Abstract:

Blacks and Browns have major health disadvantages, are less likely to rise in the social hierarchy throughout the course of life, and pertain to lower socioeconomic levels than Whites as a result of structural racism. However, little is known about the mediating role of intergenerational mobility in the association between race/skin color and health. The aim of the present study was to investigate the association between racism and self-rated health and to verify to what extent intergenerational social mobility mediates this association. This was a cross-sectional study conducted with data from 14,386 participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline (2008-2010). Maternal education, education of the participant, socio-occupational class of the head of household, and socio-occupational class of the participant were used in the indicators of intergenerational social mobility (educational and socio-occupational). Logistic regression models were used. The prevalence of poor self-rated health was 15%, 24%, and 28% among Whites, Browns, and Blacks, respectively. After adjustments for age, sex, and research center, greater chances of poor self-rated health were found among Blacks (OR = 2.15; 95%CI: 1.92-2.41) and Browns (OR = 1.82; 95%CI: 1.64-2.01) when compared to Whites. Intergenerational educational and socio-occupational mobility mediated, respectively, 66% and 53% of the association between race/color and poor self-rated health in Blacks, and 61% and 51% in Browns, respectively. Results confirm racial iniquity in self-rated health and point out that unfavorable intergenerational social mobility is an important mechanism to explain this iniquity.

Keywords:
Racism; Race; Health Status Disparities; Social Mobility; Social Inequality

Introduction

Racial iniquities in health in Brazil are markedly profound and a number of studies have shown that Blacks and Browns are at a major disadvantage when compared to Whites in different health-related outcomes, such as infant mortality ¹1. Caldas ADR, Santos RV, Borges GM, Valente JG, Portela MC, Marinho GL. Mortalidade infantil segundo cor ou raça com base no Censo Demográfico de 2010 e nos sistemas nacionais de informação em saúde no Brasil. Cad Saúde Pública 2017; 33:e00046516., maternal mortality ratio ²2. Morse ML, Fonseca SC, Barbosa MD, Calil MB, Eyer FP. Mortalidade materna no Brasil: o que mostra a produção científica nos últimos 30 anos? Cad Saúde Pública 2011; 27:623-38., infectious diseases ³3. Secretaria de Vigilância em Saúde, Ministério da Saúde. Indicadores de vigilância em saúde descritos segundo a variável raça/cor, Brasil. Brasília: Ministério da Saúde; 2017., chronic diseases ⁴4. Departamento de Articulação Interfederativa, Secretaria de Gestão Estratégica e Participativa, Ministério da Saúde. Temático Saúde da População Negra. Brasília: Ministério da Saúde; 2016.^,55. Barreto SM, Ladeira RM, Duncan BB, Schmidt MI, Lopes AA, Bensenor IM, et al. Chronic kidney disease among adult participants of the ELSA-Brasil cohort: association with race and socioeconomic position. J Epidemiol Community Health 2016; 70:380-9.^,66. Chor D, Ribeiro ALP, Carvalho MS, Duncan BB, Lotufo PA, Nobre AA, et al. Prevalence, awareness, treatment and influence of socioeconomic variables on control of high blood pressure: results of the ELSA-Brasil study. PLoS One 2015; 10:e0127382.^,77. Schmidt MI, Hoffmann JF, Diniz MFS, Lotufo PA, Griep RH, Bensenor IM, et al. High prevalence of diabetes and intermediate hyperglycemia - The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Diabetol Metab Syndr 2014; 6:123., and health risk behaviors ⁸8. Barros MBA, Lima MG, Medina LPB, Szwarcwald CL, Malta DC. Social inequalities in health behaviors among Brazilian adults: National Health Survey, 2013. Int J Equity Health 2016; 15:148.. As a result, Blacks and Browns in Brazil have a higher mortality rate from virtually all causes when compared to Whites ⁹9. Fiorio NM, Flor LS, Padilha M, Castro DS, Molina MCB. Mortality by race/color: evidence of social inequalities in Vitória (ES), Brazil. Rev Bras Epidemiol 2011; 14:522-30. and, consequently, a lower life expectancy ¹⁰10. Chiavegatto Filho ADP, Beltrán-Sánchez H, Kawachi I. Racial disparities in life expectancy in Brazil: challenges from a multiracial society. Am J Public Health 2014; 104:2156-62. and poor self-rated health ¹¹11. Rodrigues CG, Maia AG. Como a posição social influencia a auto-avaliação do estado de saúde? Uma análise comparativa entre 1998 e 2003. Cad Saúde Pública 2010; 26:762-74.^,1212. Dachs JNW. Determinantes das desigualdades na auto-avaliação do estado de saúde no Brasil: análise dos dados da PNAD/1998. Ciênc Saúde Colet 2002; 7:641-57.^,1313. Barata RB, Almeida MF, Montero CV, Silva ZP. Health inequalities based on ethnicity in individuals aged 15 to 64, Brazil, 1998. Cad Saúde Pública 2007; 23:305-13.^,1414. Szwarcwald CL, Damacena GN, Souza Júnior PRB, Almeida WS, Lima LTM, Malta DC, et al. Determinantes da autoavaliação de saúde no Brasil e a influência dos comportamentos saudáveis: resultados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18:33-44.^,1515. Chiavegatto Filho ADP, Laurenti R. Disparidades étnico-raciais em saúde autoavaliada: análise multinível de 2.697 indivíduos residentes em 145 municípios brasileiros. Cad Saúde Pública 2013; 29:1572-82.. These inequalities are absolutely unnecessary, avoidable, and unfair and, as such, must be interpreted as iniquities ¹⁶16. Whitehead M. The concepts and principles of equity and health. Int J Health Serv 1992; 22:429-45..

