Abstract

Introduction

Self-rated health is considered good indicator of health status in the elderly, since it incorporates physical, cognitive, and emotional components as well as aspects related to well-being and satisfaction with one’s own life ¹1 Lima-Costa MF, Firmo JOA, Uchôa E. A estrutura da auto-avaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38:827-34. ^{, 2}2 Pagotto V, Bachion MM, Silveira EA. Autoavaliação da saúde por idosos brasileiros: revisão sistemática da literatura. Rev Panam Salud Pública 2013; 33:302-10. ^{, 3}3 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.. This measure has been widely used in population-based studies of the elderly, since it is consistently associated with mortality and functional decline in this age group ⁴4 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. ^{, 5}5 Fayers PM, Sprangers MA. Understanding self-rated health. Lancet 2002; 359:187-8. ^{, 6}6 Sargent-Cox KA, Anstey KJ, Luszcz MA. Determinants of self-rated health items with different points of reference: implications for health measurement of older adults. J Aging Health 2008; 20:739-61., besides serving as a tool for developing health policies aimed at improving the elderly population’s health status ⁴4 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..

Prevalence of positive self-rated health differs considerably between studies. Although the question on self-rated health and the options for answers are similar between studies, the findings are not unanimous. This discrepancy in prevalence rates may be due to short-term fluctuations in health or disease caused by cyclical variations related to well-being.

Some Brazilian studies ¹1 Lima-Costa MF, Firmo JOA, Uchôa E. A estrutura da auto-avaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38:827-34. ^{, 2}2 Pagotto V, Bachion MM, Silveira EA. Autoavaliação da saúde por idosos brasileiros: revisão sistemática da literatura. Rev Panam Salud Pública 2013; 33:302-10. ^{, 3}3 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. ^{, 4}4 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. have analyzed self-rated health in the elderly, mainly approaching the variable as negative self-rated health. However, self-rated health in its positive form facilitates understanding the factors that be modified in the search for positive determinants of health.

Prevalence rates for positive self-rated health among Brazilian population-based studies varied from 24.7 to 89.1% ¹1 Lima-Costa MF, Firmo JOA, Uchôa E. A estrutura da auto-avaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38:827-34. ^{, 4}4 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. ^{, 7}7 Silva RJ, Smith-Menezes A, Tribess S, Romo-Perez V, Virtuoso Jr. JS. Prevalência e fatores associados a percepção negativa da saúde em pessoas idosas do Brasil. Rev Bras Epidemiol 2012; 15:49-62., while in international studies they varied from 35.7% to 63% ⁸8 Carvalho FF, Santos JN, Souza LM, Souza NRM. Analysis of perception of the health status of elderly from the metropolitan area of Belo Horizonte city. Rev Bras Geriatr Gerontol 2012; 15:285-94. ^{, 9}9 Chen Y, While AE, Hicks A. Self-rated health and associated factors among older people living alone in Shanghai. Geriatr Gerontol Int 2015; 15:457-64. ^{, 10}10 Gomes GAO, Cintra FA, Diogo MJD, Neri AL, Guariento ME, Sousa MLR. Comparação entre idosos que sofreram quedas segundo desempenho físico e número de ocorrências. Rev Bras Fiosioter 2009;13:430-7..

