate the impact of SUS on health

care, but the heritage of the system that developed in the

decades prior to SUS is not likely to be easily shaken. The

inefficiencies of the bureaucracy which proliferated with

each successive administrative reform have been harshly

revealed in the face of the recent national economic crisis.

In August, 1990, INAMPS announced that it would be

"trimming" some of its more redundant, dispensable personnel

(50% of which worked in Rio de Janeiro), including some

physicians ("INAMPS afasta...", 1990). While apparently a

sensible motion, it was disconcerting to the public for two

reasons: firstly, public servants (traditionally a very

secure type of position in Brazil) do not typically lose

their jobs, and, secondly, despite assurances to the

contrary by officials, the public feared the further









discontinuation of badly needed services. Indeed, two

thousand health posts and several public hospitals

throughout the nation were not providing services due to

lack of funds to pay personnel and purchase supplies

("Atraso na verba....", 1990).

The Private Sector

The private health care sector in Brazil includes

services provided by health care corporations for large

companies and institutions (such as banks, and labor

unions), religious and other charitable institutions, as

well as large and small private practices. The delivery

style in the private sector mirrors that of the public

sector and is heavily hospital-oriented. Indeed, the

character of the medical-industrial complex in Brazil is the

result of a symbiotic relationship between private medical

businesses and public funds.

Prior to 1965, there were several health-related

programs, each designed for a separate workers group (i.e.,

railroad workers, steel workers, etc.). When these various

programs were unified, Social Security began to contract

with health care organizations to provide medical services

to some of these groups. Health care corporations and group

practices, generally affiliated with private hospitals,

could be certified by Social Security and negotiate with

businesses and workers groups, and then be reimbursed by

social security. Private, subsidized services were made







39

available to salaried industry workers and various tertiary

sector (mostly commerical and services) workers. The

extension of services by the private sector to non-Social

Security beneficiaries occurred in 1974. At this time, the

right to emergency care was extended to all citizens.

Most of the empresas medical (medical corporations) are

non-profit organizations. Many offer pre-paid health plans

to members in a kind of HMO structure. Parallel to the

development of these group practices, physician cooperatives

also began to compete for patients. The cooperatives are

ideologically opposed to the closed-group, pre-payment

structure of group practices, and may be likened to the

preferred patient programs in the United States.

As Social Security grew in Brazil, extending coverage

to include more benefits to a broader population base, the

subsidized business for the private medical sector also

grew. Cordeiro (1984) argues that the increase in contracts

between Social Security and private health care

organizations indicated dissatisfaction on the part of

beneficiaries with the services provided directly by Social

Security physicians and hospitals, and that demand for these

services exceeded supply. The preference by certain

industries and businesses to contract with the health care

organizations was also a politically safe and economical

means of satisfying worker's demands (Cordiero, 1984:64-86).









As with many other businesses, these corporations are

having difficulties in dealing with the vagaries of the

contemporary Brazilian economy. Within the last few years,

the tension between the actual health care providers and the

contractors for their services has run high. Conflicts

revolve around the inadequacies of the payment structure,

(primarily reimbursement schedules), in the wake of the

prevailing inflation rates. With run-away inflation, the

more time that elapses between charging for a service and

receiving payment, the greater the devaluation of the

remuneration.

Similarly, salaries had to be constantly reajusted for

inflation. In June, 1990, the national organization for

health care corporations presented a new payment scheme for

their physicians in response to the new rates previously set

by the Brazilian Medical Association (BMA). The medical

corporations argued that they could not afford to pay their

physicians according to the BMA rates because the

corporations were not permitted to adjust the fees they

charged their clients. Unsatisfied physicians went on

strike (crippling both public and private health care

services) and began to charge for private services using the

BMA rates. It was not until nearly three months later, in

September, that a judge ruled against using the BMAs rates

as mandatory rates, and sent all parties to the negotiating

table.







41

The health care organizations were also recently faced

with other changes that directly affected their clientele.

In January, 1991, new federal regulations gave health care

organizations the option of either formally becoming health

insurance corporations, or of maintaining their health

programs as they were, but managing them as if they were

insurance policies. Previously, health plans offered

services similar to health insurance policies, but were not

subject to the price and other quality controls imposed on

insurance policies.1 Golden Cross, with over 700 thousand

clients in its health plan nation-wide, was one of the first

to switch to a formal insurance entity, Golden Cross

Insurance. Although there were no changes in service, the

monthly fees to clients did increase enough to make many

clients very concerned: in Rio de Janeiro, for example,

where more than half of Golden Cross' clients reside, rates

increased by over 150% (Susep elabora..., 1991).

Health Services Utilization in Rio de Janeiro

In 1986, a national household survey examined health

services utilization in Brazil. The study revealed that 67%

of all Brazilians who had a health problem sought medical

attention. Ninety-seven percent of all urban residents, and

53% of all rural residents with a health problem sought

1 In addition, if the corporations changed their non-
profit status to become a private insurance company, the
government could reap an estimated US$80 million per annum in
new tax revenue (Dantas, 1991).









medical attention. Of the urban residents who sought care,

10.5% were persons 60 years old or more. Of the rural

areas, 8.5% of health services users were elderly (IBGE,

1989:4).

The State of Rio de Janeiro is one of the wealthiest

states in Brazil, and boasts one of the largest metropolitan

area in the country. With 68 municipios (counties), and an

estimated population of 14 million, Rio de Janeiro has both

extensive urban and rural areas. In the urban areas of Rio

de Janeiro, 79.5% of the persons who reported having had a

health problem sought medical attention, and 14.4% of all

urban patients were elderly. In the rural areas, 77.5% of

those who reported having had a health problem sought care,

and 11% of these were elderly (IBGE, 1989:322). These

figures suggest roughly equivalent access to care on the

basis of perceived need (ie., having a health problem). The

higher percentage of elderly patients in the urban areas

reflects the relatively greater proportion of elderly in the

urban population than in the rural areas.

Reasons for not seeking care are presented in Table

2.1. Transportation and financial barriers to care were

reported less frequently in urban areas of Rio de Janeiro

than rural areas. On the other hand, scheduling and other

time barriers, probably related to the busy urban working

class lifestyle, were more likely to keep people from

seeking medical attention in urban areas.











Table 2.1 Reasons why people did not seek medical
attention but had a health problem in Brazil
and the State of Rio de Janeiro, 1986.

Reason Brazil Rio de Janeiro

Urban Rural
0 6 '6a

Transportation
problem/distance 10.1 4.4 13.7

Scheduling problem 3.4 6.7 6.4

Long wait time 4.3 5.5 1.5

No need 63.8 62.4 60.0

Financial problem 10.9 5.2 7.3

Other 7.4 15.8 11.1

Total 100.0 100.0 100.0


Source: IBGE (1989), table 7, p. 9 and p. 327.









In the municipio (with approximately 6 million

inhabitants), there are 16 municipal hospitals, two major

university hospitals, other state and federal hospitals, and

several private and philanthropic hospitals offering

distinct, specialized services. In addition, there are 70

public health posts and health centers and over 40 INAMPS

facilities. The more urban, metropolitan area also has a

relatively high concentration of private clinics and

physicians. The hospital utilization rates in both the

urban and rural areas do not differ greatly from the

national rate (see Table 2.2). This reflects the high

reliance on the curative, hospital-based health care system,

even though the public system has been struggling to keep

hospitals functioning ("Cremerj vai a Justica...", 1990).

