Abstracts

Introduction

The racial composition of the growing Brazilian elderly population has changed in recent years ¹1  Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010: características da população e dos domicílios, resultados do universo. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011.. In the first decade of the 21^st century, the Brazilian population 65 years or older increased by 29.5%, from 9.9 million (5.8%) in 2000 to 14.0 million (7.4%) in 2010 ¹1  Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010: características da população e dos domicílios, resultados do universo. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011.. In 2000, the white elderly population (61.7%) predominated over brown elderly (29.5%) and black elderly (6.9%), while by 2010 the proportion of white elderly had decreased (56.8%), with an increase in browns (33.8%) and blacks (7.7%) ¹1  Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010: características da população e dos domicílios, resultados do universo. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011..

However, recent economic, political, and health changes in the country ²2  Victora CG, Barreto ML, Leal MC, Monteiro CA, Schmidt MI, Paim J, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377:2042-53. have failed to eliminate the inequalities in living and health conditions between racial groups among elderly Brazilians ²2  Victora CG, Barreto ML, Leal MC, Monteiro CA, Schmidt MI, Paim J, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377:2042-53.^,33  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.. The impact of these changes has not been uniform ⁴4  Rebouças M, Pereira MG. Indicadores de saúde para idosos: comparação entre o Brasil e os Estados Unidos. Rev Panam Salud Pública 2008; 23:237-46.. The presence of racial inequalities among the elderly suggests the complex interaction between color/race and markers of social position ⁵5  Krieger N. A glossary for social epidemiology. J Epidemiol Community Health 2001; 55:693-700.^,66  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67. and reflects the unequal distribution of risk factors, protective factors, and health problems that accumulate over the course of various life cycles and into old age ⁶6  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67.^,77  Zorzin PLG, Wajnman S, Turra CM. Previdência social e desigualdade racial no Brasil. Belo Horizonte: Centro de Desenvolvimento e Planejamento Regional de Minas Gerais, Universidade Federal de Minas Gerais; 2011.. Brown and black elderly thus continue to experience lack of equality, worse socioeconomic situations ²2  Victora CG, Barreto ML, Leal MC, Monteiro CA, Schmidt MI, Paim J, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377:2042-53.^,88  Veras R. Fórum. Envelhecimento populacional e as informações de saúde do PNAD: demandas e desafios contemporâneos. Introdução. Cad Saúde Pública 2007; 23:2463-6., and greater health needs ⁹9  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009..

Although various studies indicate that the aging process does not occur homogeneously between persons of different social and racial gradients ²2  Victora CG, Barreto ML, Leal MC, Monteiro CA, Schmidt MI, Paim J, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377:2042-53.^,44  Rebouças M, Pereira MG. Indicadores de saúde para idosos: comparação entre o Brasil e os Estados Unidos. Rev Panam Salud Pública 2008; 23:237-46.^,88  Veras R. Fórum. Envelhecimento populacional e as informações de saúde do PNAD: demandas e desafios contemporâneos. Introdução. Cad Saúde Pública 2007; 23:2463-6.^,99  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,1010  Spencer SM, Schulz R, Rooks RN, Albert SM, Thorpe Jr. RJ, Brenes GA, et al. Racial differences in self-rated health at similar levels of physical functioning: an examination of health pessimism in the health, aging, and body composition study. J Gerontol B Psychol Sci Soc Sci 2009; 64:87-94.^,1111  Thorpe Jr. RJ, Koster A, Kritchevsky SB, Newman AB, Harris T, Ayonayon HN, et al. Race, socioeconomic resources, and late-life mobility and decline: findings from the Health, Aging, and Body Composition study. J Gerontol A Biol Sci Med Sci 2011; 66:1114-23., doubts persist as to whether health inequalities can be attributed directly to color/race, independently of individual and contextual socioeconomic inequalities ³3  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.^,1111  Thorpe Jr. RJ, Koster A, Kritchevsky SB, Newman AB, Harris T, Ayonayon HN, et al. Race, socioeconomic resources, and late-life mobility and decline: findings from the Health, Aging, and Body Composition study. J Gerontol A Biol Sci Med Sci 2011; 66:1114-23.^,1212  Chor D, Lima CRA. Aspectos epidemiológicos das desigualdades raciais em saúde no Brasil. Cad Saúde Pública 2005; 21:1586-94.^,1313  Laguardia J. Raça e epidemiologia: as estratégias para construção de diferenças biológicas. Ciênc Saúde Coletiva 2007; 12:253-61..

Worldwide, health status assessment in the elderly is frequently based on indicators of health conditions and physical mobility and autonomy ⁶6  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67.^,99  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,1010  Spencer SM, Schulz R, Rooks RN, Albert SM, Thorpe Jr. RJ, Brenes GA, et al. Racial differences in self-rated health at similar levels of physical functioning: an examination of health pessimism in the health, aging, and body composition study. J Gerontol B Psychol Sci Soc Sci 2009; 64:87-94.^,1414  Lima-Costa MF, Matos DL, Camargos VP, James M. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc Saúde Coletiva 2011; 16:3689-96.^,1515  Borim FSA, Barros MBA, Neri AL. Autoavaliação da saúde em idosos: pesquisa de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2012; 28:769-80.. The most widely used indicators include global self-related health status, number of chronic diseases or conditions, and functional capacity ⁶6  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67.^,99  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,1414  Lima-Costa MF, Matos DL, Camargos VP, James M. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc Saúde Coletiva 2011; 16:3689-96.^,1515  Borim FSA, Barros MBA, Neri AL. Autoavaliação da saúde em idosos: pesquisa de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2012; 28:769-80.. The first indicates elders’ subjective and integrated dimensions of their own health. Functional status reveals the functional dimension of performing daily tasks, and number of chronic diseases represents the medical and objective dimension of the presence of deviations from normal physiological function ⁹9  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,1616  Alves LC, Leite IC, Machado CJ. Fatores associados à incapacidade funcional dos idosos no Brasil: análise multinível. Rev Saúde Pública 2010; 44:468-78.^,1717  Do DP, Finch BK, Basurto-Davila R, Bird C, Escarce J, Lurie N. Does place explain racial health disparities? Quantifying the contribution of residential context to the black/white health gap in the United States. Soc Sci Med 2008; 67:1258-68..