Racial iniquities in health can be largely explained by structural racism, which refers to all the ways in which societies promote the maintenance of racial hierarchies and white dominance across generations ¹⁷17. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389:1453-63.. These discriminatory practices generate staggering iniquities in opportunities ¹⁷17. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389:1453-63., reducing the chances of Blacks and Browns reaching the same levels of education, income, employment, and housing as those observed among Whites. It is worth noting that this is a lifelong process, starting even before birth and shadowing the person until the death ¹⁷17. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389:1453-63.. Consequently, the probabilities of Browns and Blacks climbing the social hierarchy are much slimmer than that observed among Whites, as has been repeatedly demonstrated in empirical studies that have investigated social mobility in the Brazilian population based on race/skin color ¹⁷17. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389:1453-63.^,1818. Hasenbalg C, Silva NV. Educação e diferenças raciais na mobilidade ocupacional no Brasil. In: XXII Encontro Anual da ANPOCS - GT Desigualdades Sociais. https://www.anpocs.com/index.php/encontros/papers/22-encontro-anual-da-anpocs/gt-20/gt03-6/5050-chasenbalg-ndovalle-educacao/file (acessado em Fev/2020).
https://www.anpocs.com/index.php/encontr... .

In the Brazilian context, studies have shown that unfavorable social pathways between generations are associated with poor health outcomes, such as arterial hypertension ¹⁹19. Lopes JAS, Giatti L, Griep RH, Lopes AA, Matos SMA, Chor D, et al. Life course socioeconomic position, intergenerational social mobility, and hypertension incidence in ELSA-Brasil. Am J Hypertens 2021; 34:801-9., cardiovascular disease ²⁰20. Andrade DRS, Camelo LV, Reis RC, Santos IS, Ribeiro AL, Giatti L, et al. Life course socioeconomic adversities and 10-year risk of cardiovascular disease: cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health. Int J Public Health 2017; 62:283-92., diabetes ²¹21. Camelo LV, Giatti L, Duncan BB, Chor D, Griep RH, Schmidt MI, et al. Gender differences in cumulative life-course socioeconomic position and social mobility in relation to new onset diabetes in adults-the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Ann Epidemiol 2016; 26:858-64.e1., and subclinical atherosclerosis ²²22. Guimarães JM, Clarke P, Tate D, Coeli CM, Griep RH, Fonseca MJ, et al. Social mobility and subclinical atherosclerosis in a middle-income country: association of intra- and inter-generational social mobility with carotid intima-media thickness in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Soc Sci Med 2016; 169:9-17.. It is also known that interpersonal discrimination seems to interact with intergenerational social mobility to produce poor health outcomes, given that a previous study found that the relationship between descending social mobility and hypertension is greater among Blacks and Browns who reported discrimination in contrast with those who did not ²³23. Nishida W, Kupek E, Zanelatto C, Bastos JL. Intergenerational educational mobility, discrimination, and hypertension in adults from Southern Brazil. Cad Saúde Pública 2020; 36:e00026419.. Additionally, there is evidence from North American studies showing that the association between social mobility and health outcomes is not homogeneous between White and Black individuals ²⁴24. Assari S. Race, intergenerational social mobility and stressful life events. Behav Sci (Basel) 2018; 8:86.. Nonetheless, few studies have been conducted that would explain the contribution of intergenerational social mobility on racial iniquities in health. An investigation of this aspect is important, as unlike the fixed indicators of individuals’ socioeconomic position (e.g., income, education, and occupation), intergenerational social mobility captures individuals and racial subgroups that move from one social position of origin (the socioeconomic position of the parents) to another.