Since self-rated health bears a relationship to fundamental health issues in the elderly, such as gender ¹¹11 Ramos M. Impact of socioeconomic status on Brazilian elderly health. Rev Saúde Pública 2007; 41:616-24., age ¹¹11 Ramos M. Impact of socioeconomic status on Brazilian elderly health. Rev Saúde Pública 2007; 41:616-24., marital status ¹¹11 Ramos M. Impact of socioeconomic status on Brazilian elderly health. Rev Saúde Pública 2007; 41:616-24., schooling ³3 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. ^{, 8}8 Carvalho FF, Santos JN, Souza LM, Souza NRM. Analysis of perception of the health status of elderly from the metropolitan area of Belo Horizonte city. Rev Bras Geriatr Gerontol 2012; 15:285-94. ^{, 11}11 Ramos M. Impact of socioeconomic status on Brazilian elderly health. Rev Saúde Pública 2007; 41:616-24. ^{, 12}12 Schneider U, Pfarr C, Schneider BS, Ulrich V. I feel good! Gender differences and reporting heterogeneity in self-assessed health. Eur J Health Econ 2012; 13:251-65., monthly household income ¹1 Lima-Costa MF, Firmo JOA, Uchôa E. A estrutura da auto-avaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38:827-34., physical activity ¹1 Lima-Costa MF, Firmo JOA, Uchôa E. A estrutura da auto-avaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38:827-34. ^{, 3}3 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. ^{, 7}7 Silva RJ, Smith-Menezes A, Tribess S, Romo-Perez V, Virtuoso Jr. JS. Prevalência e fatores associados a percepção negativa da saúde em pessoas idosas do Brasil. Rev Bras Epidemiol 2012; 15:49-62. ^{, 13}13 Lucumí DI, Grogan-Kaylor A, Espinosa-García G. Asociación de laposición socioeconómica y lapercepcióndel ambiente conlaautopercepcióndel estado de saludenmujeres de Bogotá, Colombia. Rev Panam Salud Pública 2013; 34:14-20., and alcohol consumption ¹⁴14 Poikolainen K, Vartianen E, Korhonen HJ. Alcohol intake and subjective health. Am J Epidemiol 1996; 144:346-50., it is easy to understand the discrepancies in prevalence rates between studies.

In addition, health conditions also bear a relationship to self-rated health, for example falls ¹⁵15 Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Prevalence of falls and associated factors in the elderly. Rev Saúde Pública 2007; 41:749-56., physical capacity ⁴4 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. ^{, 7}7 Silva RJ, Smith-Menezes A, Tribess S, Romo-Perez V, Virtuoso Jr. JS. Prevalência e fatores associados a percepção negativa da saúde em pessoas idosas do Brasil. Rev Bras Epidemiol 2012; 15:49-62. ^{, 16}16 Arnadottir SA, Gunnarsdottir ED, Stenlund H, Lundin-Olsson L. Determinants of self-rated health in old age: a population-based, cross-sectional study using the International Classification of Functioning. BMC Public Health 2011; 11:670., depressive symptoms ¹1 Lima-Costa MF, Firmo JOA, Uchôa E. A estrutura da auto-avaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38:827-34. ^{, 16}16 Arnadottir SA, Gunnarsdottir ED, Stenlund H, Lundin-Olsson L. Determinants of self-rated health in old age: a population-based, cross-sectional study using the International Classification of Functioning. BMC Public Health 2011; 11:670., and diseases ³3 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. ^{, 4}4 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. ^{, 17}17 Lorenzo T, Millán-Calenti JC, Lorenzo-López L, Sánchez A, Maseda A. Predictores de mala salud autopercibida en una población de personas mayores. Rev Esp Geriatr Gerontol 2013; 48:272-5. ^{, 18}18 Martin LG, Schoeni RF, Freedman VA, Andreski P. Feeling better? Trends in general health status. J Gerontol B Psychol Sci Soc Sci 2007; 62:S11-21., in addition to having an impact on mortality ⁴4 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. ^{, 6}6 Sargent-Cox KA, Anstey KJ, Luszcz MA. Determinants of self-rated health items with different points of reference: implications for health measurement of older adults. J Aging Health 2008; 20:739-61. ^{, 19}19 Lacruz ME, Emeny RT, Baumert J, Ladwig KH. Prospective association between self-reported life satisfaction and mortality: results from the MONICA/KORA Augsburg S3 survey cohort study. BMC Public Health 2011; 11:579.. The use of medicines ¹1 Lima-Costa MF, Firmo JOA, Uchôa E. A estrutura da auto-avaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38:827-34. ^{, 11}11 Ramos M. Impact of socioeconomic status on Brazilian elderly health. Rev Saúde Pública 2007; 41:616-24. and healthcare services are also associated, especially the number of medical consultations ¹1 Lima-Costa MF, Firmo JOA, Uchôa E. A estrutura da auto-avaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38:827-34., number of hospitalizations, and type of health insurance ¹¹11 Ramos M. Impact of socioeconomic status on Brazilian elderly health. Rev Saúde Pública 2007; 41:616-24..

