Artigos

Conteúdo (article):

IMPACTO DO PROGRAMA ACADEMIA DA SAÚDE SOBRE A MORTALIDADE POR HIPERTENSÃO ARTERIAL SISTÊMICA NO ESTADO DE PERNAMBUCO
IMPACT OF THE HEALTH GYM PROGRAM ON MORTALITY FROM SYSTEMIC ARTERIAL HYPERTENSION (SAH)
Resumo
O objetivo deste artigo foi avaliar o impacto do Programa Academia da Saúde sobre a mortalidade por Hipertensão Arterial Sistêmica no estado de Pernambuco, Brasil. Este estudo quase-experimental configura-se como uma avaliação de impacto de políticas públicas, desenvolvida através da aplicação do método do Pareamento por Escore de Propensão, nos anos de 2010 e 2017. Utilizou-se dados socioeconômicos, demográficos e epidemiológicos dos 89 municípios que implantaram o programa (tratados) e de outros 52 que não implantaram (controles). Os dados são oriundos do Departamento de Informática do SUS, Instituto Brasileiro de Geografia e Estatística e outras bases. O impacto do programa foi estimado através de um modelo logit, com o uso do algoritmo de pareamento Kernel. Os municípios tratados tiveram uma diminuição global de 12,8% na taxa de mortalidade por hipertensão, de 12,5% entre as pessoas de cor parda e de 13,1% em maiores de 80 anos. O teste de balanceamento atesta a robustez do modelo para explicar o impacto do programa sobre a mortalidade. A implementação do programa se mostrou efetiva para diminuir a taxa de mortalidade nos municípios tratados, indicando que o mesmo parece estar contribuindo para controlar o avanço das doenças crônicas não transmissíveis.
Palavras-Chaves: Hipertensão. Mortalidade. Avaliação de Programas e Projetos de Saúde. Avaliação do Impacto na Saúde.
Abstract
The aim of this paper was to analyze the impact of the Health Gym Program (HGP) on the Systemic Arterial Hypertension mortality rate in Pernambuco state, Brazil. This public policy impact analysis used a quasi-experimental approach which consisted of the application of Propensity Score Matching in the years 2010 and 2017. Socioeconomic, demographic, and epidemiological data of 89 municipalities that implemented HGP (treated) and 54 that did not (controls) were collected from the Brazilian Health Data Department, Brazilian Institute of Geography and Statistics, and other databases. The impact of HGP on hypertension mortality rate was estimated through a logit model using the Kernel algorithm. Treated municipalities presented a decrease of 12.8% in global hypertension mortality rate, 12.5% in brown-skinned people and 13.1% in those over 80 years of age. The balancing test attests to the robustness of the estimated model to explain the impact of the program on mortality due to hypertension. The implementation of the program proved to be effective in decreasing the mortality rate in the treated municipalities, indicating that it seems to contribute to controlling the progress of chronic non-communicable diseases

Key words: Hypertension. Mortality. Health Policy. Program Evaluation. Health Impact Assessment.