The decreased reliance on public health posts and centers

and the greater utilization of clinics and physicians'

offices in the urban areas demonstrates the relative

abundance of health care plans/policies available in the

urban areas that are not widely available in the more rural

areas, and, indeed, throughout the rest of the country.

Where one seeks medical attention is related to income

(Table 2.3). Unfortunately, the data do not distinguish

between public and private facilities. Nonetheless, given

our understanding of the health care system, it is not

surprising to find that, in both urban and rural areas,










Table 2.2


Types of health services
Rio de Janeiro, 1986.


used in Brazil and


Type of Service Brazil Rio de Janeiro

Urban Rural
6* 6

Public health post or
health center 20.8 12.2 16.9

Hospital 36.9 34.5 35.6

Clinic, Polyclinic,
or physician's office 36.2 49.2 39.3

Union or employer's
infirmary 4.1 2.9 6.9


Other 2.0 1.2 1.3

Total 100.0 100.0 100.0

Source: IBGE (1989), table 9, p. 11 and p. 329.


Table 2.3 Utilization of health care serivces in Rio de
Janeiro by household income per capital, 1986.

Income Group Typve of Service
(Minimum salary) Public health Hospital Clinic, Other
post/center MD office
% (1) (2) (3) (4)


Urban
No income
<= 1/4
1/4 to 1/2
1/2 to 1
1 to 2
+ 2

Rural
No income
<= 1/4
1/4 to 1/2
1/2 to 1
1 to 2
+2


100.0
100.0
100.0
100.0
100.0
100.0


100.0
100.0
100.0
100.0
100.0
100.0


17.7
14.9
21.2
17.7
10.8
5.3


100.0
28.3
22.4
12.2
8.3


50.6
41.0
38.4
41.5
36.0
26.7



45.3
35.0
38.4
16.6
37.2


28.0
42.6
34.4
37.1
49.7
64.2


3.7
1.5
6.0
3.7
3.5
3.8


14.7
33.0
39.7
75.1
62.8


11.7
9.6
9.7


(1989), table 11, p. 331.


Source: IBGE











higher income groups rely more on clinics and physician

offices than do the lower income groups.

The Pharmaceutical Industry In Brazil

The role of medications in the Brazilian health care

system is not insignificant. In 1989, Brazil was the eighth

largest market in the world for pharmaceuticals. It was

estimated that there were approximately 20,000 products on

the market, utilizing some 2,100 different active

ingredients (Soares, 1989:43). In 1990, this was a US$2.9

billion dollar market, with room to expand. Currently,

multinational corporations control 73% of the market

("Remedios congelados",...1990). Eighty percent of all

physician visits result in a prescription (IBGE, 1989:29),

although complaints of shortages of essential medications,

even in the urban areas, are a constant (Allen, 1989). This

section explores the Brazilian pharmaceutical industry, both

private and public, and industry's recent impact on the

economic and social aspects of medication use.

The Private Sector

By the 1940s, Brazil had an established, if modest,

domestic pharmaceutical industry, including infrastructure

and trained personnel. This was due in part to the

contributions of chemists and pharamcists who immigrated

from a war-torn Europe. Brazil also had by this time an

established medical care system heavily biased in favor of







47

an individual-curative model of medicine. All thses factors

contributed to make Brazil particularly attractive for

investment by foreign pharmaceutical firms in the 1950s.

A major transformation in the make-up of the

pharmaceutical industry occurred in the early 1960s. An

extended period of political crisis triggered economic

stagnation that lasted until 1967 (Baer, 1983:93-97). The

impact was hardest on national firms: between 1960 and 1962,

75 national pharmaceutical firms disappeared from the

industry. After the military coup of 1964, strict

stabilization reforms were introduced which favored foreign

investment, and between 1966 and 1969, five of the largest

remaining Brazilian pharmaceutical firms were bought out by

international companies (Evans, 1979:125).

The local Brazilian firms that survived the waves of

denationalization seemed to have done so on the basis of

their successful commercial and marketing capacities rather

than competiveness in research and development (CEPAL,

1987). The top firms concentrated on specific therapeutic

classes and market power was gained from brand preferences.

However, each firm's power was limited by the presence of a

large number of close substitutes, indicating a market

characterized by an undifferentiated oligopoly.

Furthermore, although there was a large diversity of

different products, the required technology was relatively

simple and unconcentrated so that the market for the









introduction of new products was fragile. The basis of

competition for control of the pharmaceutical market in

Brazil, therefore, was in the area of production of

pharmaceutical specialties, including new combination drugs,

and new dosage formulations, not the development of new

drugs per se. Indeed, since Brazil has not recognized

patent protections since 1969, any laboratory could submit

registrations for any product. The small national firms

took advantage of this by registering copies of all the most

commercially important products, the vast majority of which

were MNC products. For example, in 1982, apart from

Beecham's brand of amoxycillin, under patent protection in

the United States, and that of their licensed subsidiary,

there were 17 other brands available on the market, with

many more registered (Adler, 1982:627).

The Public Sector

In 1971, CEME (Central de Medicamentos) was established

as a crucial element of the Brazilian government's answer to

the ever increasing costs of medical care in general, and

medications in particular. The stated purpose for the

creation of CEME was to provide essential medications, as

listed on the national formulary (Relat6rio Nacional de

Medicamentos), free of charge or at a reduced rate to that

segment of the population determined unable to afford them

on the open market, which at the time of CEME's inception

was estimated at 90 million people (Cordeiro, 1985). CEME









was to develop and produce medications as well as contract

out to private firms to make up for production

difficiencies.

Ideally, the merits of adopting essential drug policies

may be phrased in terms of health benefits and potential

savings, not only on the national level (Lilja, 1983;

Wang'ombe and Mwabu, 1987), but on the individual consumer

level as well (Patel, 1983). However, the promises of the

essential drugs program in Brazil were never to be

fulfilled. In 1974, over half (57%) of household health

budgets in Brazil was spent on medications (Musgrove,

1983:252), compared to 34% in the more prosperous urban Rio

de Janeiro (Cordeiro, 1985:181). Similarly, a comparison of

four communities in Sdo Paulo demonstrated that the

proportion of health care expenditures related to medication

use was greatest for the poorest socio-economic strata

(Giovanni, 1980:129). In 1990 CEME revealed that as much as

55% of the targeted population was not being served.

CEME never became the national industrial contender

some would have had it become. In 1975, CEME was

dismembered: distribution services were allocated to the

Ministry of Welfare, while research, development, and

production were incorporated into the Ministry of Trade and

Commerce. As of 1985, CEME administratively resides under

the auspices of the Ministry of Health, but remains









operating suboptimally, especially in the production of

medications.

The failure of the program has been a great

disappointment politically, economically and socially

(Evans, 1979, Landmann, 1982; Cordeiro, 1985; Cunha, 1987;

Soares, 1989). The negative implications of its failures

have been ballooning during the last few years. A recent

study by the Health Commission of the Legislative Assembly

in Rio de Janeiro reported that CEME spent 95% of its budget

on the acquisition and distribution of medications and that

contracts with private firms accounted for nearly 55% of

this amount, approximately CR$10 billion, in 1990 ("Deputado

diz...", 1991; "CEME nega...", 1991). The dependence on

private firms became a problem when government price-fixing

of medications was terminated, beginning in August, 1990,

and prices began to rise at unprecedented rates. The cost

of doing business with private firms became untenable and,

in the face of dire shortages for many drugs, CEME was

forced to look elsewhere for the medications it required.