Understanding the aspects involved in self-rated health can reveal the profile of elderly that refer to it positively, which has still received little attention in Brazilian research, as shown in a literature review on the theme, in which all the studies that were examined approached the variable in its negative form ²2 Pagotto V, Bachion MM, Silveira EA. Autoavaliação da saúde por idosos brasileiros: revisão sistemática da literatura. Rev Panam Salud Pública 2013; 33:302-10.. By considering the theme’s relevance as an important indicator for overall health surveillance in the elderly, the current study aims to identify the prevalence of positive self-rated health and its association with demographic, socioeconomic, and lifestyle factors and health conditions in the elderly in Florianópolis, the capital of Santa Catarina State, Brazil.

Methods

Study area and population

The data in this study are part of the research project on health conditions in the elderly population in Florianópolis called EpiFloripa Idoso (http://www.epifloripa.ufsc.br/category/inqueritos/epi_idoso/epi_idoso_10/fin_idoso_09, accessed on 15/Aug/2014). This is a cross-sectional, population-based, household survey with elderly (≥ 60 years) living in the urban area of the city of Florianópolis, in 2009-2010.

Details on the location, study population, and sampling have been published previously ²⁰20 Giehl MWC, Schneider IJC, Corseuil HX, Benedetti TRB, d’Orsi E. Physical activity and environment perception among older adults: a population study in Florianópolis, Brazil. Rev Saúde Pública 2012; 46:516-25. and will be presented briefly here. A two-stage sampling strategy was used to reach the initial sample size calculated at 1,599 elderly individuals. In the first stage, 420 urban census tracts were stratified upwardly according to the head-of-family’s mean monthly income (BRL 314.76 to BRL 5,057.77), aggregated in deciles with 42 tracts each, systematically picking eight tracts in each decile in order to cover all the groups. The units in the second stage were the households, picked systematically. All the elderly living in the selected households were invited to participate in the study. Losses were defined as interviews that had not been held after four attempts (including in evenings and on weekends), and refusals were defined as persons that chose not to answer the questionnaire.

Data collection

Data collection employed a structured face-to-face interview, using personal digital assistant (PDA) to record the data.

Data consistency was verified weekly by simple frequency and comparison with expected values. Incongruent responses were identified, corrected by the supervisor and the interviewer responsible for the inconsistencies, followed by reporting back to the person responsible for the final databank. Quality control was conducted by telephone with a short version of the questionnaire in 10% of the interviews, which were randomly selected.

Self-rated health status was obtained with the question “In general, would you say that your health is: very good, good, fair, poor, or very poor?” ²¹21 Ware Jr. JE, Kosinski M, Keller SD. A 12- item Short- Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34:220-33.. The five categories for the answer were dichotomized as positive (“very good” and “good”) and negative (“regular”, “poor”, and “very poor”).

Independent variables

• Demographic and socioeconomic: gender (female; male), age group (60-69 years, 70-79, and ≥ 80), marital status (married or with partner; without partner or single/separated/divorced or widowed), currently working (no; yes), schooling in years (no formal education; 1-4; 5-8; 9-11; and ≥ 12); and per capita family income stratified in quartiles (1^st quartile: ≤ BRL 327.50; 2^nd quartile: BRL 327.50-BRL 700.00; 3^rd quartile: BRL 700.00-BRL 1,500.00; and 4^th quartile: > BRL 1,500.00).

• Lifestyle: smoking (current smoker, former smoker, or never smoked), alcohol consumption (never, moderate, frequent, or very frequent) verified by the first three questions of the AUDIT questionnaire (The Alcohol Use Disorders Identification Test) ²²22 Lima CT, Freire AC, Silva AP, Teixeira RM, Farrell M, Prince M. Concurrent and construct validity of the audit in an urban Brazilian sample. Alcohol 2005; 40:584-9., leisure-time physical activity verified by the long version of the International Physical Activity Questionnaire (IPAQ) (insufficiently active: 0 to 149 minutes of physical activity/week and physically active: ≥ 150 minutes of physical activity/week) ²³23 Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003; 35: 1381-95..

• Internet use: self-reported capacity to send and receive e-mail messages ²⁴24 Medeiros FL, Xavier AJ, Schneider IJC, Ramos LR, Sigulem D, d’Orsi E. Inclusão digital e capacidade funcional de idosos residentes em Florianópolis, Santa Catarina, Brasil (EpiFloripa 2009-2010). Rev Bras Epidemiol 2012; 15:106-22..