INTRODUCTION
Evidence regarding the global burden of Hypertension indicates that 26.4% of the adult population worldwide was hypertensive in 2000 and that by 2025 this prevalence is predicted to increase by 60%, with more significant increases in developing countries 1.
Systemic Arterial Hypertension (SAH) has a multifactorial origin and is characterized by an increase in blood pressure levels to values equal to or greater than 140 mmHg for systolic pressure and 90 mmHg for diastolic pressure2, representing a risk factor for cerebrovascular and cardiovascular diseases3 and that can be aggravated by biological (dyslipidemia, abdominal obesity, glucose intolerance, diabetes)2, behavioral (smoking, eating, and physical inactivity)3, and socioeconomic factors (income, education, Human Development Index, Gross Domestic Product - GDP per capita - of the Municipalities, and access to health services) 4,5,6.
SAH is the disease with the greatest impact on morbidity and mortality in Brazil7, with a prevalence of 32.6% among adults, and above 60% in older adults8, with a mortality rate of 0.87 deaths for every 10,000 adults in Brazil8; 2.56 for the Northeast region (largest among the regions) and 2.13 in the state of Pernambuco (13th in the country). Among the main predictors of mortality from SAH in Brazil are increasing age, brown-skinned individuals9, and the level of education of the population10. In addition, deaths from SAH are inversely associated with socioeconomic variables of the municipalities6 and with the individual’s level of physical activity11,12,13.
Evidence from studies with different populations and with the Brazilian population indicate that the regular practice of physical activity reduces the risk of death from SAH and other non-communicable chronic diseases (NCDs) 11,12,13, which has led health authorities to invest in the implementation of policies and programs to encourage the adoption of more active and healthier lifestyles in the population 14,15.
In order to integrate the practice of physical activity into the country\'s health policy agenda, in 2011 the Ministry of Health instituted the Health Gym Program (HGP), with the objective of contributing to health promotion through federal and municipal co-financing for the construction and/or renovation of public spaces with infrastructure (called poles) and qualified professionals to carry out activities to promote health and care production in the field of Primary Health Care (PHC)16,17.
The HGP is considered a strategic program for the execution of national health promotion policies and among its specific objectives is the proposal to increase the population\'s level of physical activity17. Furthermore, in addition to its goal to promote health, acting in the prevention and control of chronic diseases, influencing the conditioning and determinants of health, the HGP has an important role in improving the quality of life of the population, as it deals with both physiological and social aspects of the health-disease process 18.
The activities of the HGP comprise the scope of the National Health Promotion Policy (PNPS) and the National Primary Care Policy (PNAB), and the program is presented as one of the prevention and control actions that integrate the Strategic Action Plan for the Coping with Chronic Non-Communicable Diseases (NCDs) 16,19.
Records present in the National Register of Health Establishments (CNES) indicate that in 2017, the Northeast region of the country concentrated a total of 917 centers of the program, followed by the Southeast (527), South (390), Midwest (193), and North region with 189 HGP poles20.
The state of Pernambuco was one of the pioneers in the implementation of the HGP, beginning these activities in 201121. By 2017, the state had implemented 246 centers in its territory, which corresponds to 11.10% of the total units implemented in the country 20.
In this scenario, assessment of the impact of the HGP in Pernambuco could be considered a management tool that allows the identification of the program\'s strengths and weaknesses, in addition to contributing to the decision-making process of workers, managers, and funders of this intervention22. Thus, the aim of the current study is to analyze the impact of the Health Gym Program on mortality from Systemic Arterial Hypertension in the state of Pernambuco.
The choice to assess mortality from hypertension was due to the fact that a robust set of evidence points to the association between physical inactivity and the risk of illness and death from this disease11,12,13, and that one of the specific objectives of the HGP is to increase the level of physical activity of the population16, presenting itself as one of the strategies for the prevention and control of chronic diseases provided for in the national policies of Primary Care, Health Promotion and in the Strategic Action Plan for Coping with Non-Communicable Chronic Diseases in Brazil16,23,24.

METHODS
Characterization of the Study
This study is characterized as an evaluation of the impact of public policies, developed through a quasi-experimental approach that consists of applying the propensity score matching method (herein designated as PSM) to estimate the Average Treatment Effect on the Treated (ATT). In the current study, the ATT is characterized by the effect of the Health Gym Program on the mortality rate (per 10,000 inhabitants) from Systemic Arterial Hypertension in the state of Pernambuco.

Sampling and databases
Data on the presence of the HGP poles in the municipalities of Pernambuco were collected on the website of the National Register of Health Establishments (CNES), of the SUS Department of Informatics (DATASUS).
Epidemiological data refer to deaths and their respective extracts by sex, age group, and ethnicity/color (from the Mortality Information System -SIM), the rate of hospital beds per 1,000 inhabitants (taken from the CNES), and the Coverage of Primary Care (website of the Primary Care Information and Management System - E-Manager). For the demographic variables, the study took as reference the General population by municipality, proportion of female and male population, proportion of residents by age groups from 40 to 49 years old, 50 to 59 years old, 60 to 69 years old, 70 to 79 years old, and 80 years and more (collected on the website of the Brazilian Institute of Geography and Statistics - IBGE - on the internet), the Human Development Index - HDI (in the State Database - BDE), and the FIRJAN Municipal Development Index (IFDM), FIRJAN Index of health-related and education-related development. The socioeconomic variables used for this study were GDP per capita and the FIRJAN Index for employment and income, collected from the websites of the Federation of Industries of the State of Rio de Janeiro (FIRJAN).
Of the 185 municipalities across the state, the current study considered the 89 that implemented the Health Gym Program in 2011 as treated and the 52 municipalities that did not implement it as controls. Municipalities that implemented the program after 2011 and those that implemented it that year and canceled their activities in subsequent years were excluded from the sample. Data were collected using as a reference the years 2010 (year prior to implementation) and 2017 (six years after the beginning of the implementation of the HGP in the state of Pernambuco).
The result variable for this study is the natural logarithm of the mortality rate from hypertension per 10,000 inhabitants, by place of residence of the individual. These logarithms are used in the field of econometrics, especially when the relationships between dependent and independent variables are not linear25.
Considering that some values of the SAH mortality rates were equal to zero, the artifice of adding one unit to the original rate value was used before converting to the natural logarithm, as recommended by Wooldridge (2016)25.

