Background: Brazil's Unified Health System (Sistema Único de Saúde-SUS) has played a crucial role in reducing health disparities by providing universal and free healthcare to a diverse population. However, the COVID-19 pandemic exposed significant barriers to healthcare access among vulnerable groups, particularly due to the intersection of multiple vulnerabilities. This study aimed to examine how intersectionality-specifically sex/gender, race/ethnicity, and education level-has influenced inequalities in healthcare service utilization among vulnerable populations during the COVID-19 pandemic in Brazil.
Methods: This cross-sectional study is part of the "COVID-19 Social Thermometer in Brazil" project, conducted between May 2022 and October 2023 in Brazil's state capitals and the Federal District, focusing on populations considered socially vulnerable during the pandemic. Participants were selected using sequential sampling and completed a structured questionnaire. Statistical analyses-performed using Excel, RStudio (version 4.3.2), and ArcGIS-included sociodemographic profiling, the construction of the Jeopardy Index (a measure of social vulnerability), and binary logistic regression to explore associations between Jeopardy Index and healthcare service utilization.
Results: 3406 participants, the majority were men (60%), aged 30 to 59 years (65.1%), and identified as Black or Brown (72.2%). Most participants were concentrated in the Northeast (26.6%) and North (22.3%) macroregions. A high reliance on public healthcare services (SUS) was observed, particularly in the Southeast (96%). According to the Jeopardy Index, the most socially vulnerable groups-such as women, transgender individuals, Black people, and those with no formal education-were significantly more likely to rely on SUS (OR = 3.14; 95% CI: 1.34-7.35) and less likely to use private healthcare (OR = 0.07; 95% CI: 0.02-0.20), reflecting a 214% higher likelihood of SUS use and a 93% lower likelihood of private service utilization compared to the most privileged group.
Conclusions: Our findings reveal that individuals experiencing intersecting social vulnerabilities face marked inequalities in healthcare access. Without SUS, these populations would likely have been excluded from essential care. Strengthening SUS and implementing inclusive public policies are critical to reducing disparities and ensuring equitable healthcare access for historically marginalized groups.
Keywords: COVID-19; intersectional framework; public health services; social vulnerability.