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Conteúdo (article):

Mortalidade prematura por doenças crônicas não transmissíveis e privação material em uma capital brasileira

Mortalidad prematura por enfermedades crónicas no transmisibles y privación material en una capital brasileña

Premature mortality due to noncommunicable diseases and deprivation in a Brazilian state capital


Laís Santos de Magalhães Cardoso
L.S.M. Cardoso, PhD, Programa de Pós-graduação em Saúde Pública, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. ORCID: https://orcid.org/0000-0002-1114-5470 . E-mail: laissmcardoso@gmail.com

Juliana Bottoni de Souza
J.B. Souza, PhD, Programa de Pós-graduação em Enfermagem, Escola de Enfermagem, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. ORCID: https://orcid.org/0000-0002-9308-7445 . E-mail: juliana_bottoni@yahoo.com.br

Renato Azeredo Teixeira
R.A. Teixeira, PhD, Programa de Pós-graduação em Saúde Pública, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. ORCID: http://orcid.org/0000-0002-1259-6812 . E-mail: renato115@yahoo.com

Ruth Dundas
R. Dundas. PhD, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, Scotland, United Kingdom. ORCID: https://orcid.org/0000-0002-3836-4286. E-mail: ruth.dundas@glasgow.ac.uk.

Alastair H. Leyland
A.H. Leyland. PhD, MRC/CSO Social & Public Health Sciences Unit, University of
Glasgow, Glasgow, Scotland, United Kingdom. ORCID: https://orcid.org/0000-0003-3741-7099. E-mail: alastair.leyland@glasgow.ac.uk.

Maurício Lima Barreto
M.L. Barreto, MD, PhD, Centro de Integração de Dados e Conhecimentos para Saúde
(Cidacs), Fundação Oswaldo Cruz, Salvador and Instituto de Saúde Coletiva,
Universidade Federal da Bahia, Salvador, Bahia, Brazil. ORCID: https://orcid.org/0000-0002-0215-4930. E-mail: mauricio@ufba.br.

Deborah Carvalho Malta
D.C. Malta, MD, PhD, Departamento de Enfermagem Materno Infantil e Saúde Pública, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. ORCID: https://orcid.org/0000-0002-8214-5734 . dcmalta@uol.com.br

On behalf of the Unit on Social and Environmental Determinants of Health Inequalities (SEDHI)

RESUMO

Objetivo: Investigar a desigualdade na distribuição da mortalidade prematura por doenças crônicas não transmissíveis (DCNT) em Belo Horizonte e sua evolução temporal. Método: Estudo ecológico descritivo. Taxas de mortalidade foram calculadas segundo estratos do Índice Brasileiro de Privação (IBP) nos triênios 2010-2012 (T1) e 2017-2019 (T2). Comparou-se as taxas e a variação percentual (VP) destas pelo IBP e triênios. Resultados: Taxas mais altas no grupo de maior privação em T1 e T2 para: o conjunto das DCNT (T1 = 287,4 e T2 = 272,2), doenças cardiovasculares (T1= 132,7 e T2 = 105,1); diabetes (T1 = 18,0 e T2 = 22,1); e doenças respiratórias crônicas (T1 = 19,5 e T2 = 15,6). As taxas decresceram em todos os estratos do IBP, com maior magnitude nos de menor privação por DCNT (VP = -22,4%) e doenças cardiovasculares e (VP = -37,2%). As taxas por neoplasias e diabetes aumentaram no estrato de maior privação (VP = 10,4% e VP = 22,6%), e as taxas por doenças respiratórias no de menor (VP = 5,3%). Conclusão: Estratos de maior privação apresentaram menores reduções do risco de morrer pelo conjunto das DCNT, doenças cardiovasculares, neoplasias e diabetes, aumentando as desigualdades entre os grupos de maior e menor privação.

Palavras-chave: Doenças Crônicas Não Transmissíveis. Mortalidade Prematura. Mensuração das Desigualdades em Saúde. Privação Social. Estudos Ecológicos.