In January, 1991, the president of CEME, Antonio Carlos

Alves dos Santos, asked that 16 state laboratories expand

production as a means to alleviate the shortages ("Verba

para os laboratorios...", 1991). Whether or not this was a

"reasonable" request, whether production capacity could be

expanded, and so on, is questionable.

Economic and Social Aspects of Drug Use







51

Although the price of medications in general has been a

matter of public concern, at least since the early 1970s,

the current economic crisis, marked by both hyper-inflation

and recession, has brought the issue back in full force. In

a 17 month interval, from January 1987 to May of 1988, the

price of medications increased on the average 5,297%,

although the rate of inflation during this period was

943.7%. Among the medications experiencing the greatest

increase were those commonly used for chronic diseases like

Higroton and Atenol, both antihypertensives (medications

frequently used by elderly patients), which increased 1,952%

and 2,969% respectively during this period (Caldas, 1988).

After the steps were taken to deregulate the economy in

1990, further price increases were the result of hikes in

the commercial dollar exchange rates for imports and

exports. Since 42% of the value of the primary materials

used in production is imported, this increase (approximately

30% between October and November, 1990) was transferred to

the price of medications. Although the industry argued that

price increases reflected the increases in cost of

production, as well as mark-ups to cover the cost of

producing products whose prices were still controlled, new

prices generally outstripped these increased costs and

general inflation ("A inddstria farmaceutica...", 1990;

"Remedios terdo...", 1990).









Those hardest hit by the impact of these events were

the consumers, particularly chronic medication users. The

following testimonies from letters to the editor of the

major newspaper in Rio de Janeiro, Jornal do Brasil, are

examples of the experiences consumers encountered:

(...) I went to the Drogaria Popular on Rosario
Street, downtown, to buy a box of Antak, which I
take regularly for ulcer problems. Upon arriving
home I compared the price with the last one I
bought and almost flipped. On December 5, I paid
Cr$689, and on December 14, only nine days later.
they charged me Cr$l,886, a 173.68% increase
(...). -- Paulo Sergio Pereira (RJ) (Dec. 28,
1990).

(...) On January 8, 1991, I had to buy a box of
Frontal, that was purchased by a third party, at
the Drogaria Mexico, Ltda., on Mexico Street,
downtown, upon receiving the medication I was
surprised by the price of Cr$l,375, because not
long before I bought the same medication at the
same pharmacy for a much lower price. Upon
examining the package, I noticed that the price
sticker was placed on top of others. I took it
upon myself to lift off, one by one, the old
stickers and verified that the original price,
according to the first sticker, was Cr$612, on the
second it was Cr$642, on the third Cr$919, and,
finally, on the last one, it had been changed to
Cr$1,375 a 124% increase in a month and half!
(...). Theo de Castro Drummond (RJ) (Jan. 1,
1991).

(...) I am a heart patient, having survived a
triple by-pass surgery. I am required to take the
prescription drug Ancoron. There are 20 pills per
package. For me, a package lasts 40 days, and 40
days ago I paid Cr$505 for one box. On January 5,
I went to buy the medication at the same pharmacy
and I paid Cr$960, or, an increase of 90% in 40
days. This is scandalous (...) -- Leno Cunha
(Petr6polis, RJ) (Jan. 19, 1991).

(...) I am nearly 80 years old and have had two
by-pass surgeries (...). Early December, 1990,
among the many medications that I am obliged to
purchase, I bought at the Drogaria Popular, on









Sen. Dantas Street, a package of Venalot for
Cr$471.50. One week later, at the same pharmacy,
the drug cost me Cr$l,374, which took into account
the 15% discount [for seniors] (...). Within a
week there was an increase of 342.9%. (...) -
Fritz Berg (RJ) (Jan. 19, 1991).

The beginning of 1991 was marked by a series of

hearings by the National Secretary of Economic Rights (SNDE)

in which 17 major pharmaceutical firms were summoned to

formally justify their price increases. Only one firm,

Fontoura Wyeth, refused to lower its prices and was found

guilty of violating the antitrust law ("Governo

encerra....", 1991). These actions provoked a heated

exchange between the producers, wholesalers, and retailers,

each accusing the other of illegally increasing prices

(Lapa, 1991). By February, the Secretary of the Economy was

forced to announce the return of price-fixing for

pharmaceuticals ("Governo tabela...", 1991).

The price scandals in early 1991 resulted in some

remarkable, if not positive, changes in industry behavior.

Industry, rather ironically, responded by terminating the

production of certain product lines, or certain dosage

forms, that, in reality, may be considered irrational from a

therapeutic perspective to begin with. For example, when

the price for the 30 dose package of Vibramicina, a wide

spectrum antibiotic was fixed with a ceiling very close to

that for the 15 dose package, Pfizer stopped marketing the

unnecessary 30 dose package (Rangel, 1991).









Brazil has not had a tradition of consumer interest

groups. Therefore, it is worth noting that the health care

professionals and consumers also responded, in organized

fashion, to the situation that appeared to be getting out of

(the government's) hand. In February, 1991, SOBRAVIME

(Sociedade Brasileira de Vigilancia de Medicamentos), was

created as the first civilian organization to be concerned

with pharmaceutical quality control. Its self-purported

role is to denounce irregularities in the production,

licensing, propaganda, and sale or use of pharmaceuticals.

SOBRAVIME, while comprised principally of physicians and

pharmacists, is guided by the principals of the recently

published Consumer Defense Code (C6dico de Defesa do

Consumidor) which represented the efforts of an incipient,

broad-based consumer movement.

These organizations are interested in monitoring not

only the price of medications, but also the medications that

are marketed. Some experts estimate that more than 50% of

the medications sold in Brazil have no proven therapeutic

value, and the number of products on the Brazilian market

that are known to be dangerous or inappropriate is large.

In 1990, Health Action International, the Berne Declaration

Group, and BUKO-Pharmakampagne denounced the sale of

products in the Third World, including combination drugs

which nave no pharmacologic justification, products with an

inappropriate dosage or with "inadequate" (subtherapeutic)







55

amounts of the active ingredient (Autran, 1990). The study

revealed that 32% (142) of the German products sold in

Brazil in 1984/1985, and 37% (127) of those distributed in

1988, were considered to be inadequate. Of the Swiss

products put on the Brazilian market, 44% were inadequate.

Dipirone, a very controversial analgesic that is prohibited

in Germany, the United States, and other nations, was among

the products listed as inadequate yet currently available in

at least 99 different products in Brazil (Autran, 1991).

Pharmacies and Drugstores

Up to this point, the discussion has focused on the

production and consumption of medications. In between these

two polar ends of the path to medication use, there remains

the point of interface between the medication and the

consumer, namely, the pharmacy. According to Brazilian law

(Lei No. 5.991, 17/12/73; Decreto No. 74.170, 10/6/74),

medications may only be dispensed from four different

places: a pharmacy (farmacia), a drug store (drogaria)2, a

health/medication post (including mobile posts), and

hospital dispensaries. Medicinal plants are also restricted

to sale in pharmacies and herbal stores. Although


2 Technically, pharmacies are distinct from drug
stores in that pharmacies are allowed to formulate
medications, and drug store are strictly retail outlets for
prepackaged medications. This distinction is of little
practical significance in contemporary Brazil because tha vast
majority of pharmacies no longer formulate medications.
Hence, the term pharmacy will be used interchangeably for
both.









supermarket chains are trying to gain the right to sell

pharmaceuticals, only establishments such as hotels or non-

profit, philanthropic organizations are currently permitted

to sell or otherwise dispense non-legend (OTC) medications,

and these only to their clients (CRF-8, 1983:120-121;136-

141), although the illegal sale of medications outside of

pharmacies has been documented (Costa et al., 1988).