• Health conditions: number of diseases (none; 1 to 2; or ≥ 3 self-reported diseases) verified by the question “Has some doctor or other health professional ever told you that you have...?”, followed by a list of 16 health problems (the questionnaire from the Brazilian National Household Sample Survey – PNAD ²⁵25 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios – PNAD de 2003. PNAD 1.01 questionário da pesquisa. http://www.ibge.gov.br/home/estatistica/populacao/trabalhoerendimento/pnad2003/questpnad2003.pdf (acessado em 20/Mar/2009).
  http://www.ibge.gov.br/home/estatistica/... ), functional dependence ²⁶26 Rosa TEC, Benício MHD, Latorre MRDO, Ramos LR. Fatores determinantes da capacidade funcional entre idosos. Rev Saúde Pública 2003; 37:40-8. was assessed by the Brazilian Questionnaire for Multidimensional Functional Assessment, adapted from the questionnaire Older Americans Resources and Services (BOMFAQ/OARS), categorized as no functional dependence ²⁶26 Rosa TEC, Benício MHD, Latorre MRDO, Ramos LR. Fatores determinantes da capacidade funcional entre idosos. Rev Saúde Pública 2003; 37:40-8. (absence of dependence), mild dependence (dependence in one to three activities), and moderate/severe (dependence in four or more activities). Cognitive status (normal versus presence of probable cognitive deficit) was investigated by the Mini-Mental State Examination (MMSE), with cutoff points that took schooling into account, according to Brucki et al. ²⁷27 Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr 2003; 61:777-81.. A fall in the previous year was verified by the question: “Did you suffer any fall in the last year?”, categorized as yes or no.

• Use of medicines and healthcare services: health plan coverage was verified by the question “Do you have a private, company, or government health plan?” (yes; no); hospitalization in the previous 6 months (yes; no); and use of polypharmacy ²⁸28 Ziere G, Dieleman JP, Hofman A, Pols HA, van der Cammen TJ, Stricker BH. Polypharmacy and falls in the middle age and elderly population. Br J Clin Pharmacol 2005; 61:218-23. (yes; no), obtained from packages and/or physician’s prescriptions for medicines, recorded by the brand name and later classified according to the Anatomical Therapeutic Chemical Code (ATC) ²⁹29 Aziz MM, Calvo MCM, d’Orsi E. Medicamentos prescritos aos idosos em uma capital do Sul do Brasil e a Relação Municipal de Medicamentos. Cad Saúde Pública 2012; 28:52-64., defined as concurrent use of four or more medicines.

Interviews answered by informants (n = 49) were excluded, since self-rated health is subjective and can only be provided by the elderly themselves.

Data analysis

Descriptive analyses were performed for all the variables. Prevalence rates and respective 95% confidence intervals (95%CI) were calculated for positive self-rated health according to the nature of the exposures. Bivariate and adjusted analysis used Poisson regression ³⁰30 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. estimating crude and adjusted prevalence ratios (PR) with the respective 95%CI. Adjusted analysis used a hierarchical model that included the demographic and socioeconomic variables (first level), lifestyle (second level), Internet use (third level), health conditions (fourth level), and use of medicines and healthcare services (the fifth and last level, more proximal in relation to the dependent variable). The statistical significance of each variable in the model was verified by the Wald test for heterogeneity or trend. Variables were entered into the model by level, and the adjusted analysis included all those with p < 0.20. Statistical significance was set at 5%.

Data analysis used Stata SE 12.0 (Stata Corp., College Station, USA). All the analyses considered the cluster sample design effect, incorporating sample weights with the svy command.

Ethical issues

The project was approved by the Ethics Research Committee at the Federal University of Santa Catarina, protocol n. 352/2008. Free and informed consent was obtained from all the subjects. The authors reported no conflicts of interest.

Results

Of all the elderly eligible for the study (n = 1,911), 1,705 were interviewed, or 89.1% response rate, including the interviews with informants. Still, for the current analysis, the latter interviews were excluded (n = 49), totaling an analytical sample of 1,656 elderly. Median age was 69 years (range: 60 to 102). More than half were females (62.5%), belonged to the 60 to 69 year age group (51.7%), reported being married or having a partner (58.9%), and were not working at the time of the interview (86.5%), and 32.5% had 1 to 4 years of schooling. More than 60% reported not consuming alcoholic beverages, and 59.2% reported never having smoked. Less than one-third (31.5%) were classified as sufficiently active in their leisure time. The majority reported not using the Internet (76.7%), reported 3 or more diseases (52%), showed normal cognitive status (54.3%), had not suffered falls in the previous year (82.1%), had a private health plan (66%), reported a hospitalization in the previous six months (92.9%), and did not use polypharmacy (55.4%), and 43.9% reported mild dependence in activities of daily living (ADL) (Table 1).