RESUMEN

Objetivo: Investigar la desigualdad en la distribución de la mortalidad prematura por enfermedades crónicas no transmisibles (ECNT) en Belo Horizonte y su evolución temporal.
Método: Estudio ecológico descriptivo. Se calcularon las tasas de mortalidad según los estratos del Índice Brasileño de Privación (IBP) en 2010-2012 (T1) y 2017-2019 (T2). Se compararon las tasas y la variación porcentual (VP) de estas según el IBP y los trienios. Resultados: Tasas más altas en el grupo de mayor privación en T1 y T2 para: el conjunto de las ECNT (T1 = 287,4; T2 = 272,2), enfermedades cardiovasculares (CV) (T1 = 132,7; T2 = 105,1); diabetes (DB) (T1 = 18,0; T2 = 22,1); y respiratorias crónicas (RC) (T1 = 19,5; T2 = 15,6). Las tasas disminuyeron en todos los estratos del IBP, con mayor magnitud en los de menor privación por ECNT (VP = -22,4%) y enfermedades CV (VP = -37,2%). Las tasas por neoplasias y DB aumentaron en el estrato de mayor privación (VP = 10,4%; VP = 22,6%), y las tasas por RC aumentaron en el de menor (VP = 5,3%). Conclusión: Los estratos de mayor privación presentaron menores reducciones del riesgo de morir por el conjunto de las ECNT, CV, neoplasias y DB, aumentando las desigualdades entre los grupos de privación.

Palabras clave: Enfermedades no Transmisibles. Mortalidad Prematura. Monitoreo de las Desigualdades en Salud. Privación Social. Estudios Ecológicos.


ABSTRACT

Objective: To investigate the inequality in the distribution of premature mortality from Noncommunicable Diseases (NCDs) in the city of Belo Horizonte and its temporal evolution. Method: This work was a descriptive ecological study. Mortality rates were calculated according to the Brazilian Deprivation Index (BDI) in 2010-2012 (T1) and 2017-2019 (T2). The rates and the percentage variation (PV) were compared by BDI and triennia. Results: Higher rates were found in the most deprived group in both T1 and T2 for: all NCDs (T1 = 287.4; T2 = 272.2); cardiovascular diseases (T1 = 132.7; T2 = 105.1); diabetes (T1 = 18.0; T2 = 22.1); and chronic respiratory diseases (T1 = 19.5; T2 = 15.6). The rates decreased in all BDI strata, with the greatest reduction occurring in the least deprived strata for NCDs (PV = -22.4%) and cardiovascular diseases (PV = -37.2%). Rates for neoplasms and diabetes increased in the most deprived stratum (PV = 10.4% and PV = 22.6%), while rates for respiratory diseases increased in the least deprived stratum (PV = 5.3%). Conclusion: The most deprived strata showed lower reductions in the risk of dying from the set of NCDs, cardiovascular diseases, neoplasms, and diabetes, increasing the inequalities between the most and the least deprived groups.

Keywords: Noncommunicable Diseases. Premature Mortality. Health Inequality Monitoring. Social Deprivation. Ecological Studies.