The association between brown and black color/race and worse health conditions and functional decline in elderly Brazilians has received little research attention ⁷7  Zorzin PLG, Wajnman S, Turra CM. Previdência social e desigualdade racial no Brasil. Belo Horizonte: Centro de Desenvolvimento e Planejamento Regional de Minas Gerais, Universidade Federal de Minas Gerais; 2011.^,99  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,1212  Chor D, Lima CRA. Aspectos epidemiológicos das desigualdades raciais em saúde no Brasil. Cad Saúde Pública 2005; 21:1586-94., and the results of this association are controversial and conflicting ¹⁵15  Borim FSA, Barros MBA, Neri AL. Autoavaliação da saúde em idosos: pesquisa de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2012; 28:769-80.^,1616  Alves LC, Leite IC, Machado CJ. Fatores associados à incapacidade funcional dos idosos no Brasil: análise multinível. Rev Saúde Pública 2010; 44:468-78.. This has limited the current understanding of the impacts of racial inequalities in this phase of life ⁷7  Zorzin PLG, Wajnman S, Turra CM. Previdência social e desigualdade racial no Brasil. Belo Horizonte: Centro de Desenvolvimento e Planejamento Regional de Minas Gerais, Universidade Federal de Minas Gerais; 2011.^,1212  Chor D, Lima CRA. Aspectos epidemiológicos das desigualdades raciais em saúde no Brasil. Cad Saúde Pública 2005; 21:1586-94.. In Brazil, various studies based on data from the National Household Sample Survey (PNAD) have explored the influence of gender, income, schooling, age bracket, and social housing context on the health of elderly ¹⁴14  Lima-Costa MF, Matos DL, Camargos VP, James M. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc Saúde Coletiva 2011; 16:3689-96.^,1818  Travassos CF, Viacava F, Laguardia J. Os Suplementos Saúde na Pesquisa Nacional por Amostra de Domicílios (PNAD) no Brasil. Rev Bras Epidemiol 2008; 11 Suppl 1:98-112.^,1919  Rede Interagencial de Informação para a Saúde. Demografia e saúde: contribuição para análise de situação e tendências. Brasília: Organização Pan- Americana da Saúde; 2009., but the association between health-disease and functional incapacity indicators and the color/race variable has not been explored ¹1  Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010: características da população e dos domicílios, resultados do universo. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011.^,1919  Rede Interagencial de Informação para a Saúde. Demografia e saúde: contribuição para análise de situação e tendências. Brasília: Organização Pan- Americana da Saúde; 2009..

This study aimed to analyze the associations between color/race and health indicators in elderly Brazilians, using data from the health supplement of PNAD for 2008.

Methods

This cross-sectional study analyzed the relationship between color/race and health indicators in elderly Brazilians included in the PNAD data- base ²⁰20  Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2008., conducted in 2008 by the Brazilian Institute of Geography and Statistics (IBGE).

PNAD is a nationwide population-based household survey that aims to obtain representative information on the Brazilian population concerning socio-demographic, educational, housing, work, and income characteristics. The 2008 edition included a health supplement with information on the sample’s health conditions and physical mobility ²⁰20  Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2008..

The PNAD uses a complex probabilistic sample of households from all regions of Brazil, obtained in three selection stages ²⁰20  Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2008.. The first stage involves the selection of municipalities (counties), which are classified as self-representative, with 100% probability of belonging to the sample, and non-self-representative, where the probability of belonging to the sample is proportional to the resident population. In the second stage, census tracts are selected, where the probability of inclusion is proportional to the number of households in the tract. In the last stage, households are sampled in each census tract, collecting information on the households and all their individual residents ²⁰20  Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2008..

The data covered 391,868 persons and 150,591 households distributed in all States of Brazil. This analysis used the elderly population 65 years or older (n = 28,437). The inclusion criterion was self-reported color/race ¹1  Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010: características da população e dos domicílios, resultados do universo. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011.^,2020  Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2008.^,2121  Silva PLN, Pessoa DGC, Lila MF. Análise estatística de dados da PNAD: incorporando a estrutura do plano amostral. Ciênc Saúde Coletiva 2002; 7:659-70., removing the elderly whose color/race was reported by third parties in order to reduce the odds of information and classification bias in this variable and prevalence bias in the target racial groups ¹1  Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010: características da população e dos domicílios, resultados do universo. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011.^,33  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.. After removing the elderly whose color/race was reported by others (n = 8,752), “yellow” color/race (i.e., Asian or Asian-descent) (n = 153), indigenous (n = 69), missing (n = 15), and those with no information on per capita family income (n = 764), the final study population included 18,684 elderly.

Study variables

The study outcomes were two health indicators – global self-rated health (GSRH) and number of chronic diseases and conditions – and an indicator of physical mobility and autonomy – functional capacity.

GSRH has five response categories: very good, good, fair, bad, and very bad. The number of chronic diseases and conditions was calculated by adding all those included in the PNAD: arthritis/rheumatism, cancer, diabetes, hypertension, depression, spinal column disease/back pain, bronchitis/asthma, tuberculosis, heart disease, chronic kidney disease, cirrhosis, and tendinitis/tenosynovitis.

Functional incapacity was defined as the degree of difficulty in performing the activity of daily living (ADL) “eating, bathing, and toileting”. In the PNAD, this indicator has four categories: no difficulty, major difficulty, minor difficulty, and unable to perform. In the current study, this indicator was organized in three categories; none, some (combining minor and major difficulty), and total functional incapacity.

The main explanatory variable was self-reported color/race of the elderly, categorized as white, black, and brown. In the PNAD, interviewees are asked to report their skin color as a proxy for race. The color/race item thus shows which which racial group the individuals identify ³3  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.^,2222  Travassos C, Williams DR. The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States. Cad Saúde Pública 2004; 20:660-78..