Pharmacists are responsible for the direct sale to

consumers of medications and other pharmaceutical

specialties, but Brazilian law also stipulates that others

may also have this responsibility (Decreto No. 20.377,

8/9/31). This includes individuals who may have some

limited formal training or apprenticeship, but are not

registered pharmacists, known as "praticos" and "oficiales".

In 1960, these practitioners were permitted to register with

the regional boards of pharmacy to qualify as a technician,

capacitated with all the rights of a pharmacist except in

the formulation of medications. This includes the right to

own and register a pharmacy and to give injections. Law No.

5,991 (17/12/73) and Decree No. 74,170 (10/6/74) stipulate

that the presence of the responsible technician (either

pharmacist or other technician) is obligatory during all

commercial hours, but a pharmacist is not required to be

present at all times.

The concern for ensuring access to medications to all

communities is also cited as the rationale for legislation









regarding the number and distribution of pharmacies

permitted in any area. New pharmacies must demonstrate a

need for services, based on a population-to-service ratio,

in order to be licensed. If no pharmacists are available in

a given area, other qualified technicians can be designated

as the responsible party. Furthermore, pharmacies are

required to participate in a rotation system with other

pharmacies to ensure the uninterrupted provision of pharmacy

services in a given area. In the event that there is a

demonstrated need but neither qualified technicians nor

pharmacies are available, there are provisions for the

licensing of postos de medicamentos, which are simply

medication outlets of limited capacity that carry only the

most basic supplies (CRS-8, 1983:117-159).

In 1991, there were 2,851 pharmacies and drugstores

(excluding hospital pharmacies and dispensaries) registered

in the state of Rio de Janeiro. Forty-four percent of these

(1,241) were in the metropolitan area so that the

population-to-pharmacy ratio was approximately 4,100:1.

There were 3,870 pharmacists (including 300 oficiales and

praticos) registered with the state, and 63% (2,439) were

registered in the municipal area. Although the data are not

broken down into smaller geographical units, the

distribution of pharamcies in the city is not uniform.

Regulation regarding distribution did not affect established

pharmacies, so older sections of the city have a relatively









high concentration of pharmacies, as much as two or three

per city block, and sometimes even more, as in the

commercial district of Copacabana. The vast majority of

registered pharmacists are employed in industry (personal

communication, CRF), although there is a small and lucrative

business in specialty pharmaceuticals, primarily

dermatological products, as well as several homeopathic

pharmacies that compound their own products.

Pharmacy Practice and Self-Medication

A significant proportion of private health care

spending in Brazil represents drug purchases occurring

outside the direct control of the formal medical care system

(McGreevey, 1988:158). The frequency of self-medication in

Brazil has been estimated to be approximately 50% to 60% of

all medication use (Giovanni, 1980:132; Haak, 1988:1420;

Cordeiro, 1985:190). However, because commercial pharmacies

do not typically keep records of prescriptions, and due to

the lack of other systematic record keeping, there is

relatively little known about both self-medication and

prescription medication use.

Today, pharmacists, or otherwise qualified technicians,

are hard to come by in the community setting. A consumer is

more likely to interact only with salespersons (balconistas)

with no formal training in pharmacy at all. According to

Giovanni (1980), the disappearance of the community

pharmacist was inevitable. Giovanni argues that there is no







59

data to justify the claim of a pharmacist shortage and that

the laws mentioned above were based on questionable, if not

false, premises (1980:104-105). These laws served to

conspire with the pharmaceutical industry to promote

drugstores as efficient commercial outlets for their

products. The traditional pharmacy that formulated its own

drugs could not compete with the industries that operated

with large economies of scale. As pharmacists no longer

held exclusive rights to operate establishments for the sale

of pharmaceuticals, this represented a virtually untapped

market for the entrepreneur. By the end of World War II,

the drugstore boom had begun and pharmacists left the

community setting and headed for industry.

The impact of these changes on pharmacies and practice

has not been uniform. In some areas, especially where

medical care is scarce, the pharmacy still represents an

important health care resource. In an ethnography of two

neighborhoods in the Rio de Janeiro suburb of Nova Iguazu,

Loyola (1983) describes two general types of practicing

community "pharmacists": practitioners who provide

therapeutic assistance ("farmacduticos-praticantes" or

"farmacduticos-terapeutas") and commercial or business

"pharmacists" ("farmaceuticos-comerciantes"). These two









types of pharmacists3 differ in social origin, location of

practice, and practice style and philosophy.

In this typology, therapist-pharmacists are community-

oriented, are familiar with their clients and their families

and lifestyle. These represent the fading "farmacia do

bairro", the neighborhood pharmacy, run by an involved,

active member of the community. This kind of pharmacist

assumes the role of a health care professional, and may even

provide a diagnosis and recommend drug treatment in "banal"

cases. As a professional, he is expected to refer the

client to a trusted physician if deemed necessary.

The second type of pharmacist may be considered the

antithesis of the first. The practice location is generally

in the central business areas, near medical laboratories,

physician offices and clinics. Their identification is with

the medical profession yet their focus is on the commercial

aspects of pharmacy practice. The clientele reflect this:

they too are more closely articulated with the formal health

care system, and tend to be of the more privileged socio-

economic groups that utilize the medical services in the

area. As the pharmacist's primary job is generally in

industry, s/he visits the pharmacy for only a few hours a

week, and then only to check the books for the sale of


3 In this discussion, references to pharmacists,
unless otherwise stated, describe the person who works in the
pharmacy/drugstore, regardless of training.







61

controlled substances, such as potent narcotics. The volume

of drugs dispensed is large in these establishments and

there is little opportunity and no expectation for any

professional-client relationships to develop. A similar

characterization of pharmacy practice has been described for

urban pharmacy practice in Cost Rica (Low, 1981).

Given their "strictly business" orientation, commercial

pharmacies are more likely to engage in illegal

"empurroterapia" (push therapy). This practice, which

involves pushing products onto gullible clients with little

regard for therapeutic usefullness, evolved from the custom

of paying pharmacy salepersons (balconistas) on a commission

basis. Enforcement of regulations regarding the sale of

medications was and continues to be beyond the capacity of

enforcement agencies. Therefore, if the intent of the law

that encouraged the evolution of drugstores was to make

medications more accessible to the public the secondary

effect was the loss of control over their appropriate

commercialization and use.

Some of the concerns regarding the recommendations lay

salespeople might offer to clients for the purposes of self-

medicating is exemplified by the following recent example

that involved an ulcer medication, Cytotec (a prostaglandin)

that was being pushed as an abortifacient. A study

conducted by the Federal University of Ceara (UFC) in 1990

used a "shopper" technique to determine the extent to which







62

medications were recommended by the pharmacy for the purpose

of provoking an abortion. The study found that 83% of the

pharmacies studied (N=102) recommended a medication for this

purpose. Cytotec was recommended in 67% of the pharmacies.