INTRODUCTION
Noncommunicable diseases (NCDs) are the leading cause of death worldwide, with an estimated 41 million victims each year. Of these, 17 million deaths occur prematurely in the population under 70 years of age, 86% of which occur in low- and middle-income countries1. Cardiovascular diseases, neoplasms, diabetes, and chronic respiratory diseases constitute the four main NCD groups and, combined, account for 76% of deaths from all causes in Brazil2. In 2017, these causes led to the death of a total of 327,954 individuals, aged 30 to 69 years, which represented 58.4% of all deaths in this age group2.
Premature mortality from NCDs affects individuals in the same population unequally, and this disparity is related to individual (biological, metabolic and behavioral), demographic, social, economic, and environmental aspects, which interact in a complex manner. Some of the factors that help explain this phenomenon are related to social markers of inequality, such as income and education, and the most socially vulnerable population groups are more exposed to risk factors for these diseases, such as smoking, alcohol consumption, unhealthy diets3, less physical activity in their free time, among others. These groups also have less access to health services and information, and are therefore at greater risk of developing more serious outcomes related to NCDs1.
In order to understand the processes of health inequalities it is necessary to understand how the territory and its social, demographic, economic, political, and environmental elements influence the health-disease process, beyond individual biological and behavioral determinants4. In this sense, methods for measuring social inequalities in health are widely used in epidemiological studies and report the application of isolated indicators and synthetic indexes, which measure the so-called “dimensions of inequality”, which usually reflect social vulnerability according to socioeconomic and demographic conditions, including: income, education, location, as well as characteristics of the household, geographic region, and gender5.
It is well-known that large urban centers present enormous social inequalities within their territory. From this perspective, studies that analyze intra-urban health inequalities are essential, as they enable the detection of at-risk population groups, allow for the evaluation of the effectiveness of public health policies, and provide the redirection of actions to monitor and control health events within the scope of local health management.
Previous publications have investigated inequality in the distribution of mortality from NCDs according to markers of social vulnerability using different spatial approaches and geographic segments6–9. Therefore, an opportunity to contribute to the field of knowledge of studies on intra-urban inequalities in the distribution of mortality from NCDs was identified, namely, the need to advance analytical proposals that simultaneously consider: an analysis of the four major groups of NCDs; death data corrected for under-reporting and unspecified causes; and analytical segments in small areas, using a measure of social inequality on a census tract scale so that it can be applied to any aggregate of sectors with national coverage and, therefore, replicated in other contexts and territories.
In view of the above, this article aimed to investigate inequality in the distribution of premature mortality from NCDs in the city of Belo Horizonte, Minas Gerais, according to social deprivation strata of the Brazilian Deprivation Index (BDI) and the evolution of this distribution over time.

METHODS

Study design, population, and period
This work was a descriptive ecological study in which premature mortality rates due to NCDs were analyzed as regards deaths occurring in the municipality of Belo Horizonte (BH), capital of the state of Minas Gerais, Brazil, according to strata of the Brazilian Deprivation Index (BDI), in the two triennia from 2010 to 2012 and from 2017 to 2019.

Indicators and data source

Premature mortality rates due to NCDs
Premature mortality rates due to NCDs (deaths due to cardiovascular diseases, chronic respiratory diseases, neoplasms, and diabetes mellitus in the population aged 30 to 69 years10) were calculated for individuals of both sexes. The death data came from a database provided by the Brazilian Ministry of Health, derived from the Mortality Information System (Sistema de Informações sobre Mortalidade – SIM), which already counted on geocoded data by census sector. The denominator used the estimated population, calculated from the population of the 2010 census, according to the method reported by Passos et al. 202111.
To minimize random fluctuations, the data were aggregated by triennia (2010 to 2012 and 2017 to 2019). Mortality rates were age-standardized, using the direct method12. The Brazilian population of the 2010 census was adopted as the standard population13 and was presented per 100,000 inhabitants.
In summary, the rate can be expressed by:


Measure of social inequalities in health: material deprivation index

Although Belo Horizonte has its own index, the Health Vulnerability Index (Índice de Vulnerabilidade da Saúde – IVS), it was decided to use the BDI, developed by the Center for Data Integration and Knowledge for Health (Centro de Integração de Dados e Conhecimentos para Saúde – CIDACS), of Fiocruz Bahia, in collaboration with the University of Glasgow, and launched in 202014. This is a summary measure also calculated on the scale of census sectors, but it advances in relation to others, as it uses a national cut-off point. Thus, it can be used in any other geographic region within the Brazilian territory. The analysis proposed in this study can therefore be replicated in other contexts in the country.
The calculation of the BDI considered the combination of z-scores of three deprivation indicators: percentage of households with income less than half the minimum wage; percentage of individuals aged 7 or older who are illiterate; percentage of individuals with inadequate access to water, sanitation, waste collection, and with no bathroom14. Details on the calculation of the index can be obtained in a technical report available on the CIDACS website14.