For this study, the socioeconomic, demographic, and health covariates were: sex (male or female); age (in complete years grouped in three age brackets: 65 to 69, 70 to 79, and ≥ 80 years); schooling (in years, grouped in three strata: 0, 1 to 8, and ≥ 9 years of schooling); workforce status in the reference week (in the workforce versus not in the workforce); role in the family (in three categories: reference person, spouse, and other); number of residents in the household (grouped in three categories: 1, 2, and ≥ 3 persons); location of the household (urban versus rural); major geographic region of Brazil, in five categories (North, Northeast, Central, Southeast, and South); private health plan (yes or no), and per capita household income quintile [in five strata: 1^st (lowest), 2^nd, 3^rd, 4^th, and 5^th (lowest)], where median income was R$: 207.00 in the 1^st quintile and R$ 1,572.00 in the 5^th quintile.

Analysis

The study estimated prevalence rates and 95% confidence intervals (95%CI) for the socioeconomic, demographic, and health variables according to color/race, considering the sampling design.

Differences in distribution of socioeconomic, demographic, and health variables in the color/race categories were estimated by the Pearson chi-square test.

Two final regression models were constructed for each outcome. First, color/race was divided into three categories: white, brown, and black. The associations were then tested by combining brown and black into one category (“blacks”).

To estimate the associations between color/race and the outcomes self-rated health status and functional incapacity, ordinal logistic regression analyses (proportional odds type model) were used to obtain odds ratios (OR) and respective 95%CI ²³23  Abreu MNS, Siqueira AL, Caiaffa WT. Regressão logística ordinal em estudos epidemiológicos. Rev Saúde Pública 2009; 43:183-94.^,2424  Moraes JR, Moreira JPL, Luiz RR. Efeito do plano amostral em modelo logístico ordinal: uma análise do estado de saúde autorreferido de adultos no Brasil usando a Pesquisa Nacional por Amostra de Domicílios de 2008. Cad Saúde Pública 2012; 28:913-24.. For the number of chronic conditions, prevalence ratios (PR) and 95%CI were estimated by Poisson regression. The proportional odds type model of ordinal logistic regression was used because the model considers the ordinal polychotomous nature of the study outcome and indicates the likelihood or accumulated odds ratio between the ordinal outcome categories ²³23  Abreu MNS, Siqueira AL, Caiaffa WT. Regressão logística ordinal em estudos epidemiológicos. Rev Saúde Pública 2009; 43:183-94.^,2424  Moraes JR, Moreira JPL, Luiz RR. Efeito do plano amostral em modelo logístico ordinal: uma análise do estado de saúde autorreferido de adultos no Brasil usando a Pesquisa Nacional por Amostra de Domicílios de 2008. Cad Saúde Pública 2012; 28:913-24.. Meanwhile, Poisson regression models have been used as a good alternative for obtaining adequate PR estimates, even in cross-sectional studies, when the outcome is frequent ²⁵25  Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3:21.^,2626  Coutinho LMS, Scazufca M, Menezes PR. Métodos para estimar razão de prevalência em estudos de corte transversal. Rev Saúde Pública 2008; 42:992-8..

Variables associated with the outcome with p < 0.20 were selected as potential confounders. Only the variables with p < 0.01 were kept in the multivariate model.

All the analyses used Stata version 10.0 (Stata Corp., College Station, USA), with the svy command (with weighting factors, strata, and primary sampling units) which incorporates the effect of the complex sampling design ²¹21  Silva PLN, Pessoa DGC, Lila MF. Análise estatística de dados da PNAD: incorporando a estrutura do plano amostral. Ciênc Saúde Coletiva 2002; 7:659-70. in PNAD 2008 in the analyses. The Wald t test was used to test the models’ fit. For the number of chronic conditions, the determination coefficient was estimated (pseudo R2). For the other outcomes, the observed and estimated values were compared for the outcome categories, calculating the percentage of agreement.

Results

Among the 18,684 elderly in this study, median age was 72 years (68-77). Some 56.2% (95%CI: 55.1-57.2) of the elderly identified themselves as white, 36.3% as brown (95%CI: 35.3-37.3), and 7.5% as black (95%CI: 7.1-8.0). Among the elderly analyzed, 7.5% (95%CI: 7.0-8.0) rated their health status as very good, 74.4% (95%CI: 73.7-75.2) had at least one chronic disease, and 14.9% (95%CI: 14.2-15.6) reported functional incapacity.

For the three racial groups, all the socioeconomic, demographic, and health variables showed statistically significant differences (p < 0.001), considering design effect (Table 1).

Women predominated in the three racial groups. Some 40.6% of the brown elderly and 38.1% of the blacks were young elderly (65-69 years) and 17.1% of the whites were among the oldest old (≥ 80 years). Some 50.8% of the brown elderly and 50.6% of the black elderly had no schooling. Only 7.4% of the brown elderly and 7.2% of the blacks reported ≥ 9 years of schooling. The data showed that 27.9% of the brown elderly, 25% of the blacks, and 12.6% of the whites belonged to the lowest income quintile. Some 30% of the white elderly belonged to the highest income quintile, compared to 10.2% of the browns and 8.8% of blacks. The proportion of elderly in the country’s rural area was higher among browns (24.9%) and lower among whites (14.5%). Nearly 77% of the white elderly lived in the South and Southeast of Brazil, while 55% of the brown elderly and 37% of the blacks lived in the North and Northeast. Exclusive reliance on the Brazilian Unified National Health System (SUS) included 85% of the black elderly, 83.8% of the browns, and 62.7% of the whites (Table 1).

Self-rated health status in elderly Brazilians differed significantly in the racial groups analyzed here (p < 0.001). Prevalence of very good self-rated health was higher among whites, while bad and very bad self-rated health was higher in browns and blacks (Table 1).

Very good self-rated health in elderly Brazilians in 2008 was also more common in women, elders in the workforce, reference persons in the household, those with private health plans, residents of urban areas, and those from the South and Southeast. Very good self-rated health decreased with age and with the number of household members, while increasing with income and schooling (Table 2).

In the crude analysis, brown and black elderly had higher odds of worse self-rated health. The odds of bad self-rated health were 54% greater in browns (OR = 1.54; 95%CI: 1.44-1.64) and 39% greater in blacks (OR = 1.39; 95%CI: 1.24-1.57) than in whites. After adjusting for confounding, the odds ratios were attenuated, but brown color/race remained directly associated with the odds of very bad self-reported health. Brown elderly had 11% higher odds of worse self-reported health (OR = 1.11; 95%CI: 1.03-1.18) than whites (Table 2).