In addition to there being fewer opportunities for upward social mobility between Blacks and Browns than those observed among Whites ²⁵25. Ribeiro CAC. Classe, raça e mobilidade social no Brasil. Dados 2006; 49:833-73.^,2626. Telles EE. Racismo à brasileira: uma nova perspectiva sociológica. Rio de Janeiro: Relume-Dumará; 2003.^,2727. Telles E, Flores RD, Urrea-Giraldo F. Pigmentocracies: educational inequality, skin color and census ethnoracial identification in eight Latin American countries. Res Soc Stratif Mobil 2015; 40:39-58., they also have a harder time in holding onto the social positions they have attained, as they have less chance of remaining at the top the class hierarchy and a greater chance of downward social mobility ¹⁸18. Hasenbalg C, Silva NV. Educação e diferenças raciais na mobilidade ocupacional no Brasil. In: XXII Encontro Anual da ANPOCS - GT Desigualdades Sociais. https://www.anpocs.com/index.php/encontros/papers/22-encontro-anual-da-anpocs/gt-20/gt03-6/5050-chasenbalg-ndovalle-educacao/file (acessado em Fev/2020).
https://www.anpocs.com/index.php/encontr... ^,2525. Ribeiro CAC. Classe, raça e mobilidade social no Brasil. Dados 2006; 49:833-73.. However, until the end of the 1970s, it was believed that these differences were explained merely by the over-representation of Whites in higher socioeconomic positions of origin and of Blacks and Browns in the lower positions ²⁶26. Telles EE. Racismo à brasileira: uma nova perspectiva sociológica. Rio de Janeiro: Relume-Dumará; 2003.. For this reason, several authors came to believe that racial iniquity in social mobility would disappear as Blacks and Browns secured the same social position as that reached by Whites ²⁷27. Telles E, Flores RD, Urrea-Giraldo F. Pigmentocracies: educational inequality, skin color and census ethnoracial identification in eight Latin American countries. Res Soc Stratif Mobil 2015; 40:39-58.. However, we now know that even when they have the same socioeconomic position of origin as Whites, Blacks and Browns have more difficulty in moving up the social hierarchy ²⁶26. Telles EE. Racismo à brasileira: uma nova perspectiva sociológica. Rio de Janeiro: Relume-Dumará; 2003.^,2727. Telles E, Flores RD, Urrea-Giraldo F. Pigmentocracies: educational inequality, skin color and census ethnoracial identification in eight Latin American countries. Res Soc Stratif Mobil 2015; 40:39-58.. Furthermore, there are important racial iniquities in the conversion of acquired education into positions within the occupational hierarchy, since regardless of the educational level attained by Blacks and Browns, this group tends to be more concentrated at the lower occupational strata than Whites of the same level ¹⁸18. Hasenbalg C, Silva NV. Educação e diferenças raciais na mobilidade ocupacional no Brasil. In: XXII Encontro Anual da ANPOCS - GT Desigualdades Sociais. https://www.anpocs.com/index.php/encontros/papers/22-encontro-anual-da-anpocs/gt-20/gt03-6/5050-chasenbalg-ndovalle-educacao/file (acessado em Fev/2020).
https://www.anpocs.com/index.php/encontr... .