The study suggested that salespersons who recommended

Cytotec were "informed" by the product package insert, which

listed pregnancy as a contra-indication for use ("Remedio

para ulcera...", 1991).

There is an increasing awareness on the part of the

pharmacy profession in Brazil of the need to return to the

community pharmacy. In January, 1990, the National Board of

Pharmacy (Conselho Federal de Farmacia--CFF) announced that

it was presenting to Congress a plan, the "Project for

Assistance to the Pharmacy", that called for the mandatory

presence of a professional pharmacist in all pharmacies.

The principal objective of this plan is to curb self-

medication. On Februrary 21, 1991, the National Assembly of

the CFF met in Brasilia to address this issue, to identify

barriers, and to set goals and objectives for the future of

the profession which would include a return to community

practice. There are decades of resignation to shake off,

and little economic incentive to leave the harbor of

industry employment, but it appears that the public

continues to value the pharmacist and is likely to welcome a

return to the pharmacy, if it doesn't cost too much!









Summary

This chapter outlined the context of health services

utilization in Brazil. Brazil's health care system includes

an expansive, yet chronically troubled, public sector. The

difficulties it faces have risen from conflicts between

promises to provide first-rate medical attention to certain

segments of the population while neglecting basic primary

care needs of other segments, and the constraints placed on

a Third World nation suffering an economic crisis. A

private sector dominated by large health care corporations

was able to flourish on the promises of the public sector

(through subsidies) and the expectations of their clients.

In addition, the private sector promised less bureaucracy, no

endless lines and waiting, and a diminished threat of

shortages in manpower and supplies; in short, it promised

that "private is better than public". Public facilities

became the principal source for medical care for the poor

and otherwise marginal or disenfranchised, and for a few

beneficiaries, a source for otherwise expensive, high

technology procedures free of charge.

The availability of medications has been a concern in

health care politics in Brazil since the 1930s and 1940s,

especially following the development of new antibiotics and

vaccines, and the advent of the industrialization of

pharmaceuticals. Prepackaged medications could be sold in

drugstores, where the presence of a professional was no









longer mandatory. As pharmaceuticals became more

accessible, the professional pharmacist abandoned community

practice to commercial interests, and a new dimension was

added to the potential hazards of self-medication, relative

to other countries with more controlled environments.

The relationship between the health care system and

care-seeking behaviors in Brazil reflects an historical

process that is deeply rooted in the culture and politics of

the country. Health care services have not been universal

nor uniform for all: some groups have had quite different

experiences and individuals' expectations regarding services

are bound to be related to their experiences and needs.

With this understanding of the context in which health

services are utilized in Brazil, the question of the

relationship between perceived access to medical care,

perceived access to pharmacy services, and medication use

may be addressed. The following chapter discusses the

methodology that will be employed to examine this question

for elderly residents in three different socio-economic

areas in Municipio of Rio de Janeiro.













CHAPTER 3
METHODOLOGY

Introduction

This project required the development of a survey

instrument that would measure the access dimensions of

interest since there was no instrument available for the

Brazilian context. This entailed a process that began with

a general model of medication use that included variables

believed to be relevant based on previous studies in Brazil

and elsewhere. Item selection for the access variables

involved the adaptation of items used in the United States,

the participation of experts in the field in the translation

and formulation of new items, revision as a part of the

interviewer training, and field testing of the instrument,

which resulted in further revisions of the instrument. This

chapter discusses each step of the instrument development,

the selection of the sample, the research procedures and the

analysis strategy.

Building a Medication Use Model for Brazil

The theoretical framework that was used to analyze

medication use behavior among the noninstitutionalized

elderly in Brazil was based on the health care utilization

model developed by Andersen and Newman (1973), discussed in

Chapter 1, and builds upons previous studies of medication

65










use. The unique aspect of the model presented is the

emphasis on subjective measures of access to both medical

and pharmacy services in relation to prescribed and

nonprescribed medication use. Each variable to be examined

and its measurement is listed in Table 3.1, and will be

discussed in this section.

Predisposing Variables

The predisposing variables examined in this model

include the patient's age, gender, education, household

size, income, as well as attitudes toward formal medical

care, and attitudes toward accepting lay advice about

pharmaceuticals.

Age: The elderly are defined as 60 years old or more,

which is the definition currently accepted for many

developing countries. Age, in this study, is measured as a

continuous variable.

An increase in prescription drug use has been found to

correspond with an increase in the age of the patient in

studies in Western countries (see review in Stewart, 1988;

Dunnell and Cartwright, 1972). This trend probably reflects

normal physiological changes in health status over time.

However, the rate of nonprescription drug use appears to

stabilize and in some reports it has been found to drop with

increasing age (cf. Simonson, 1984; Johnson and Pope, 1983).

The reasons for this phenomenon are not well understood,

although similar patterns have been noted for other forms of








Table 3.1 Variable

Variable name

Predisposing variables:


s and their measurement

Measurement


Age

Gender

Household size

Education

Income


Attitudes toward medical care
(AttMedCare)

Attitudes toward lay advice about
drugs (Att_Lay_Advice)

Enabling variables:

Perc'd acceptability of medical services
(Accept_Med_Serv)

Perc'd availability of medical services
(Avail_Med_Serv)

Perc'd affordability of medical services
(AffordMedServ)


Number of years of age

0=male, l=female

No. persons living in the home

No. of years of schooling completed

Estimated personal monthly income,
adjusted for monthly inflation

Summated score of 7 items
(ordinal measures)

Summated score of 3 items
(ordinal measures)



Summated score of 15 items
(ordinal measure)

Summated score of 11 items
(ordinal measures)

Summated score of 2 items
(ordinal measures)








Table 3.1--continued


Variable name


Measurement


Perc'd acceptability of pharmacy services
(Accept_PharmServ)

Perc'd availability of pharmacy services
(Avail_Pharm_Serv)

Perc'd affordability of Drugs
(Afford Drugs)


Need variables:


Perc'd health status


Symptom experience


Summated score of 15 items
(ordinal measures)

Summated score of 13 items
(ordinal measures)

Summated score of 2 items
(ordinal measures)



Summated score of 2 items
(ordinal measures)

No. of reported symptoms
experienced with frequency


Use variables:


Physician prescribed (PP) medication use


Non-physician prescribed (NPP) medication use


No. of medications used prescribed
(or recommended) by a physician

No. of medications (incl. home
remedies) used recommended by
a lay friend or family member,
pharmacist, nurse, self, or other
lay individual.









self-care as well (Segall and Goldstein, 1989). Indirect

relationships with both prescription and non prescription

drug use in old age have been found through enabling

such as the availability of transportation (Sharpe et al.,

1985) and need variables, such as perceived morbidity, in

studies using path analytic techniques (Bush and Osterweis,

1978).

Gender: Gender has been found to have consistent

relationships with drug use. Women are more likely to use

medicines than men, both prescribed and nonprescribed. In

addition there are differences based on gender in use of

drugs of different therapeutic classes, although the reasons

for this are not always clear (Johnson and Pope, 1983;

Verbrugge, 1982; Verbrugge and Steiner, 1985; Svarstaad et

al., 1987). Furthermore, the effect of gender in old age

appears to be even more dramatic. This is especially true

for the use of prescribed psychotropic drugs, although their

use is less chronic in females than in males. It has been

suggested that the role of gender and age in provoking

agismm" in physician prescribing behavior may be a

contributing factor (Arluke and Peterson, 1981). There is

no apparent reason to suspect major departures from this

pattern for the Brazilian urban elderly.