Prevalence of chronic conditions in elderly Brazilians differed significantly between racial groups (p < 0.001) (Table 1). Prevalence was higher in blacks (78.6%; 95%CI: 76.4-80.6) than whites (74.9%; 95%CI: 73.9-76.0) and browns (72.9%; 95%CI: 71.6-74.0) (Table 3). It was higher in women, elders outside the workforce, with less schooling, spouses, urban residents, in the South and Southeast, and those with private health plans. Prevalence of chronic diseases increased directly with age and household income and decreased with number of household members. In the crude analysis, black color/race did not differ significantly (p = 0.266) and brown color/race was inversely associated with the outcome, with 8% lower prevalence of chronic diseases than whites (PR = 0.92; 95%CI: 0.89-0.95). After adjusting for confounding, black elderly showed 7% higher prevalence of chronic diseases than whites (PR = 1.07; 95%CI: 1.02-1.13) (Table 3).

Prevalence rates of functional incapacity in elderly Brazilians differed significantly between racial groups (p = 0.0175). Prevalence of any functional incapacity was greater in black elderly (17%) than in whites (13.8%) and browns (13.3%) (Table 1).

Prevalence of preserved functional status in elderly Brazilians in 2008 was higher in men, elders in the workforce, spouses, urban residents, in the Southeast region, and in those with private health plans. The proportion of preserved functional capacity decreased with schooling and with increasing age, while increasing with household income. In the crude analysis, the odds of elderly rating their functional status in the functional decline categories were directly associated with black color/race (p < 0.001). The odds of functional decline were 26% greater in black elderly than in whites (OR = 1.26; 95%CI: 1.07-1.47). There was no significant difference for browns as compared to whites (p = 0.741). After adjusting for confounding, the odds ratio for black color/race changed and lost the association with worse functional status (OR = 0.97; 95%CI: 0.82-1.15). Brown elders showed 20% lower likelihood (OR = 0.80; 95%CI: 0.73-0.89) of evolving on the functional incapacity scales when compared to whites (Table 4).

When analyzing the black and brown categories jointly (hereinafter designated as “black”, i.e., in quotes), there was a loss of statistically significant difference in prevalence rates for functional incapacity between whites and the combined “black” category (p = 0.612). For the other outcomes, the same p-value remained (< 0.001).

The crude analysis showed that the odds of “black” elders reporting worse self-rated health were 51% greater (OR = 1.51; 95%CI: 1.42-1.61) than for whites. In the adjusted analysis, these odds were attenuated to 9% (OR = 1.09; 95%CI: 1.02-1.16). For the number of chronic conditions, “black” color/race showed a protective effect, with 6% lower prevalence (PR = 0.94; 95%CI: 0.91-0.97) than in whites. In the adjusted analysis, there was no statistically significant association with the outcome (p = 0.132). For functional incapacity, only the adjusted analysis showed an association with “black” color/race: the odds of “blacks” reporting functional decline were 17% lower than for whites (Table 5).

All the models showed good fit (p < 0.001). However, for number of chronic conditions, the model explained 5.6% of the variance in the outcome when two or three racial categories were used. For self-rated health status and functional incapacity, agreement between the observed and predicted values was 27.9% and 52.4%, respectively, independently of considering two or three racial categories.

Discussion

The results of this analysis suggest the presence of racial inequalities in health and socioeconomic and demographic conditions in elderly Brazilians ≥ 65 years in 2008. Brown and black elderly compared to white elderly predominate in the younger age brackets (65-69 years), those relying exclusively on the SUS, with less schooling, in the lowest income quintile, and in regions of the country with worse social and health indicators.

Elderly in the sample showed important differences in the estimates for risk and protective factors, revealing that aging among browns and blacks occurs in a context of significant inequalities. These inequalities result from denial of social rights throughout life, with repercussions on overall living conditions in old age ⁵5  Krieger N. A glossary for social epidemiology. J Epidemiol Community Health 2001; 55:693-700.^,66  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67..

In other countries, the estimates of black elderly with worse socioeconomic status are similar to those observed in this study, indicating the overlapping of blacks among poor elderly and those with less schooling ⁶6  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67.^,2727  Federal Interagency Forum on Aging-related Statistics. Older Americans 2010: key indicators of well-being. Washington DC: US Government Printing Office; 2010.^,2828  Howard DH, Sentell T, Gazmararian JA. Impact of health literacy on socioeconomic and racial differences in health in an elderly population. J Gen Intern Med 2006; 21:857-61..

In the current study, brown and black elderly showed the worst outcomes for the target health indicators, both when compared to elderly in general in our own study and in relation to estimates by Lima-Costa et al. ¹⁴14  Lima-Costa MF, Matos DL, Camargos VP, James M. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc Saúde Coletiva 2011; 16:3689-96. for the total Brazilian population, using the PNAD data from 1998, 2003, and 2008.

Color/race was directly associated with indicators that are widely used in health surveys in Brazil and elsewhere in the world to evaluate and monitor health in the elderly ⁶6  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67.^,1010  Spencer SM, Schulz R, Rooks RN, Albert SM, Thorpe Jr. RJ, Brenes GA, et al. Racial differences in self-rated health at similar levels of physical functioning: an examination of health pessimism in the health, aging, and body composition study. J Gerontol B Psychol Sci Soc Sci 2009; 64:87-94.^,1414  Lima-Costa MF, Matos DL, Camargos VP, James M. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc Saúde Coletiva 2011; 16:3689-96.^,1515  Borim FSA, Barros MBA, Neri AL. Autoavaliação da saúde em idosos: pesquisa de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2012; 28:769-80., especially in browns for worse global self-rated health status and in blacks for more chronic conditions. For maintenance of functional capacity, brown color/race appeared a as potential protective factor. In brown elderly, the odds of worse self-rated health were independent of differences in socioeconomic and demographic factors. After multivariate analysis, the higher likelihood of chronic diseases in the black elderly suggests that the effect of black color/race is influenced by the factors considered in the model.