It is important to use a comprehensive and robust health-related outcome, such as self-rated health, to investigate whether intergenerational social mobility at least partially explains racial iniquities in health. This indicator is a condensed, multidimensional measurement of health status ²⁸28. Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med 2009; 69:307-16.^,2929. Singh-Manoux A, Martikainen P, Ferrie J, Zins M, Marmot M, Goldberg M. What does self rated health measure? Results from the British Whitehall II and French Gazel cohort studies. J Epidemiol Community Health 2006; 60:364-72.^,3030. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38:21-37., capable of predicting serious events, such as mortality, often exceeding the predictive power of objective health status indicators ³⁰30. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38:21-37.. Additionally, iniquities found in this indicator tend to reflect not only current objective health differentials (e.g., medical diagnoses, clinical/laboratory tests, functionality, signs and symptoms of disease, and risk factors), but also iniquities in past health experiences, in expectations regarding future health and exposure to psychosocial stressors ²⁸28. Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med 2009; 69:307-16.^,2929. Singh-Manoux A, Martikainen P, Ferrie J, Zins M, Marmot M, Goldberg M. What does self rated health measure? Results from the British Whitehall II and French Gazel cohort studies. J Epidemiol Community Health 2006; 60:364-72..

Therefore, this study aimed to investigate the association between racism and self-rated health, using the self-reported race/skin color variable as a social marker of racism, and then verify the extent to which intergenerational social mobility (educational and socio-occupational) mediates this association. The study hypotheses are: (1) Blacks and Browns have a higher prevalence of poor self-rated health than Whites, (2) Blacks and Browns have a lower prevalence of upward social mobility and immobility at the top of the hierarchy and a higher prevalence of downward social mobility and immobility at the bottom of the hierarchy than Whites, and (3) a portion of racial iniquity in self-rated poor health is mediated by intergenerational social mobility.

Methods

Study design and population

This study used baseline data from Brazilian Longitudinal Study of Adult Health (ELSA-Brasil, 2008-2010), a multicenter cohort with 15,105 public servants of both sexes, aged between 35 and 74 years, from teaching and research institutions in six Brazilian cities: Belo Horizonte (Minas Gerais State), Porto Alegre (Rio Grande do Sul State), Rio de Janeiro, Salvador (Bahia State), São Paulo, and Vitória (Espírito Santo State). Efforts were made to recruit ELSA-Brasil cohort participants with similar numbers of men and women, as well as a predefined balance of age groups and occupational categories. More details on study design, selection criteria, recruitment methods and cohort characteristics have been reported in other publications ³¹31. Aquino EM, Barreto SM, Bensenor IM, Carvalho MS, Chor D, Duncan BB, et al. Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): objectives and design. Am J Epidemiol 2012; 175:315-24.^,3232. Schmidt MI, Duncan BB, Mill JG, Lotufo PA, Chor D, Barreto SM, et al. Cohort profile: Longitudinal Study of Adult Health (ELSA-Brasil). Int J Epidemiol 2015; 44:68-75.. ELSA-Brasil was approved by the Ethics Research Committee of each of the participating research institutions and the Brazilian National Research Ethics Commission (CONEP). All participants signed an Informed Consent Form.

Participants who reported Asian descendent race/color (n = 374) and Brazilian indigenous (n = 157) were excluded because they represent a very small number of individuals and present distinct characteristics that do not allow aggregation to other race/color categories. Participants with missing data on self-reported race/skin color (n = 184) and self-rated health (n = 4) were also excluded. Thus, 14,386 participants were included in this study for descriptive analysis. Participants with missing data on maternal level of education (n = 343) were excluded for analyses involving intergenerational educational mobility. The sample for this analysis included 14,043 participants. Participants with missing data on socio-occupational class (n = 239) and socio-occupational class of the head of household when the participant started working (n = 679) were excluded from the analysis involving intergenerational socio-occupation mobility. The sample for this analysis consisted of 13,468 participants.

Participants with missing educational mobility data were more likely (p ≤ 0.05) to be older, male, Black and Brown race/skin color, and with a poor self-rated health. No difference was found regarding gender and self-rated health among participants with missing data for occupational mobility, although they were more likely to be older and report White race/skin color (p ≤ 0.05).

Study variables

Self-related health

Self-rated health was measured by using the following question: “In general, compared to people your age, how do you rate your health status?”. This question had five answer choices: very good, good, fair, poor, and very poor. For analysis purposes, they were grouped into two categories: “good” (very good and good) and “poor” (fair, poor, and very poor). The “good” category was used as a reference. This allows comparison of results between studies as it is the most frequently used categorization in studies with an adult population ¹⁵15. Chiavegatto Filho ADP, Laurenti R. Disparidades étnico-raciais em saúde autoavaliada: análise multinível de 2.697 indivíduos residentes em 145 municípios brasileiros. Cad Saúde Pública 2013; 29:1572-82.. Additionally, both the “fair” category and the “poor” and “very poor” categories have been associated with a higher risk of mortality ³³33. DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality prediction with a single general self-rated health question. J Gen Intern Med 2006; 21:267-75..