Household size: In Western countries, studies indicate

that individual medicine use rates, as measured by the

number of medications obtained per individual, for both







70

prescribed and nonprescribed medicine use, has been found to

decrease as household size increases. This is generally

considered a function of income (Rabin, 1977). However, a

larger household increases the opportunity for and may thus

increase the likelihood of the sharing and lay prescribing

of medications among household members. Therefore, a

positive association may be expected between increase in

household size and number of nonprescribed medicines

actually used.

Education: The influence of formal education on

medication use in Western societies is not clear. One

difficulty in assessing it is that, together with income and

occupation, education is one of the indicators of social

class, a variable frequently used in many medication use

studies in lieu of education. Education is associated with

a greater ability to manipulate the socio-political system,

to excert control over one's environment and to mobilize

resources needed for health-related needs (Wood and

Carvalho, 1988:90). Generally, educational achievement and,

hence, social class, is thought to imply greater health

knowledge. According to Blum and Kreitman,

"health knowledge, including information about
medicines, is but one instance of that general
sophistication which is predictable on the basis
of economic, social, political and personal
factors which affect the availability of, access
to, interest in, and capacity to utilize knowledge
sources" (1981:134-135).







71

The relationship between education and health services

utilization and other care seeking behavior is a relevant

issue in Brazil (Singer et al., 1981) and other countries

with high levels of illiteracy. In particular, there is a

well known inverse association of female (and to a lesser

extent, male) education with infant and child mortality and

fertility, through a variety of intervening factors,

including greater use of health care services (Wood and

Carvalho, 1988:170-2).

In 1990, a significant proportion of the urban

Brazilian elderly (41%) were considered illiterate (IBGE,

1987). There is no reason to suspect that the relationship

between education with health services utilization among the

elderly would differ from that for the general population.

With respect to medication use in particular, the

relationship between education and prescribed medication use

may be considered a proxy for use of medical services.

Conversely, lower levels of educational achievement may be

associated with increased self-care behaviors, including

self-medication.

Income: For the purposes of this study, education and

income will be included as separate variables, while

recognizing their close relationship. Generally, household

income is considered a more reliable indicator in health

services utilization, however, it is a more difficult

measure to obtain because it requires that the respondent be









informed about the income contributions of other household

members. In this study, because the number of individuals

who were not able to report an estimated household income

was relatively large, severely affecting the sample size,

personal income was used. Personal income was adjusted for

inflation on a monthly basis using FIPE/IPC (Fundacgo de

Investigacgo e Pesquisa Econ6mica/Indice de Pregos ao

Consumo) estimates, and standardized to March, 1991 values.

Attitudes toward Medical Care (Att Med Care): The

indicators for measuring attitudes towards medical care are

adapted from Stoller (1988). Items included in a summated

ratings include skepticism regarding the efficacy of medical

care, reluctance to accept professional recommendations, and

belief that a person understands his or her own health

better than a physician. High scores indicate positive

attitudes toward modern medicine.

Attitudes toward Lay Advice about Drugs

(AttLay Advice): The items for this measure tap the

willingness to accept non-professional advice about

medications. The measures are derived from the summated

scores of responses to each item. High scores indicate a

greater willingness to accept non-professional (lay) advice

about medications.

Enabling Variables

Enabling variables address various aspects of access

to care. Ware and Snyder (1975) have identified several







73

indicators related to patient satisfaction with medical care

in the United States which address issues of perceived

access to medical care. Similarly, McKeigan and Larson

(1989) developed a list of items for pharmacy services.

These indicators served as a guide to identify or formulate

revised items that were relevant to the Brazilian context or

could be appropriately adapted. Responses to items were

scaled in Likert fashion and indicators for all enabling

variables are derived from the summated scores of responses

to each item so that high scores reflect greater perceived

access to care. The items selected for the final analysis

are presented in Chapter Four.

Perceived Acceptability of Medical Services

(Accept Med Serv) and Perceived Acceptability of Pharmacy

Services (Accept Pharm Serv): The first dimension of access

considered is acceptability. Acceptability of services

refers to the extent to which a patient or client is

satisfied with the quality of care received. Traditionally,

in the developed countries, quality of care has been

associated with increased sophistication in medical

technology. More recently, however, the development of a

socially amenable and operational definition for quality of

care that includes aspects of patient-provider dynamics has

become a central concern for health policy analysts:

patients who are unsatisfied with the care they receive are

less likely to continue treatment, and are more likely to









seek alternative care than satisfied patients (Donabedian,

1982).

Perceived Availability of Medical Services

(Avail Med Serv) and Perceived Availability of Pharmacy

Services (Avail Pharm Serv): Availability suggests not only

locational dimensions, but also convenience in terms of

operating hours, and assurance of regularity of services.

In rural areas, for example, where distances are greater

than in urban areas, transportation appears to be a

significant factor affecting medication use patterns among

the elderly (Sharpe et al., 1985). Bush and Osterweis

(1978), interested in perceived access to services, found

that although there was a positive association with

prescription medicine use, there was an inverse association

with OTC use. The authors suggest that OTC use may be a

substitute for physician visits when access to medical care

is perceived as inconvenient. Sharpe et al. (1985) also

suggest a substitution effect when perceived access to

pharmacy services was found to be inversely related to

prescription medication use in their rural sample. Some

elderly may be particularly handicapped by disability or

disease such that the perceived availability of services is

of particular importance.

Perceived Affordability of Medical Services

(Afford Med Serv) and Perceived Affordability of Drugs

(Afford Drugs): Affordability, the third dimension of









access considered, is often assumed given certain

conditions. These conditions may be measured in terms of

direct and indirect costs. Typically, direct costs are

related to insurance status, income, out-of-pocket

expenditures and other financial barriers. Indirect costs

include time needed to get to the services, time waiting for

services to be rendered, and related expenses. In many

countries like Brazil, however, organizational mechanisms

may exist for the provision of medical care as well as

needed medications to targeted groups, such as CEME for

generic drugs in Brazil, but these mechanisms often do not,

in fact, function as indicated. Therefore, although the

potential barriers are seemingly minimized, the reality is

another case and enrollment in a public program may not

correspond to availability nor increased perceived

affordability of care. Therefore, the extent to which the

cost of receiving care is perceived as a burden remains a

relevant political and social issue. Items included the

frequency of skipped or reduced doses of a medication for

the purpose of economizing, delaying the purchase of a

medication and delaying medical care due to lack of funds.

Need Variables

The need variables that will be used in the analysis

include perceived health status and number of symptoms.

Ideally, these measures would include clinical diagnosis of

disease states, but usually this information is not









available for HSU studies, and, hence, perceived health

status and symptom experience are the most commonly used

indicators. Measures of health status typically are the

strongest predictors of health services utilization

(Wolinsky and Arnold, 1988), and, by extension, of

prescription drug use (Bush and Osterweis, 1978; Sharpe et

al., 1985, Stoller, 1988). The relationship between

perceived health status and self-medication, or use of OTC

medications, has not been found to be as significant. These

findings suggest that prescription medications are used for

more serious health problems among the elderly, whereas OTC

medicines are used for less serious conditions.