Treatment and data analysis

Processing of death data

Methods were applied to correct missing data and improve the definition of underlying causes of death by redistributing garbage codes (GC). Missing data were addressed by proportionally redistributing “ignored” data and blank fields according to year, age, sex, and place of residence15. Deaths classified as GC were then redistributed among specific causes of death by BDI category, considering each cause, age group, and study period. GCs comprise groups of ill-defined or unspecific causes that make it difficult to identify the real causes of the chain of events that led to death16. They should be identified and redistributed among deaths from specific causes in order to improve the reliability and quality of mortality estimates.
More information on the GC redistribution process can be found in previous publications15,17.

Treatment of the deprivation index
The database of BDI scores by census tracts provides a grouping of areas into quintiles weighted by population, ranging from the lowest to the highest deprivation14. The last three BDI deprivation quintiles were grouped in this study, given that these classes represent a smaller portion of census tracts and the population of the municipality in question, as shown in Table 1 and described in other publications11,14,17. Therefore, three strata of material deprivation will be considered: lowest deprivation (1st quintile), intermediate deprivation (2nd quintile) and highest deprivation (3rd, 4th, and 5th quintiles). In the census tract database of the Brazilian Institute of Geography and Statistics (IBGE), referring to the 2010 demographic census, Belo Horizonte has a total of 3,895 tracts, of which 3,831 were included in the BPI calculation14. Figure 1 represents the spatial distribution of census sectors in Belo Horizonte according to the BDI classification.

Analytical Procedures
The census sectors corresponding to the places of residence of the deceased were used as a key variable to cross-reference the death database with the BDI database, thus allowing these individuals to be classified according to BDI strata. Deaths without address information in SIM were excluded from the analysis due to the impossibility of identifying the census sector and, consequently, the impossibility of classifying them in one of the BPI categories.
The 95% confidence intervals (95% CI) of premature mortality rates due to NCDs were calculated according to the method published by the Centers for Disease Control and Prevention (CDC)18. The assessment of inequality in the distribution of mortality due to the investigated causes was made by comparative analysis of the values of the rates and the percentage variation (PV) between the BDI strata and between the two triennia. The PV is given by the following expression:

where PMR is the premature mortality rate by BDI stratum.
Microsoft Excel and R19 software were used in the data processing, analysis, and presentation stages.

Ethical Aspects
This study is part of the project “Inequalities in small geographic areas of indicators of Noncommunicable Diseases (NCDs), violence, and their risk factors”, approved by the UFMG Research Ethics Committee (Comitê de Ética em Pesquisa – CEP), logged under opinion number 3,258,076, and follows the ethical precepts of Resolution No. 466, of December 12, 2012, of the National Health Council. Our study used data from anonymized secondary databases requested directly from the Ministry of Health.