Racism

The self-reported race/skin color variable was considered a social marker of racism in this study. The following question was used to receive information on race/skin color: “The Brazilian Census (IBGE) uses the terms ‘Black’, ‘Brown’, ‘White’, ‘Asian descendent’, and ‘Brazilian indigenous’ to classify people’s skin color or race. If you had to respond to the IBGE census today, how would you classify yourself regarding your skin color or race?”. This question had the following answer choices: Black, Brown, White, Asian descendent, and Brazilian indigenous. White race/skin color was used as the reference category.

Intergenerational educational mobility

Maternal education was measured using the question: “What is your mother’s level of educational?” (she never attended school, incomplete primary education, complete primary education, complete secondary education, and complete higher education); and the participant’s education by the question: “What is your level of education?” (incomplete primary education, complete primary education, complete secondary education, complete higher education, and graduate studies).

Maternal education was put into two categories (high: ≥ complete primary education; low: < complete primary education), as was the participant’s education (high: ≥ complete higher education; low: < complete higher education). As a result, intergenerational educational mobility consisted of four educational pathways: immobility at the top of the hierarchy, upward mobility, downward mobility, and immobility at the bottom of the hierarchy. The categorization of maternal education and participant education needed different cutoff points to consider the continuous improvement in education levels that transpired in Brazilian society over time. That being the case, the distribution of educational level varies according to the birth cohort, with secondary and higher education in the older (maternal) cohorts being infrequent. Moreover, it is known that the value of educational qualifications drops as the number of individuals acquiring them rises ³⁴34. Galobardes B, Shaw M, Lawlor DA, Lynch JW, Davey Smith G. Indicators of socioeconomic position (part 1). J Epidemiol Community Health 2006; 60:7-12.^,3535. Breen R, Luijkx R, Müller W, Pollak R. Nonpersistent inequality in educational attainment: evidence from eight European countries. Am J Sociol 2009; 114:1475-521..

Intergenerational socio-occupational mobility

Intergenerational socio-occupational mobility was obtained from the occupational social class of the head of the household when the participant started working (assessed retrospectively) and the participant’s current occupational social class. Occupational social class is a concise measurement based on the person’s occupation, expected income based on level of education (average market value), and observed income. More information on the methodology used to create this variable can be found in another publication ²¹21. Camelo LV, Giatti L, Duncan BB, Chor D, Griep RH, Schmidt MI, et al. Gender differences in cumulative life-course socioeconomic position and social mobility in relation to new onset diabetes in adults-the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Ann Epidemiol 2016; 26:858-64.e1..

The occupational social class of the head of the family and the occupational social class of the participant were dichotomized into high (high, upper-middle, middle-middle) and low (low-middle, low). Accordingly, intergenerational socio-occupational mobility was comprised of immobility at the top of the hierarchy, upward mobility, downward mobility, and immobility at the bottom of the hierarchy.

Covariates

Age (continuous, in years), sex, and research center (São Paulo, Minas Gerais, Rio Grande do Sul, Rio de Janeiro, Bahia, and Espírito Santo) were used as covariates in this study.

Data analysis

The characteristics of the population, the prevalence of poor self-related health, and intergenerational mobility (educational and socio-occupational) were described according to race/skin color.

The association between racism and self-rated health was investigated using logistic regression models, obtaining the odds ratio (OR) and its 95% confidence interval (95%CI). A causal diagram of the proposed associations was constructed to guide our analyses (see Supplementary Material. http://cadernos.ensp.fiocruz.br/static//arquivo/supl-e00341920-ingl_3069.pdf). After obtaining the crude OR, the age, sex, and research center variables were then added, as they are potential confounding factors (Model 1). Subsequently, the intergenerational educational mobility variable was included to investigate to what extent intergenerational educational mobility explains racial iniquities in a self-rated health (Model 2). The OR percentage of the association between racism and self-rated health mediated by intergenerational educational mobility (mediated percentage) was estimated using the following formula:

The same steps were taken separately to investigate the mediating role of intergenerational socio-occupational mobility in racial iniquity in self-rated health.

The level of significance was set at 0.05 and all analyses were performed using Stata 14.0 (https://www.stata.com/).