The proportion of elderly with positive self-rated health was 51.2% (95%CI: 48.8-53.6). Table 2 shows the associations in the crude and adjusted analysis between positive self-rated health and independent variables. All independent variables presented significant associations with the outcome. Adjusted analysis showed that prevalence of positive self-rated health was 1.13 times higher in men than in women. Prevalence of positive self-rated health was also directly associated with schooling.

Prevalence rates for the outcome were 33% and 37% higher in the elderly with moderate and high alcohol consumption, respectively, compared to non-consumers. Elders that were active in their leisure time showed 20% higher prevalence of positive self-rated health when compared to their inactive peers.

Internet users presented 21% higher prevalence of positive self-rated health when compared to non-users. Elderly that reported no diseases or only 1 to 2 diseases showed 52% and 45% higher prevalence of the outcome when compared to those with 3 or more diseases. Those with mild dependence or absence of dependence presented 2.20 and 2.67 times the prevalence of positive self-rated health when compared to elderly with moderate to severe dependence.

Prevalence of the outcome was 19% and 27% higher in the elderly that had not suffered falls in the previous year and those not using polypharmacy, respectively, when compared to their peers.

Discussion

In the current study, prevalence of positive self-rated health was 51.2%. This result is consistent with a previous study by Silva et al. ⁷7 Silva RJ, Smith-Menezes A, Tribess S, Romo-Perez V, Virtuoso Jr. JS. Prevalência e fatores associados a percepção negativa da saúde em pessoas idosas do Brasil. Rev Bras Epidemiol 2012; 15:49-62., who found 50.4% prevalence in three municipalities (counties) in the Northeast, Southeast, and South of Brazil. The study in Bambuí, Minas Gerais State ¹1 Lima-Costa MF, Firmo JOA, Uchôa E. A estrutura da auto-avaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38:827-34., showed a prevalence rate of 24.7% for this outcome, while a study by Borim et al. ⁴4 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. in the elderly in Campinas, São Paulo State, found a higher estimated prevalence of positive self-rated health (80.9%) than in the current study. Two possibilities may explain the differences between prevalence rates in the various studies: first, different options for answers to the question on self-rated health or even the kind of categorization, which is not homogeneous, and second, potential differences between the target regions in socioeconomic and demographic terms, both of which can affect the prevalence of self-rated health.

Positive self-rated health was associated with male gender, corroborating previous studies ³¹31 Robert AS, Cherepanov D, Palta M, Dunham NC, Feeny D, Fryback DG. Socioeconomic status and age variations in health-related quality of life: results from the National Health Measurement Study. J Gerontol B Psychol Sci Soc Sci 2009; 64:S378-89. ^{, 32}32 Szwarcwald CL, Souza-Júnior PRB, Esteves MAP, Damacena GN, Viacava F. Socio-demographic determinants of self-rated health in Brazil. Cad Saúde Pública 2005; 21 Suppl 1:S54-64.. The aging process is marked by differences in health status between men and women, which may result from a combination of biological, social, and behavioral factors, leading to different perceptions of health status ³³33 Crimmins EM, Kim JK, Sole-Auro A. Gender differences in health: results from SHARE, ELSA and HRS. Eur J Public Health 2011; 21:81-91. ^{, 34}34 Lawlor DA, Ebrahim S, Davey Smith G. Sex matters: secular and geographical trends in sex differences in coronary heart disease mortality. BMJ 2001; 323:541-5.. Women also tend to use healthcare services more, have a higher life expectancy, are susceptible to more diseases and functional decline, which can influence and favor the discovery of health problems ³⁵35 Camarano AA, Kanso S. Perspectivas de crescimento para a população brasileira: velhos e novos resultados. Brasília: Instituto de Pesquisa Econômica Aplicada; 2009. (Textos para Discussão, 1426)., and are more prone to less lethal conditions ³⁵35 Camarano AA, Kanso S. Perspectivas de crescimento para a população brasileira: velhos e novos resultados. Brasília: Instituto de Pesquisa Econômica Aplicada; 2009. (Textos para Discussão, 1426). ^{, 36}36 Lang I, Wallace RB, Huppert FA, Melzer D. Moderate alcohol consumption in older adults is associated with better cognition and well-being than abstinence. Age Ageing 2007; 36:256-61., so that they perceive their own health worse than men.