RESULTS
In the first triennia, 17,898 deaths of individuals aged 30 to 69 were recorded in Belo Horizonte, while in the second triennia, 17,779 deaths were recorded. Considering only premature deaths due to NCDs in this municipality, 9,084 deaths were recorded in the first triennia, while 9,509 deaths were recorded in the second. Of the total number of premature deaths due to NCDs in Belo Horizonte, from both sexes, the percentage of losses – deaths not geocoded due to a lack of information on the census sector of the residence of the deceased – corresponded to 24.4% in the first triennia and 26.7% in the second (data not shown).
The impossibility of geocoding deaths due to the lack of information on the census sector of residence of these resulted in a relative reduction in premature mortality rates, which varied between approximately 23% and 27% (Table 2). Between the triennia, a decline was observed in premature mortality rates from all investigated causes, taking into account both total deaths (coded and non-geocoded) and only geocoded deaths. Considering total deaths, the rates for all NCDs decreased from 285.1 per 100,000 inhabitants in the first triennia to 245.4 per 100,000 inhabitants in the second (a reduction of 23.38%). When considering only geocoded deaths, the values varied from 218.4 per 100,000 inhabitants to 181.3 per 100,000 inhabitants between the periods (a reduction of 26.10%) (Table 2).
Neoplasms accounted for the highest premature mortality rates in Belo Horizonte in both triennia, followed by cardiovascular diseases, diabetes, and chronic respiratory diseases. Between the two triennia, a decline was identified in the rates for all causes. The greatest decline occurred in the rates for cardiovascular diseases (VP = -30.9%), while the smallest was found in the rates for chronic respiratory diseases (VP = -3.9%) (Table 3).
The analysis by social deprivation strata revealed that mortality rates for all NCDs were higher in the most deprived group and lower in the least deprived group in both triennia. There was a relative temporal reduction within the same deprivation category, and this decrease was smaller in the most deprived stratum (-5.3%), when compared to the intermediate deprived stratum (-13.8%) and, above all, to the least deprived stratum (-22.4%) (Table 3).
The premature mortality rates for cardiovascular diseases were also higher in the most deprived stratum and lower in the least deprived stratum in both triennia. This group of diseases accounted for the largest percent reductions in rates over time. As was seen for all NCDs, this relative decline was smaller in the stratum of greatest deprivation (-20.8%) when compared to that of intermediate deprivation (-27.0%) and especially to that of least deprivation (-37.2%) (Table 3).
In general, an increase was also found in premature mortality rates from neoplasms with increasing deprivation, with the exception of what occurred in the 2010-2012 triennium between the intermediate and highest deprivation strata, in which a decrease from 124.1 to 117.2 deaths per 100,000 inhabitants was observed. Over time, there was a 14.2% decrease in rates in the lowest deprivation stratum and a smaller decrease of 2.2% in the intermediate deprivation stratum. By contrast, there was a 10.4% increase in rates in the highest deprivation stratum between the triennia (Table 3).
Premature mortality rates from diabetes also followed the pattern of increase with increasing deprivation in both triennia. These varied from 10.2 to 18.0 deaths per 100,000 inhabitants between the strata of least and greatest deprivation in the first triennia (VP = 76.5%). In the second triennia, these varied from 8.7 to 22.1 deaths per 100,000 inhabitants between the strata of least and greatest deprivation (VP = 154.0%). Comparing the evolution between the two triennia, the stratum of least deprivation showed a smaller relative reduction in rates (-14.1%) in relation to the stratum of intermediate deprivation (-16.1%). The stratum of greatest deprivation showed an increase of 22.6% in premature mortality rates due to diabetes between the two triennia, which exceeded the increase observed for rates due to neoplasms (Table 3).
Regarding chronic respiratory diseases, a pattern of increased mortality rates was also observed with increasing deprivation. Between the lowest and highest deprivation categories, there was an increase from 7.5 to 19.5 deaths per 100,000 inhabitants in the first triennia (VP = 160.0%) and from 7.9 to 15.6 deaths per 100,000 inhabitants in the second (VP = 97.5%). Between the two triennia, while an increase of 5.3% was observed in the rates in the lowest deprivation stratum, there was a decrease of 2.0% in the intermediate deprivation stratum and an even greater decrease, of 19.9%, in the highest deprivation stratum. This temporal pattern, whose situation is better for the highest deprivation stratum, differed from that observed for the other causes of death (Table 3).
Comparing the groups with the highest and lowest deprivation, the relative difference given by the percentage variation between the rates of one group in relation to the other increased from the first to the second triennia, which denotes an increase in inequality or distance between these strata of deprivation (Figure 2).