The effects of color/race on the health of the elderly Brazilian population still show differences between studies ⁹9  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,1515  Borim FSA, Barros MBA, Neri AL. Autoavaliação da saúde em idosos: pesquisa de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2012; 28:769-80.^,2929  Fuller-Thomson E, Nuru-Jeter A, Minkler M, Guralnik JM. Black-white disparities in disability among older Americans: further untangling the role of race and socioeconomic status. J Aging Health 2009; 21:677-98.. Some authors indicate that health inequalities cannot be attributed directly to color/race, independently of socioeconomic differences between individuals and context ³3  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.^,1212  Chor D, Lima CRA. Aspectos epidemiológicos das desigualdades raciais em saúde no Brasil. Cad Saúde Pública 2005; 21:1586-94.^,1313  Laguardia J. Raça e epidemiologia: as estratégias para construção de diferenças biológicas. Ciênc Saúde Coletiva 2007; 12:253-61.. Meanwhile, other studies contend that the color/race variable influences various levels of exposure to different individual and contextual health risks throughout life ⁵5  Krieger N. A glossary for social epidemiology. J Epidemiol Community Health 2001; 55:693-700.^,1212  Chor D, Lima CRA. Aspectos epidemiológicos das desigualdades raciais em saúde no Brasil. Cad Saúde Pública 2005; 21:1586-94.. It assumes the role of a sociopolitical variable, acting through interactive and complex mechanisms according to the context in which individuals live ⁷7  Zorzin PLG, Wajnman S, Turra CM. Previdência social e desigualdade racial no Brasil. Belo Horizonte: Centro de Desenvolvimento e Planejamento Regional de Minas Gerais, Universidade Federal de Minas Gerais; 2011.^,1212  Chor D, Lima CRA. Aspectos epidemiológicos das desigualdades raciais em saúde no Brasil. Cad Saúde Pública 2005; 21:1586-94.. However, regardless of whether the color/race variable has a direct effect or a joint effect together with socioeconomic factors, the current study’s evaluation of health indicators showed that color/race cannot be ruled out in the production of health inequalities in this sample of elderly Brazilians.

In the current analysis, prevalence of very good or good self-rated health was 23.6% less common in brown elderly than in whites. In a population-based study of 1,432 elderly in Campinas, São Paulo State, prevalence of excellent or very good self-rated health in non-whites was similar, namely 25.8% less common than in whites ¹⁵15  Borim FSA, Barros MBA, Neri AL. Autoavaliação da saúde em idosos: pesquisa de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2012; 28:769-80..

Studies in other countries also indicate an association between color/race and worse self-rated health in the elderly, independently of socioeconomic and demographic factors ¹⁰10  Spencer SM, Schulz R, Rooks RN, Albert SM, Thorpe Jr. RJ, Brenes GA, et al. Racial differences in self-rated health at similar levels of physical functioning: an examination of health pessimism in the health, aging, and body composition study. J Gerontol B Psychol Sci Soc Sci 2009; 64:87-94.^,1717  Do DP, Finch BK, Basurto-Davila R, Bird C, Escarce J, Lurie N. Does place explain racial health disparities? Quantifying the contribution of residential context to the black/white health gap in the United States. Soc Sci Med 2008; 67:1258-68.. Still, in some studies of elderly Brazilians, this association is either questioned or not observed after adjusting for socioeconomic and health variables ¹⁵15  Borim FSA, Barros MBA, Neri AL. Autoavaliação da saúde em idosos: pesquisa de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2012; 28:769-80.^,3030  Dachs JNW. Determinantes das desigualdades na autoavaliação do estado de saúde no Brasil: análise dos dados da PNAD/1998. Ciênc Saúde Coletiva 2002; 7:641-57.. The current study showed a direct association between color/race and worse self-rated health status. Adjustment for confounding decreased the size of the association but did not eliminate the statistically significant effect among browns. Brown elderly had 11% higher odds of worse self-rated health status than white elderly.

A population-based study of 1,940 elderly in the city of São Paulo using hierarchical ordinal logistic analysis also showed that blacks and browns reported worse health status (OR = 1.27; p < 0.01) than whites ⁹9  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.. After adjusting for gender and age, a cross-sectional population-based study in Campinas showed that non-white elderly had 29% lower odds of excellent or very good self-rated health. As in our results, this suggests that non-white elderly rated their own health more negatively ¹⁵15  Borim FSA, Barros MBA, Neri AL. Autoavaliação da saúde em idosos: pesquisa de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2012; 28:769-80..

One possible explanation for this result is that blacks display cultural and psychosocial variations in their conceptualization of this health indicator, or even that they are more pessimistic than whites about their own health ¹⁰10  Spencer SM, Schulz R, Rooks RN, Albert SM, Thorpe Jr. RJ, Brenes GA, et al. Racial differences in self-rated health at similar levels of physical functioning: an examination of health pessimism in the health, aging, and body composition study. J Gerontol B Psychol Sci Soc Sci 2009; 64:87-94.^,2929  Fuller-Thomson E, Nuru-Jeter A, Minkler M, Guralnik JM. Black-white disparities in disability among older Americans: further untangling the role of race and socioeconomic status. J Aging Health 2009; 21:677-98.. When they consider their lifetime experiences with worse living conditions, material deprivation, or social racism, they tend to perceive their own health more negatively ⁷7  Zorzin PLG, Wajnman S, Turra CM. Previdência social e desigualdade racial no Brasil. Belo Horizonte: Centro de Desenvolvimento e Planejamento Regional de Minas Gerais, Universidade Federal de Minas Gerais; 2011.^,2727  Federal Interagency Forum on Aging-related Statistics. Older Americans 2010: key indicators of well-being. Washington DC: US Government Printing Office; 2010.. In other words, the direct effects of race on self-rated health may result indirectly from individual and contextual socioeconomic disadvantages for blacks ¹⁰10  Spencer SM, Schulz R, Rooks RN, Albert SM, Thorpe Jr. RJ, Brenes GA, et al. Racial differences in self-rated health at similar levels of physical functioning: an examination of health pessimism in the health, aging, and body composition study. J Gerontol B Psychol Sci Soc Sci 2009; 64:87-94.^,2929  Fuller-Thomson E, Nuru-Jeter A, Minkler M, Guralnik JM. Black-white disparities in disability among older Americans: further untangling the role of race and socioeconomic status. J Aging Health 2009; 21:677-98..