According to the current study, positive self-rated health was associated with more schooling, corroborating a previous study ¹²12 Schneider U, Pfarr C, Schneider BS, Ulrich V. I feel good! Gender differences and reporting heterogeneity in self-assessed health. Eur J Health Econ 2012; 13:251-65.. Individuals with more schooling and higher income are known to have more access to information, leading to the adoption of healthy habits like adequate, balanced diet and regular physical activity ³⁷37 Simsek H, Doganay S, Budak R, Ucku R. Relationship of socioeconomic status with health behaviors and self-perceived health in the elderly: a community-based study, Turkey. Geriatr Gerontol Int 2014; 14:960-8.. Elderly with more schooling thus have better health-related quality of life ³¹31 Robert AS, Cherepanov D, Palta M, Dunham NC, Feeny D, Fryback DG. Socioeconomic status and age variations in health-related quality of life: results from the National Health Measurement Study. J Gerontol B Psychol Sci Soc Sci 2009; 64:S378-89. and therefore better self-rated health.

As for health behaviors, the current study found that positive self-rated health was associated with alcohol consumption. According to Poikolainen et al. ¹⁴14 Poikolainen K, Vartianen E, Korhonen HJ. Alcohol intake and subjective health. Am J Epidemiol 1996; 144:346-50., after adjusting for socio-demographic and lifestyle variables, moderate alcohol intake was associated with positive self-rated health. Lang et al. ³⁶36 Lang I, Wallace RB, Huppert FA, Melzer D. Moderate alcohol consumption in older adults is associated with better cognition and well-being than abstinence. Age Ageing 2007; 36:256-61. found that individuals 50 years or older that drank moderately showed better cognition and quality of life and fewer depressive symptoms. The latter authors reported that moderate alcohol intake is frequently associated with more active social life, which may explain such associations. Still, the results should be interpreted with caution, given the risk of excessive alcohol intake, especially by the elderly. Further research is thus needed to elucidate this relationship.

Two studies ³3 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. ^{, 13}13 Lucumí DI, Grogan-Kaylor A, Espinosa-García G. Asociación de laposición socioeconómica y lapercepcióndel ambiente conlaautopercepcióndel estado de saludenmujeres de Bogotá, Colombia. Rev Panam Salud Pública 2013; 34:14-20. found an association between leisure-time activity and positive self-rated health, corroborating the current study’s findings. Physical activity provides benefits such as the maintenance and/or improvement of functional capacity, maintenance of independence and autonomy, reduction of diseases ³⁸38 Organização Mundial da Saúde. Envelhecimento ativo: uma política de saúde. Brasília: Organização Mundial da Saúde; 2005., and improvement in quality of life ¹³13 Lucumí DI, Grogan-Kaylor A, Espinosa-García G. Asociación de laposición socioeconómica y lapercepcióndel ambiente conlaautopercepcióndel estado de saludenmujeres de Bogotá, Colombia. Rev Panam Salud Pública 2013; 34:14-20., which fosters more social activity and thus biopsychosocial well-being and preservation of physical and mental health ³⁸38 Organização Mundial da Saúde. Envelhecimento ativo: uma política de saúde. Brasília: Organização Mundial da Saúde; 2005..