The measure of health status used in this study results

from the summated scores for two items: perceived current

health status, and perceived health status relative to

others of the same age. By including an item of relative

health status, one may control for possible confounding of

perceived morbidity and what might be perceived as the

effects of normal aging.

Number of symptoms experienced by an individual is also

used in this study as a need variable. Although a very

crude measure which does not take into account severity of

symptoms experienced, when analysed together with perceived

health status, it may provide some insight to use of

medications in the presence of a few or many symptoms, given









perceived health status, as in the case of self-medication

for relatively banal health problems.

These measures are not without shortcomings in health

services research, and they bear mentioning. Often, in

research using the HSU model, the researcher presumes an

implicit causal relationship between the patient population

characteristics. For example, the relationship between

symptoms (and health status in general) is assumed to be a

precursor to health services utilization. However, it is

conceivable that the relationship is actually in the

opposite direction and is not discovered given the cross-

sectional nature of the study design. That is to say that a

patient may experience poor health as a result of a

treatment being received. This may be the case with number

of symptoms and side effects in medication use. In the

absence of longitudinal data, inferences should be made

cautiously about relationships that emerge from cross-

sectional data.

Use Variables

The dependent variables examined are number of

physician prescribed (PP) and non-physician prescribed (NPP)

medications used by the participant. The reference period

selected for this study is two weeks prior to the interview.

Participants were asked to recall all medications used

during this period, and to identify who recommended the

medication for them, and for what purpose. Prior to the







78

inquiry, participants were asked to retrieve their medicine

containers, if available. Included in this analysis are

home remedies. This served to enhance the respondent's

recall and to assist the interviewer to correctly identify

the medicines.

Area

The sample was drawn from three socio-economic areas in

the Municipio (county) of Rio de Janeiro. The basis for the

selection of these areas and a description of their salient

characteristics are discussed in a following section on

sampling.

Instrument Development

Instrument development and interviewer training in this

cross-sectional survey were very much intertwined and are

best characterized as a single process. A participatory

approach afforded unique instrument development

opportunities and, in addition, allowed the interviewer to

apply an instrument with which s/he was intimately familiar.

This section will discuss the research procedures, the

survey instrument development, and interviewer training

employed in this study.

Item Selection

Studies of patient satisfaction with medical care

services (Ware and Snyder, 1975) and pharmacy services

(McKeigan and Larson, 1989) provided the basis for item

selection for the instrument in this study. Aspects of









these services relevant to the issues of accessibility,

availability, and affordability were identified and modified

for the Brazilian context. These items (see Appendix A),

together with new items developed for the purpose of model

building and medication use, were reviewed by Brazilian

health care professionals and social scientists, including

two sociologists, two physicians, a dentist, a pharmacist, a

social worker, a psychologist, and a nurse.

Preliminary "test runs" on a small independent sample

of individuals, elderly and not, indicated that response

sets which required responses to items on a five point

"strongly disagree" to "strongly agree" scale, used in the

above mentioned studies, were not successful. It was noted

that these tended to result in monotonic response sets with

little to no variation, and increasingly so as the interview

progressed. This may have been due to the fact that, unlike

the previous studies, items were stated verbally by the

interviewer and subjects were not permitted to read their

alternatives. The use of an interview format rather than

the written questionnaire used in previous studies was

thought necessary to increase response rates and to control

for the effects of high rates of illiteracy. Because of the

problems with five point response scales, the statement

format of the items was changed to a question format

requiring responses which were more concrete, making

reference to actual experiences, and had a more limited







80

number of alternatives. For example, rather than requiring

a respondent to "agree" or "disagree" with the statement,

"The pharmacy is always open when I need", the question was

posed as, "Is the pharmacy always open when you need?" and

possible responses included "Always", "Sometimes", and

"Never". The format also encouraged the respondent to

clarify or expound on their responses and recount specific

relevant experiences. Interviewers were instructed to make

note of these experiences in the questionnaire. The

instrument is included as Appendix B.

Interviewer Training and Instrument Pilot

Interviews were conducted by a team of twelve

individuals in addition to the principal investigator,

selected on the basis of personal or professional interest

in the subject matter. Interviewers were identified by the

field coordinator of the BOAS project. The interview team

included a social worker, a pharmacist, a medical student, a

physical therapist, a sociologist, a journalist, and five

senior university students from the School of Social

Sciences at the State University of Rio de Janeiro (UERJ).

Three training sessions were held. The first session

briefed 15 potential interviewers on the nature of the

project. Printed background material on aging in Brazil and

related health care concerns distributed prior to the first

meeting were reviewed in conjunction with the specific

objectives of the project. Basic survey logistics and the









chronogram were presented at the first session. This

allowed potential interviewers to decide whether or not they

could commit their time for the project, and three did drop

out at this point.

The interviewers reviewed the questionnaire for

content, readability, and clarity in a second meeting. Each

interviewer was asked to complete three questionnaires for

elders not included in the study sample. Results were

discussed in a third training session after which the

questionnaire was again modified to accommodate the

observations and comments offered by the team.

Approximately four weeks after the pilot, interviewers were

asked to re-interview one of the three subjects previously

interviewed. This allowed for the evaluation of the changes

made in the instrument as well as to establish a test-retest

reliability (stability) coefficient for unchanged items.

For unchanged items, those which had coefficients of .70 or

higher were maintained, and others were eliminated or

revised.

The survey was conducted between October 1990 and March

1991. Each interviewer was assigned a quota of interviews

for selected clusters and areas.' Interviewers were

provided with the names, addresses, and if available,

1 Three of the original interviewers resigned from the
team during the course of the survey, and replacements were
trained. Two other interviewers were dismissed during the
survey due to research fraud.









telephone numbers of subjects. The interviewers were

provided with letters of introduction (Appendix C) which

could either be presented personally to the subject or sent

in the mail. These letters advised the subject that they

would be contacted by someone from the research team in

order to make an appointment for an interview.

Each interviewer was accompanied by the principal

investigator for the evaluation of at least one interview

prior to the completion of the interviewer's fifth

interview. The principal investigator observed the

interview and filled in a questionnaire as the interviewer

proceeded with the interview in order to determine the

inter-rater reliability of the instrument. In all cases,

there were no discrepancies between scores. This was

probably due to the closed nature of the response sets which

left little room for interpretation. However, interviewers

had been instructed to note in the questionnaire any

pertinent observations or comments on the survey form,

including responses that did not correspond to any of the

options provided. The principal investigator was then able

to return to the subject at a future date for further

clarification of responses or to re-address a question if

needed.

Quality control mechanisms were in place throughout the

survey, and several cases of fraud in the data collection







83

were discovered.2 Although interviewers were forewarned of

a reinterview schedule for the purpose of quality control,

they were not informed of the actual schedule. Every third

questionnaire completed and returned by each interviewer was

selected for review. A follow-up call or visit with the

subjects who had been interviewed included an explanation to

the subject of the purpose of the reinterview. A selected

subset of questions with high stability coefficients was

repeated to the subject to verify the answers obtained in

the interview. This also afforded the principal

investigator an opportunity to ask other questions of the

subject that would help to clarify responses, as well as to

collect any missing data.

The Sample

The sample for this study consisted of a randomly

selected subsample of all surviving and consenting

participants of the 1989/90 Brazilian Old Age Survey (BOAS).

The BOAS survey was developed and conducted by the Institute

of Social Medicine of the State University of Rio de Janeiro

(IMS/UERJ). The sample consisted of 738 respondents aged

60 years or more, selected to be representative of municipio

of Rio de Janeiro.