Meanwhile, studies that fail to observe an association between self-reported color/race and self-rated health in the elderly assume that low income and schooling are more determinant of health status than cultural values associated with race ¹⁵15  Borim FSA, Barros MBA, Neri AL. Autoavaliação da saúde em idosos: pesquisa de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2012; 28:769-80.^,3030  Dachs JNW. Determinantes das desigualdades na autoavaliação do estado de saúde no Brasil: análise dos dados da PNAD/1998. Ciênc Saúde Coletiva 2002; 7:641-57.. Among Brazilians 20 years or older, some studies have observed that such factors play a more relevant role in self-reported health status than non-white color/race ³¹31  Pavão ALB, Werneck GL, Campos MR. Autoavaliação do estado de saúde e a associação com fatores sociodemográficos, hábitos de vida e morbidade na população: um inquérito nacional. Cad Saúde Pública 2013; 29:723-34.^,3232  Moraes JR, Moreira JPL, Luiz RR. Associação entre o estado de saúde autorreferido de adultos e a área de localização do domicílio: uma análise de regressão logística ordinal usando a PNAD 2008. Ciênc Saúde Coletiva 2011; 16:3769-80..

Numerous studies have shown that chronic conditions have become more common in the elderly ²⁷27  Federal Interagency Forum on Aging-related Statistics. Older Americans 2010: key indicators of well-being. Washington DC: US Government Printing Office; 2010.^,3333  Barros MBA, César CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Ciênc Saúde Coletiva 2006; 11:911-26.^,3434  Barros MBA, Francisco PMSB, Zanchetta LM, Cesar CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Ciênc Saúde Coletiva 2011; 16:3755-68., increasing the demand for medical and social services ²⁷27  Federal Interagency Forum on Aging-related Statistics. Older Americans 2010: key indicators of well-being. Washington DC: US Government Printing Office; 2010.^,3333  Barros MBA, César CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Ciênc Saúde Coletiva 2006; 11:911-26.^,3434  Barros MBA, Francisco PMSB, Zanchetta LM, Cesar CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Ciênc Saúde Coletiva 2011; 16:3755-68.. Among elderly Brazilians, the prevalence of at least one chronic disease also increased according to socioeconomic variables ³⁴34  Barros MBA, Francisco PMSB, Zanchetta LM, Cesar CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Ciênc Saúde Coletiva 2011; 16:3755-68.^,3535  Freitas LRS, Garcia LP. Evolução da prevalência do diabetes e deste associado à hipertensão arterial no Brasil: análise da Pesquisa Nacional por Amostra de Domicílios, 1998, 2003 e 2008. Epidemiol Serv Saúde 2012; 21:7-19.. For the racial groups in this population, such prevalence rates are still unknown. The current study showed a high prevalence of chronic diseases in the three racial groups, but prevalence in black elderly was higher than in the other groups (Table 3).

In other countries, the color/race variable shows a direct and independent association with the number of chronic conditions in the elderly ²²22  Travassos C, Williams DR. The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States. Cad Saúde Pública 2004; 20:660-78.^,2727  Federal Interagency Forum on Aging-related Statistics. Older Americans 2010: key indicators of well-being. Washington DC: US Government Printing Office; 2010.. In Brazil, this association has not only been questioned ³3  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.^,1313  Laguardia J. Raça e epidemiologia: as estratégias para construção de diferenças biológicas. Ciênc Saúde Coletiva 2007; 12:253-61., but it has not been studied with data from the PNAD. Our study shows that black elderly experience more chronic diseases, even after adjusting for confounding factors. Other Brazilian studies have also found racial differences in the presence of chronic comorbidities and adjusted estimates with a similar magnitude for black color/race in the adult population in the PNAD surveys for 2003 ³³33  Barros MBA, César CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Ciênc Saúde Coletiva 2006; 11:911-26. (PR = 1.04; 95%CI: 1.01-1.07) and 2008 ³⁴34  Barros MBA, Francisco PMSB, Zanchetta LM, Cesar CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Ciênc Saúde Coletiva 2011; 16:3755-68. (PR = 1.06; 95%CI: 1.05-1.08).

Studies have attributed this fact to unequal exposure to risk factors between racial groups throughout life cycles ⁶6  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67.^,77  Zorzin PLG, Wajnman S, Turra CM. Previdência social e desigualdade racial no Brasil. Belo Horizonte: Centro de Desenvolvimento e Planejamento Regional de Minas Gerais, Universidade Federal de Minas Gerais; 2011. whereby individual and contextual characteristics influence the adoption of healthy or harmful behaviors ³⁶36  Dubowitz T, Heron M, Basurto-Davila R, Bird CE, Lurie N, Escarce JJ. Racial/ethnic differences in US health behaviors: a decomposition analysis. Am J Health Behav 2011; 35:290-304.. These factors vary between racial groups and favor the occurrence of racial differences in estimates of chronic diseases ²⁷27  Federal Interagency Forum on Aging-related Statistics. Older Americans 2010: key indicators of well-being. Washington DC: US Government Printing Office; 2010.^,3636  Dubowitz T, Heron M, Basurto-Davila R, Bird CE, Lurie N, Escarce JJ. Racial/ethnic differences in US health behaviors: a decomposition analysis. Am J Health Behav 2011; 35:290-304.. Blacks may thus experience more chronic diseases in old age because this condition is associated with more vulnerable social groups ⁹9  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,2727  Federal Interagency Forum on Aging-related Statistics. Older Americans 2010: key indicators of well-being. Washington DC: US Government Printing Office; 2010.^,3333  Barros MBA, César CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Ciênc Saúde Coletiva 2006; 11:911-26.^,3434  Barros MBA, Francisco PMSB, Zanchetta LM, Cesar CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Ciênc Saúde Coletiva 2011; 16:3755-68.^,3535  Freitas LRS, Garcia LP. Evolução da prevalência do diabetes e deste associado à hipertensão arterial no Brasil: análise da Pesquisa Nacional por Amostra de Domicílios, 1998, 2003 e 2008. Epidemiol Serv Saúde 2012; 21:7-19.^,3636  Dubowitz T, Heron M, Basurto-Davila R, Bird CE, Lurie N, Escarce JJ. Racial/ethnic differences in US health behaviors: a decomposition analysis. Am J Health Behav 2011; 35:290-304..