As for Internet use, no studies were found that demonstrate this association. This is a new and promising field of study, since digital inclusion of the elderly is a recent phenomenon with various positive effects on health and quality of life. Studies show that elderly Internet users have healthier habits ²⁴24 Medeiros FL, Xavier AJ, Schneider IJC, Ramos LR, Sigulem D, d’Orsi E. Inclusão digital e capacidade funcional de idosos residentes em Florianópolis, Santa Catarina, Brasil (EpiFloripa 2009-2010). Rev Bras Epidemiol 2012; 15:106-22. ^{, 39}39 Xavier AJ, d’Orsi E, Wardle J, Demakakos P, Smith SG, von Wagner C. Internet use and cancer-preventive behaviors in older adults: findings from a longitudinal cohort study. Cancer Epidemiol Biomarkers Prev 2013; 22:2066-74. and better functional capacity ²⁴24 Medeiros FL, Xavier AJ, Schneider IJC, Ramos LR, Sigulem D, d’Orsi E. Inclusão digital e capacidade funcional de idosos residentes em Florianópolis, Santa Catarina, Brasil (EpiFloripa 2009-2010). Rev Bras Epidemiol 2012; 15:106-22. ^{, 40}40 d’Orsi E, Xavier AJ, Steptoe A, Oliveira C, Ramos LR, Orrel M, et al. Sociodemographic and lifestyle factors related to instrumental activities of daily living dynamics: results from the English Longitudinal Study of Ageing. J Am Geriatr Soc 2014; 62:1630-9. and cognitive status ⁴¹41 Xavier AJ, d’Orsi E, Oliveira CM, Orrell M, Demakakos P, Biddulph JP, et al. English Longitudinal Study of Aging: can internet/e-mail use reduce cognitive decline? J Gerontol A Biol Sci Med Sci 2014; 69:1117-21., which can foster better self-rated health. Elderly that use new technologies are also motivated to improve their connection to the world, seek communication and interaction, especially with family and friends, pursue possibilities for leisure, and want to feel less excluded from society in the digital age ⁴²42 Vieira MC, Santarosa LMC. O uso do computador e da Internet e a participação em cursos de informática por idosos: meios digitais, finalidades sociais. In: XX Simpósio Brasileiro de Informática na Educação. http://www.br-ie.org/pub/index.php/sbie/article/view/1145 (acessado em 15/Nov/2014).
http://www.br-ie.org/pub/index.php/sbie/... . This may be linked to better self-esteem, self-confidence, and mental health ⁴³43 Gatto SL, Tak SH. Computer, internet, and e-mail use among older adults: benefits and barriers. Educ Gerontol 2008; 34:800-11., which could explain the relationship between Internet use and more optimistic self-rated health.

The current study found that the absence or lower number of diseases increased the prevalence of positive self-rated health. This finding may be explained by the fact that elderly that reported 1 or 2 chronic diseases might have more ease in controlling them, and thus see themselves as healthy and enjoy better self-rated health. Previous studies found an association between diseases ⁴⁴44 Alves LC, Rodrigues RN. Determinantes da autopercepção de saúde entre idosos do Município de São Paulo, Brasil. Rev Panam Salud Pública 2005; 17:333-41. and negative self-rated health ³3 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. ^{, 17}17 Lorenzo T, Millán-Calenti JC, Lorenzo-López L, Sánchez A, Maseda A. Predictores de mala salud autopercibida en una población de personas mayores. Rev Esp Geriatr Gerontol 2013; 48:272-5. (the more the diseases, the higher the prevalence of negative self-rated health). Elderly with three or more diseases present worse quality of life ⁴⁵45 Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury S. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med 2012; 10:134-41. ^{, 46}46 Santos JLF, Lebrão ML, Duarte YAO, Lima FD. Functional performance of the elderly in instrumental activities of daily living: an analysis in the municipality of São Paulo, Brazil. Cad Saúde Pública 2008; 24:879-86., worse health conditions ⁴⁵45 Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury S. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med 2012; 10:134-41., and more difficulty in performing ADL and consequently worse functional capacity ⁴⁵45 Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury S. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med 2012; 10:134-41.. These elements may lead older individuals with 3 or more diseases to rate their health less optimistically.