DISCUSSION

In the present study, neoplasms, followed by cardiovascular diseases, accounted for the highest premature mortality rates in Belo Horizonte in both triennia. The present study also showed a decline in rates for all causes during the investigated period. Rates increased with the progression of deprivation in both triennia, and their temporal evolution differed between groups of causes. Rates for all NCDs and cardiovascular diseases decreased, but this decline was smaller in the most deprived stratum. In this same stratum, rather than decreasing, mortality rates for neoplasms and diabetes increased. An opposite pattern was observed in the percentage variation in rates for chronic respiratory diseases, in which an increase was observed in the least deprived stratum, as compared to a decrease in the most deprived stratum. The decline in premature mortality rates for NCDs in the city of Belo Horizonte follows the pattern shown for Brazil in other recently published ecological studies2,17,20,21. Estimates from the Global Burden of Disease (GBD) study indicated that premature mortality from NCDs in Brazil varied from 509.1 deaths per 100,000 inhabitants in 1990 to 329.6 deaths per 100,000 inhabitants in 2017, equivalent to a decline of 35.3%2. The burden of morbidity and mortality from NCDs has driven the prioritization of the topic on national and international health agendas, notably in the last two decades, a fact that helps to explain the observed pattern of decline.
In the national scenario, notable political and institutional frameworks have been established to guide the implementation of policies to combat NCDs and their risk factors, which is in line with international agreements. Among these, the most notable in the last decade are the “Strategic Action Plan to Tackle Chronic Noncommunicable Diseases (NCDs) in Brazil, 2011-2022” and, more recently, the “Strategic Action Plan to Tackle Chronic Diseases and Noncommunicable Injuries in Brazil 2021-2030”, which reaffirmed and expanded the strategic proposals22. Therefore, the reduction in mortality due to NCDs can be attributed to advances in surveillance, health promotion, and comprehensive care within the scope of the Unified Health System (SUS)23.
The decrease in mortality caused by cardiovascular diseases in this study is consistent with the trend that has been observed in Brazil and worldwide for decades24, and numerically reflects the decline in all NCDs. Factors that help explain the decline in mortality caused by these diseases include improvements in the socioeconomic situation of the population25,26 and in the provision of health services27,28, as well as the significant increase in specific care in the country in recent decades, such as the number of clinical and surgical procedures, especially for heart failure, cerebrovascular diseases and acute coronary syndrome, and hospitalizations for percutaneous coronary intervention29. Actions to prevent and control risk factors also stand out, including high blood pressure and, especially, smoking, one of the most important preventable causes of death28. Despite the observed decline, the risk of death from cardiovascular diseases still reflects the magnitude and severity of morbidity from this cause in Belo Horizonte.
The mortality rates from neoplasms found in this study were higher than the rates from cardiovascular diseases, diverging from the findings of other studies that analyzed Brazil, its federative units, or macro-regions21,30. This pattern is similar to that observed for most high-income countries, in which neoplasms are the leading causes of death, and it is estimated that it will expand to even more countries throughout this century31. The small decline between the two triennia observed for Belo Horizonte seems, however, to converge with the findings of other studies for the Brazilian population, which found a small decrease2, an increase in the risk of death, or a stationary trend32. It is important to mention that hospitalization rates due to neoplasms in the city of Belo Horizonte increased substantially, by 56.7%, between 2000 and 202033. While a reduction in the mortality rate, such as that observed for cardiovascular diseases, would not be expected, since the obstacle of access to diagnostic support tests and late diagnoses in the country still needs to be overcome for cancers34, in addition to the waiting time for treatment after diagnosis35.
The present study showed an 8.5% decline in the premature mortality rate due to diabetes in Belo Horizonte between the two triennia investigated, but found a significant increase of 22.6% in the most deprived stratum. Another publication showed a 17.8% reduction for Brazil between 1990 and 20172. However, the authors identified variations in the pattern between the states, with a predominance of increasing or stable trends, and states in the North and Northeast regions presenting the highest rates. In the same sense, other authors stated that estimates of morbidity and mortality due to diabetes in Brazil demonstrate a shift in prevalence and burden to poorer regions of the country, such as the North and Northeast regions36. The increase in rates observed in the most deprived stratum in Belo Horizonte is in line with these findings.