Similar to other work, the current study assesses functional incapacity of elderly according to activities of daily living ⁶6  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67.^,99  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,2929  Fuller-Thomson E, Nuru-Jeter A, Minkler M, Guralnik JM. Black-white disparities in disability among older Americans: further untangling the role of race and socioeconomic status. J Aging Health 2009; 21:677-98.^,3737  Camargos MCS, Machado CJ, Rodrigues RN. Life expectancy among elderly Brazilians in 2003 according to different levels of functional disability. Cad Saúde Pública 2008; 24:845-52.. In some studies, the explanatory role of color/race in the functional decline of elderly is controversial. In the United States, race explains functional decline in the elderly, even after adjusting for socioeconomic variables ²⁹29  Fuller-Thomson E, Nuru-Jeter A, Minkler M, Guralnik JM. Black-white disparities in disability among older Americans: further untangling the role of race and socioeconomic status. J Aging Health 2009; 21:677-98.^,3838  Dunlop DD, Song J, Manheim LM, Daviglus ML, Chang RW. Racial/ethnic differences in the development of disability among older adults. Am J Public Health 2007; 97:2209-15.. However, in England and Brazil this association has still not been observed ⁶6  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67.^,99  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,1616  Alves LC, Leite IC, Machado CJ. Fatores associados à incapacidade funcional dos idosos no Brasil: análise multinível. Rev Saúde Pública 2010; 44:468-78.. Our findings agree with studies indicating the protective effect of brown and black color/race in maintaining functional status in the elderly. A study of elderly in the city of São Paulo showed that blacks and browns had 26% lower odds of reporting functional decline ⁹9  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.. A study with the PNAD data for 2003 showed that black and brown elderly had lower odds (0.28, 0.18 to 0.07) of evolving in the three levels of disability ¹⁶16  Alves LC, Leite IC, Machado CJ. Fatores associados à incapacidade funcional dos idosos no Brasil: análise multinível. Rev Saúde Pública 2010; 44:468-78.. And a study of non-white English elderly showed 36% lower odds of functional limitations ⁶6  Clarke P, Smith J. Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England. J Gerontol B Psychol Sci Soc Sci 2011; 66:457-67..

According to some authors, the fact that the association between color/race and functional decline does not occur in the expected direction is due to the shorter life expectancy among blacks and browns with worse socioeconomic status ¹¹11  Thorpe Jr. RJ, Koster A, Kritchevsky SB, Newman AB, Harris T, Ayonayon HN, et al. Race, socioeconomic resources, and late-life mobility and decline: findings from the Health, Aging, and Body Composition study. J Gerontol A Biol Sci Med Sci 2011; 66:1114-23.^,3939  Bharmal N, Tseng CH, Kaplan R, Wong MD. State-level variations in racial disparities in life expectancy. Health Serv Res 2012; 47:544-55.^,4040  Chang CF, Nocetti D, Rubin RM. Healthy life expectancy for selected race and gender subgroups: the case of Tennessee. South Med J 2005; 98:977-84.. This would lead the current group of elderly blacks to have lower odds of functional decline due to unequal survival between racial groups. This phenomenon was also demonstrated in a longitudinal population-based study of 2,969 elderly in the United States ¹¹11  Thorpe Jr. RJ, Koster A, Kritchevsky SB, Newman AB, Harris T, Ayonayon HN, et al. Race, socioeconomic resources, and late-life mobility and decline: findings from the Health, Aging, and Body Composition study. J Gerontol A Biol Sci Med Sci 2011; 66:1114-23.. The authors cited survival bias to explain the loss of association between race and functional decline after adjusting for socioeconomic factors in both sexes ¹¹11  Thorpe Jr. RJ, Koster A, Kritchevsky SB, Newman AB, Harris T, Ayonayon HN, et al. Race, socioeconomic resources, and late-life mobility and decline: findings from the Health, Aging, and Body Composition study. J Gerontol A Biol Sci Med Sci 2011; 66:1114-23..

In Brazil, the standard racial classification combines phenotype and socioeconomic characteristics ²²22  Travassos C, Williams DR. The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States. Cad Saúde Pública 2004; 20:660-78.^,4141  Maio MC, Monteiro S, Chor D, Faerstein E, Lopes CS. Cor/raça no Estudo Pró-Saúde: resultados comparativos de dois métodos de autoclassificação no Rio de Janeiro, Brasil. Cad Saúde Pública 2005; 21:171-80.. Studies have recognized that the racial categories are not homogeneous, that individuals do not always belong definitively to the same racial groups ⁴¹41  Maio MC, Monteiro S, Chor D, Faerstein E, Lopes CS. Cor/raça no Estudo Pró-Saúde: resultados comparativos de dois métodos de autoclassificação no Rio de Janeiro, Brasil. Cad Saúde Pública 2005; 21:171-80., and that there are differences between the classificatory system adopted by the IBGE and that defended by the Brazilian black movement ³3  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.^,2222  Travassos C, Williams DR. The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States. Cad Saúde Pública 2004; 20:660-78.^,4242  Muniz JO. Sobre o uso da variável raça-cor em estudos quantitativos. Revista de Sociologia e Política 2010; 36:277-91.. The divergence results from the IBGE’s use of the “brown” (or mixed-race) category, potentially belonging to either the group of whites or that of blacks. This racial instability is one limitation to racial self-classification in Brazil ³3  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.^,4242  Muniz JO. Sobre o uso da variável raça-cor em estudos quantitativos. Revista de Sociologia e Política 2010; 36:277-91.. The Brazilian black movement claims the inclusion of both browns and blacks in the same category of “blacks”. Although the black/white binary classification has become widely accepted by the media, it is not unanimous among policymakers and researchers ³3  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.^,2222  Travassos C, Williams DR. The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States. Cad Saúde Pública 2004; 20:660-78.^,4242  Muniz JO. Sobre o uso da variável raça-cor em estudos quantitativos. Revista de Sociologia e Política 2010; 36:277-91..