2 Two interviewers turned in completed questionnaires
without having actually conducted the interviews. All of the
questionnaires provided by these interviewers were
disqualified, and their behavior reported to relevant
authorities. The respondents were later interviewed in order
to recuperate the sample.









In order to capture the heterogeneity of the

residential zones in the municipio, the BOAS sample was

drawn from three residential areas representing different

socio-economic strata. Five indicators were used to

identify the census districts to represent these strata. The

indicators included mean household income, availability of

piped water and sewage, the average number of children for

women 15 to 49 years of age, the proportion of elderly in

each district, and the number of banking establishments.

Each of these indicators had been shown to be valid and

reliable markers of community socio-economic status in

Brazil (Veras et al., 1989:3-7).

The original targeted BOAS sample size was to be 780

persons aged 60 years or more, with 260 from each designated

SES area. However, the final BOAS sample consisted of only

738 respondents (see Table 3.2). Moreover, 28 participants

who had served as the pilot sample for the BOAS were not

included in this study because their identity was not

available from the BOAS project staff. Therefore, the base

sample from which this study selected its sample included

only 710 elderly.

In selecting a sample for the BOAS project, twenty-four

census districts were ranked according to scores received on

an index composed of the above listed indicators. The three

districts selected as representative of high, middle, and

low socio-economic status communities were, respectively,







85

Copacabana (including the neighborhoods of Copacabana, Leme,

part of Ipanema and Botafogo), Meier (including Meier, Maria

da Graca, Cachambi, Pilares, del Castilho, Todos os Santos,

Abolicao, Cavalcante, Inhauima, Engenho N6vo, Engenho da

Rainha, Tomas Coelho and Piedade), and Santa Cruz, including

the communities of Santa Cruz, Pacidncia, Cosmos, and

Sepetiba (Veras et al., 1989:10-11).


Table 3.2 Summary Statistics of BOAS Study Participants

Copacabana Meier Sta. Cruz

Gender
Female (%) 63.5 60.7 60.3
Male (%) 36.5 39.3 39.7

Mean Age (years) 71.65 71.39 69.37
(SD) (7.57) (7.59) (6.65)

n= 252 244 242





For the present study the targeted sample size was 150

elderly for each district selected from the BOAS

enumeration, for a total of 450. This would allow a power

on the ability to detect a difference between the three

strata on medication use of .97, with f=.25, which is a

medium effect size, and alpha=.05 (Cohen, 1977). This was

considered to be both an attainable figure and one that

would allow for analysis with multivariate techniques. The

sample was selected by using a random numbers table and BOAS

questionnaire numbers as proxies for subject identification







86

until the target sample size for each area was obtained. In

anticipation of attrition due to mortality and change in

residence, as well as refusal to participate, the remaining

subjects were retained as alternates.

Study Areas

Rio de Janeiro is the capital city of the State of Rio

de Janeiro. Rio de Janeiro, together with its neighbors to

the south (S&o Paulo) and east (Belo Horizonte) make up the

core cities of the Southeast region of Brazil, the

wealthiest and most diversified region of the country. Rio

de Janeiro, in addition to being a major tourist center, is

one of the most important commerical, financial, and

industrial centers in the country. It also harbors the

largest slum (Roginha) in Latin America. The Municipio

(county) of Rio de Janeiro, with a population of more than

5.5 million, encompasses a part of a vast metropolitan area,

several suburban and rural areas. The three study areas

selected for this study are representative of this

diversity. A map of the study areas is presented in Figure

3.1.

Copacabana

Copacabana is the most metropolitan of the areas

studied. International known for its beaches, night-life

and social clubs, became a haven for the affluent in the

1940s and 1950s, after the construction of tunnels that made

the area more accessible by automobile and increased the









..-"SAO JOAO DE MERITI
......... .
.................................
..... .o...
S.. NILO-.-
'POLIS.-'


RIO DE JANEIRO


municipio boundaries
municipal railroad
areas represent study areas


Study areas in the Municipio of Rio de Janeiro, Rio de Janeiro, Brazil.


MESQUITA


Legend:


I IShaded I
Shaded


Figure 3.1


4 .... -


12w









value of the property. Previously, it was dotted by beach

houses used by vacationing middle class families from the

older, more established parts of the city (Velho, 1973).

Now, apartment buildings are the modal dwelling

structure and the principal streets are bordered by busy

groundlevel shops and boutiques (i.e., a horizontal

distinction between residential and business and commerical

areas). Mass transportation in the form of buses are

plentiful, their routes criss-cross major avenues, and lead

directly to important points in the city. Most of the

residents in this area are white collar workers and

professionals. Although no longer the most wealthy part of

the city (the money has since moved south to Barra de

Tijuca), the level of infrastructural completeness and

wealth of Copacabana relative to other areas remains high.

There is a INAMPS hospital in Ipanema, known for being

one of the best, and numerous physician offices and clinics

as well as smaller private hospitals. In addition, compared

to the other two study areas, this area is the closest in

proximity to larger facilities in the center of the city.

Pharmacies of various types of pharmacies (homeopathic,

herbal, specialty), are plentiful, with as many as two or

more to a block. The BOAS project estimated that 45,775

elders lived in this area in 1988.









Meier

Meier and surrounding neighborhoods constitute what

once was the growing suburban residential area before

interest turned to the beachfront. Meier was traditionally

considered to be an upwardly mobile, middle class area. The

suburban train routes and the subway also reach out to most

of the neighborhoods in this area. There is an old,

established commerical area that embraces these points of

mass transit.

Single family houses still predominate although some

areas are "building up". In some neighborhoods, such as

Cachambi, there are apartment complexes more than thirty

years old, developed by institutions like the Bank of Brazil

(Branco do Brasil) for its employees with grants obtained

from the federal government (elders living in these

apartments today were among the first tenants).

There are several hospitals throughout the area

(university, public and private), but fewer physician

offices and more public health posts are visible than in the

Copacabana area. The distribution of pharmacies is less

concentrated as well. Approximately 11,249 elders lived in

this area in 1988.

Santa Cruz

Santa Cruz is literally the end of the line: it is the

last stop of the suburban train route after an hour and

forty-five minute ride from downtown. Although there are









bus lines that go into the downtown area from Santa Cruz,

they are relatively expensive and not practical unless one

can afford to go by fresco&o, an air-conditioned express

bus that goes straight to downtown Rio de Janeiro.

Santa Cruz is a rapidly developing suburban area, yet

it still has a rural flavor. Only the principal streets are

paved, and construction is relatively simple, and there are

still many open spaces. The population density in the area

is relatively low compared to the other two study areas.

The estimated number of elders living in this area in 1988

was 11,249.

In Santa Cruz, there is a public hospital, some clinics

scattered about, and various small pharmacies, three of

which are within walking distance of the train station.

There is a large military base and a new industrial complex

near Santa Cruz that provide employment for some residents,

but many residents must commute into the city for their

jobs.

Although there are obvious signs of prosperity in some

of the houses in Santa Cruz proper and neighboring Sepetiba

(approaching the coast), this is less so for the adjacent

neighborhoods of Pacidncia and Cosmos. In these

neighborhoods there are more dwellings in various stages of

a slow construction, or, as the case may be, deconstruction.

A local public elementary school lies in half completion,

and the sewer drainage is open. There is minimal