The decrease in premature mortality rates from chronic respiratory diseases observed in Belo Horizonte is consistent with the pattern of decrease for Brazil reported in another study2. Another publication reported a 42% drop in mortality from these diseases, but an overall increase of 34% in the rate of disability-adjusted life years (DALYs) 37, a measure that simultaneously captures premature mortality and the time lived with disability caused by the disease. This increase appears to be mainly due to population growth and aging, and chronic obstructive pulmonary disease37. Finally, although the relative variation showed a direction opposite to that expected - with an increase in the stratum of least deprivation and a greater decline in the stratum of greatest deprivation between the two triennia – the values of the rates for Belo Horizonte were higher in the strata of greatest deprivation, following the pattern of the inequality gradient observed in the other causes.
Brazil is experiencing a demographic transition and, inseparably, an epidemiological transition. However, this has been occurring in a heterogeneous manner in the country, highlighting the geographic polarization resulting from social polarization23. The divergences in the mortality pattern would therefore be explained by differences in the demographic structure32, living conditions of the populations, the structure and organization of health care networks, as well as the quality of information on deaths2. Estimates have indicated, for example, higher mortality rates due to diabetes and neoplasms in states in the North and Northeast regions25, regions that historically have worse socioeconomic indicators and worse access to and use of health services38. In this perspective and in a similar manner, the present study demonstrated disparities in the magnitude and temporal evolution of premature mortality rates due to NCDs in Belo Horizonte between the strata of social vulnerability, a result that is highly relevant when it comes to assessing health inequalities on an intra-urban scale.
Analyzing the local context of Belo Horizonte specifically, the findings of this study are in line with the production on the distribution of risk factors for NCDs in the city. Research that analyzed data from the 2010 Telephone Survey on Surveillance of Risk and Protection Factors for Chronic Diseases (Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico – VIGITEL) grouped the health districts of the capital according to sociodemographic indicators into 4 clusters, and identified that the cluster that presented the best sociodemographic indicators also presented the highest frequencies of protective factors and the lowest frequencies of risk factors for NCDs, a situation opposite to that observed in the cluster that presented the worst sociodemographic indicators39. Other studies also identified a higher prevalence of smokers40, an abusive consumption of alcoholic beverages, a lower prevalence of consumption of fruits and vegetables, and practice of physical activity in leisure time in areas with a higher risk of health vulnerability in Belo Horizonte41. It is worth mentioning that Belo Horizonte is among the capitals with the largest population coverage of the Family Health Strategy (FHS), and nearly a decade ago, in 2014, it covered approximately 82% of its population42. Despite this, the FHS still faces challenges in terms of quality of care and ensuring access to health services43, especially with regard to the line of care aimed at people with NCDs, given the care model that still prioritizes acute conditions and exacerbations of chronic conditions44. Hence, future studies that explore in depth, and with the application of other methodological approaches, the increase in the difference between the deprivation strata over time in the city of Belo Horizonte, should provide political and contextual elements necessary to understand this specific phenomenon.
This study adds to other analyses on the pattern of premature mortality due to NCDs in Brazil in intra-urban areas and produces methodological advances due to: i) the corrections applied to the death data, which improved the quality of the information on the causes of death; ii) as well as the use of a deprivation index developed for the country on a census tract scale, which can be applied to any other national geographic area, strengthening investigations in small areas. Furthermore, choosing a capital city in the Southeast Region as the unit of analysis adds robustness to the results of the study, given the higher quality of the SIM information in these locations.
Among this study’s limitations, it is necessary to consider the percentages of loss, whose potential impact is the underestimation of the value of the rates. Moreover, the BDI was calculated based on data from the 2010 census and, therefore, the distribution and magnitude of deprivation in the city of Belo Horizonte may have changed in the last decade, which can only be captured after analysis with data from the 2022 census.
In this study, the most deprived population strata had the highest rates of premature mortality from NCDs and the lowest reductions in the risk of dying from these causes between the analyzed periods. Analyses of health inequalities in small areas - such as intra-urban spaces - are essential to reveal nuances in morbidity and mortality profiles masked by analyses of aggregated data. They can, therefore, provide local management with information on at-risk population groups and support more efficient decision-making in public health.

FUNDING

This research was funded by the NIHR (NIHR134801) using UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. This study also received funding from the Minas Gerais Research Support Foundation (FAPEMIG), via the project “Inequalities in mortality indicators due to Noncommunicable Diseases and COVID-19 in Brazil and Minas Gerais” (process APQ-00505-21). This manuscript is a product of LSMC\'s doctoral thesis, made possible with support from the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001.

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