The association between self-rated health and less dependence in ADL was found in other studies ⁷7 Silva RJ, Smith-Menezes A, Tribess S, Romo-Perez V, Virtuoso Jr. JS. Prevalência e fatores associados a percepção negativa da saúde em pessoas idosas do Brasil. Rev Bras Epidemiol 2012; 15:49-62. ^{, 44}44 Alves LC, Rodrigues RN. Determinantes da autopercepção de saúde entre idosos do Município de São Paulo, Brasil. Rev Panam Salud Pública 2005; 17:333-41.. Greater difficulty in performing ADL is known to lead to worse functional capacity ⁴⁵45 Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury S. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med 2012; 10:134-41., negatively impacting quality of life in the elderly ⁴⁷47 Ribeiro AP, Souza ER, Atie S, Souza AC, Schilithz AO. The influence of falls on the quality of life of the aged. Ciênc Saúde Coletiva 2008; 13:1265-73.. In addition, dependence in ADL interferes in the social activities in which the elderly participate, such as attending church, visiting friends ⁴⁶46 Santos JLF, Lebrão ML, Duarte YAO, Lima FD. Functional performance of the elderly in instrumental activities of daily living: an analysis in the municipality of São Paulo, Brazil. Cad Saúde Pública 2008; 24:879-86., and attending social groups, among others. This may explain the lower prevalence of positive self-rated health in more dependent elderly.

The association between better self-rated health and not suffering falls may be understood by the loss of autonomy and independence in ADL generated by falls, which involve feelings of frailty and insecurity, decrease in social activities, and low self-esteem ⁴⁷47 Ribeiro AP, Souza ER, Atie S, Souza AC, Schilithz AO. The influence of falls on the quality of life of the aged. Ciênc Saúde Coletiva 2008; 13:1265-73.. Falls can negatively affect quality of life in the elderly and lead to lower prevalence of positive self-rated health. Another study found similar results ¹⁵15 Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Prevalence of falls and associated factors in the elderly. Rev Saúde Pública 2007; 41:749-56..

Non-use of polypharmacy is associated with positive self-rated health. Among the elderly, medication is one of the most widely used interventions to treat diseases. Thus, the use of medicines can indicate that something is wrong and interfere in their self-rated health ⁴⁸48 Murray MD, Callahan CM. Improving medication use for older adults: an integrated research agenda. Ann Intern Med 2003; 139(5 Pt 2):425-9.. Polypharmacy can also be attributed to one or more self-reported diseases, which can contribute to clinical alterations, in addition to higher frequency of drug-drug interactions with potential adverse effects, worse health status ³3 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. ^{, 45}45 Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury S. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med 2012; 10:134-41., and less optimistic self-rated health.

This study has some limitations to be considered when interpreting the results. The cross- sectional design does not allow establishing causal relations between self-rated health and the exposure variables, but indicates the magnitude of the associations and can raise new hypotheses for developing this area of study. Second, the use of self-reported measures (socioeconomic and lifestyle variables, health conditions, and use of medication and healthcare services) may involve an information bias. However, various precautions were taken to avoid biases, using standardized instruments and extensive training of the field team.

Among the study’s strengths, the results are population-based data with a representative sample of the elderly population in Florianópolis. These findings may differ from those of other studies, due to the reasons presented in the introduction, since the city has one of the highest Municipal Human Development Indices (IDH-M) in Brazil, in addition to high income and educational indicators (Programa das Nações Unidas para o Desenvolvimento. Atlas do Desenvolvimento Humano no Brasil 2013. Ranking – todo o Brasil (2010). http://atlasbrasil.org.br/2013/ranking, accessed on 08/Nov/2014). This may influence residents’ quality of life and self-rated health.

Self-rated health is a subjective measure that is considered a good indicator of health status in the elderly. This study can reveal the profile of older persons with positive self-rated health, essential for monitoring their overall health. Based on this, the development of health policies can support measures on issues associated with positive self-rated health and indirectly promote strategies to improve quality of life in this population group.

In conclusion, more schooling, more alcohol consumption, leisure-time physical activity, Internet use, fewer chronic illnesses, less dependence in ADL, absence of falls, and non-use of polypharmacy were associated with positive self-rated health in the elderly in the city of Florianópolis.

Acknowledgments

The authors wish to thank the staff of the Brazilian Institute of Geography and Statistics (IBGE) and the Florianópolis Municipal Health Secretariat for assisting with the study’s logistics. They also thank the study participants and the Coordination for the Advancement of Graduate Level Personnel (Capes-REUNI) for granting the PhD scholarship to S.C. Confortin. This article is part of the research Project EpiFloripa 2009-2010, an Epidemiological Study of Health Conditions in the Elderly in Florianópolis, Santa Catarina. The study was funded by CNPq, grant number 569834/2008-2, and developed under the Graduate Studies Program in Public Health at the Federal University of Santa Catarina.

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