Control covariates
The covariates in this study were selected based on scientific evidence about the confounding relationship they can exert on the relationship between exposure and the outcome of interest. In this case, the epidemiological model that guided the selection of explanatory variables took as reference the studies by Guimarães et al. (2015) and Santos, Prado and Santos (2018), which point to factors associated with mortality from hypertension in the Brazilian population7,9.

Propensity Score Matching and impact of the Health Gym Program on SAH mortality
Considering that the implementation of the HGP in the municipalities was due to adherence and that there was no randomness in the composition of the groups exposed and not exposed to this intervention, the sample that makes up this study could be subject to problems such as selection bias, and sensitive to multidimensionality of the factors that determine the probability of implementation of this policy. To minimize these problems, the current study used the propensity score matching (PSM) method, which compares the two groups in relation to some socioeconomic, demographic, and epidemiological characteristics and calculates the probability of municipalities joining the program based on these profiles, creating a counterfactual scenario that enables comparison of treated municipalities and controls26.
The PSM is characterized as a quasi-experimental method that allows the formation of groups (of individuals or other aggregated units) with similar characteristics, but that differ from each other in terms of exposure (or not) to a given intervention27,28.
The method was developed to solve the problem of multidimensionality of matching and consists of identifying untreated units that are similar to treated units and comparing the means in the result, seeking to identify, through the selection of observable characteristics between these two groups, the impact of treatment (HGP). The propensity score matching configures itself as an important pairing resource used for the evaluation of public policies 26,27.
The matching procedures use a balanced score, computed from a regression model (logit or probit) that uses a dummy dependent variable that takes the value one if the individual (or unit) was exposed to the policy under analysis, or zero, if not.
The choice between the logit and probit models was performed using the Akaike Information Criterion (AIC) and the Bayesian Information Criterion (BIC), considering the lowest values found in both criteria as a reference for the best fit of the model29.
The PSM is defined as the probability of the individual (municipality) being a beneficiary of the program, given its characteristics (socioeconomic, demographic, and epidemiological).
Through the estimate of the PSM, subgroups are identified within the control group, with similar probabilities to the municipalities in the intervention group. Then, the variables are balanced, which allows testing of each block of the propensity score, as to whether the mean of each variable used in the model differed between beneficiary and non-beneficiary municipalities of the HGP.
After this step, a final number of blocks was defined and we proceeded with the calculation of the Average Treatment Effect on the Treated (ATT) by testing the matching algorithms. These tests aim to build a counterfactual scenario from the weighted average of the number of control units with each treatment unit28. Using this method, each unit of the treated group was paired with the unit of the control group with the closest propensity score. The ATT was determined to assess the impact of the Health Gym Program on mortality from Hypertension for each of the groups of municipalities (treated and controls).

Data analysis
Descriptive statistical procedures (frequencies, means, and standard deviations) were adopted to characterize the socioeconomic, demographic, and epidemiological profile of the treated and control municipalities before matching. To compare the means and standard deviations of the variables related to those exposed and not exposed to the policy under analysis (Health Gym Program) and the respective calculation of the effect size, Cohen\'s d measure was used.
To estimate the PSM, regression models for binary data were tested using the link functions logit and probit30, to determine the probability of participation of municipalities in the HGP, given the socioeconomic, demographic, and epidemiological characteristics of the municipalities that made up the sample, using a vector of characteristics from the period prior to exposure to the program (Xi,-1)31, which is given by:
P(