In our study, the adjusted analysis showed that when blacks and browns were analyzed jointly, “black” color/race remained associated with worse self-reported health status and maintenance of functional status, but with lower association than for browns in the two health outcomes. Still, for the number of chronic conditions, the direct association between “black” (black + brown) color/race was not maintained, as observed previously in blacks (not including browns). Thus, the dichotomous black/white analysis appears not to modify the analysis of differential health characteristics between white, brown, and black elderly Brazilians, but it does appear to produce an absence of clear distinctions between various racial groups of elderly Brazilians or even disguise inequalities among these groups ²²22  Travassos C, Williams DR. The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States. Cad Saúde Pública 2004; 20:660-78.^,4242  Muniz JO. Sobre o uso da variável raça-cor em estudos quantitativos. Revista de Sociologia e Política 2010; 36:277-91..

The study’s limitations include the intrinsic cross-sectional design, which prevents verifying temporal associations or direction in the associations observed with some of the socioeconomic and demographic variables included in the models. However, to study the association between the target outcomes and color/race, the cross-sectional design does not alter the study’s validity, since racial classification remains more stable throughout life.

Importantly, in the analysis of data from the PNAD data, prevalence and survival bias may occur, since the elderly with worse socioeconomic status experience shorter survival ⁹9  Campos NOB. Os determinantes das condições de saúde dos idosos do município de São Paulo em uma perspectiva de ciclo de vida [Tese de Doutorado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2009.^,1111  Thorpe Jr. RJ, Koster A, Kritchevsky SB, Newman AB, Harris T, Ayonayon HN, et al. Race, socioeconomic resources, and late-life mobility and decline: findings from the Health, Aging, and Body Composition study. J Gerontol A Biol Sci Med Sci 2011; 66:1114-23.^,3535  Freitas LRS, Garcia LP. Evolução da prevalência do diabetes e deste associado à hipertensão arterial no Brasil: análise da Pesquisa Nacional por Amostra de Domicílios, 1998, 2003 e 2008. Epidemiol Serv Saúde 2012; 21:7-19.^,3939  Bharmal N, Tseng CH, Kaplan R, Wong MD. State-level variations in racial disparities in life expectancy. Health Serv Res 2012; 47:544-55.^,4040  Chang CF, Nocetti D, Rubin RM. Healthy life expectancy for selected race and gender subgroups: the case of Tennessee. South Med J 2005; 98:977-84.. This would lead to a selection bias of the elderly in the more vulnerable racial groups. Another potential limitation is the influence of the large sample size, making some minimal differences statistically significant, thus requiring that these race differentials be evaluated for their relevance and the sociopolitical significance of the race issue in the Brazilian context ¹³13  Laguardia J. Raça e epidemiologia: as estratégias para construção de diferenças biológicas. Ciênc Saúde Coletiva 2007; 12:253-61.^,2222  Travassos C, Williams DR. The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States. Cad Saúde Pública 2004; 20:660-78..

According to some authors, the significant associations found in this study may result from confounding factors not measured in the mo-dels ³3  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.^,1313  Laguardia J. Raça e epidemiologia: as estratégias para construção de diferenças biológicas. Ciênc Saúde Coletiva 2007; 12:253-61.. Furthermore, the observed association between the racial categories and the health outcomes may be influenced by limitations in the terms, concepts, and methods, often cited as capable of weakening and underestimating the results of studies with a racial focus ³3  Araújo EM, Costa MCN, Hogan VK, Araújo TM, Batista A, Oliveira LOA. The use of the race/color variable in public health: possibilities and limitations. Interface Comun Saúde Educ 2010; 5(n. spe):383-94.^,1212  Chor D, Lima CRA. Aspectos epidemiológicos das desigualdades raciais em saúde no Brasil. Cad Saúde Pública 2005; 21:1586-94.^,1313  Laguardia J. Raça e epidemiologia: as estratégias para construção de diferenças biológicas. Ciênc Saúde Coletiva 2007; 12:253-61..

However, such limitations should not discourage reflection on racial inequalities in health, since this study’s results were obtained from a representative and probabilistic sample of the elderly population from all regions of Brazil. This sample is sufficient to allow precise estimates for this population ¹⁴14  Lima-Costa MF, Matos DL, Camargos VP, James M. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc Saúde Coletiva 2011; 16:3689-96.. The current study only included elderly that reported their color/race according to the categories recommended by IBGE ¹1  Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010: características da população e dos domicílios, resultados do universo. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011., thus reducing the impact of information bias on the classification of racial categories.

In addition, the statistical analysis of the outcomes was adjusted for the main factors commonly associated with health indicators in the elderly, using a narrower level of significance (α = 0.01) in order to obtain more precise estimates. Despite such care, estimates of the models’ fit indicated that the target variables explain little of the variation in each outcome, suggesting that other factors should be considered in explaining these outcomes.

Importantly, this study used both objective and subjective health indicators simultaneously. These measures suggest varied impacts from color/race on the three health dimensions that were evaluated, indicating that this variable’s effect on one dimension may not necessarily appear in another ¹⁴14  Lima-Costa MF, Matos DL, Camargos VP, James M. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc Saúde Coletiva 2011; 16:3689-96..

The results thus suggest the presence of racial inequalities in health and overall living conditions in elderly Brazilians. They indicate that black and brown elderly form a vulnerable group and experience aging with overlapping risks. Despite controversies on the racial issue in Brazil, the color/race variable partially explained the health of the elderly. However, other socioeconomic inequalities – related to schooling, work status, and income – had a greater effect on the health of the elderly in the sample. Even so, these racial inequalities pose a challenge for health systems, based on principles of equity and included in a context of rapid demographic and epidemiological transition, thus supporting this variable’s use in analyses on the health of elderly Brazilians.

Acknowledgments

The authors wish to thank Luana Giatti for her assistance in managing and using the PNAD 2008 databank and Professors Antônio Augusto, Alcione dos Santos, and Luís Eduardo for their critical revision and suggestions in the original manuscript.

References

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