Results

Of the 14,386 participants included in the descriptive analysis, most were female (55%) and reported White race/skin color (54%). Although most participants had mothers with no education or incomplete elementary education (57%) and low socio-occupational class heads of household at the time they started working (50%), most participants themselves had completed a higher education program (52.4%), with the high socio-occupational class being the most frequent (33.1%), indicating that intergenerational social mobility was commonplace. Low maternal education, as well as low socio-occupational class of the head of the household when the participant started working, was more frequent among Blacks and Browns than among Whites. Similar disadvantages for Browns and Blacks in relation to Whites can also be observed in terms of education and current socio-occupational class (Table 1).

The prevalence of poor self-related health among ELSA-Brasil participants was 19.7%. However, it varied greatly according to race/skin color and, while only 15% of Whites rated their health as poor, it was 24% among Browns and 28% among Blacks (Figure 1).

Significant racial iniquity could be observed in intergenerational social mobility from an educational and socio-occupational perspective. The percentage with immobility at the top of the social hierarchy was greater among Whites than Browns and Blacks, while immobility at the bottom of the hierarchy was more prevalent among Blacks and Browns than Whites (Figure 2). It was also observed that Browns had some disadvantages when compared to Whites and advantages over Blacks (Figure 2). Moreover, upward educational mobility proved to be greater among Whites (24.3%) than Browns (20.2%) and Blacks (16.5%), whereas the opposite was observed with greater downward mobility among Blacks (15.7%) and Browns (14.3%) than among Whites (9.7%) (Figure 2a). Racial differences in downward and upward socio-occupational mobility were small (Figure 2b).

Regardless of potential confounding factors, Black and Brown individuals had greater odds of reporting their health as poor than did Whites: 115% (OR = 2.15; 95%CI: 1.92-2.41) and 82% (OR = 1.82; 95%CI: 1.64-2.01), respectively (Figure 3). Intergenerational educational mobility mediated 66% of the association between Black race/skin color and poor self-rated health (Figure 3a) and 61% of the association between Brown race/skin color and poor self-rated health (Figure 3b). Intergenerational socio-occupational mobility mediated 53% of the association between race/skin color and poor self-rated health among Blacks (Figure 4a) and 51% among Browns (Figure 4b).

Discussion

Racial iniquity in poor self-rated health and intergenerational social mobility were significant among the participants in the ELSA-Brasil cohort. Black individuals were more than twice as likely to rate their health as poor and more often in lower rungs of social mobility, i.e., immobility at the bottom of the hierarchy and descending educational mobility, than Whites. It was also observed that, although there were non-negligible differences between Blacks and Browns regarding the prevalence of poor self-rated health and the frequency of adverse social pathways, Blacks and Browns were relatively closer to each other, and both presented social and health disadvantages when compared to Whites. This result showed that racial iniquity in poor self-rated health was strongly mediated by intergenerational social mobility, especially considering its educational component, thus corroborating our hypothesis. However, an important part of racial iniquity in poor self-rated health was not mediated by intergenerational social mobility, indicating that other mechanisms also contribute to the enormous racial iniquity in health in our country.

Several Brazilian population studies have investigated the association between race/skin color and self-rated health and consistently found that White individuals have a lower frequency of self-rated poor health than individuals who self-reported being of other races/colors ¹¹11. Rodrigues CG, Maia AG. Como a posição social influencia a auto-avaliação do estado de saúde? Uma análise comparativa entre 1998 e 2003. Cad Saúde Pública 2010; 26:762-74.^,1212. Dachs JNW. Determinantes das desigualdades na auto-avaliação do estado de saúde no Brasil: análise dos dados da PNAD/1998. Ciênc Saúde Colet 2002; 7:641-57.^,1313. Barata RB, Almeida MF, Montero CV, Silva ZP. Health inequalities based on ethnicity in individuals aged 15 to 64, Brazil, 1998. Cad Saúde Pública 2007; 23:305-13.^,1414. Szwarcwald CL, Damacena GN, Souza Júnior PRB, Almeida WS, Lima LTM, Malta DC, et al. Determinantes da autoavaliação de saúde no Brasil e a influência dos comportamentos saudáveis: resultados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18:33-44.^,1515. Chiavegatto Filho ADP, Laurenti R. Disparidades étnico-raciais em saúde autoavaliada: análise multinível de 2.697 indivíduos residentes em 145 municípios brasileiros. Cad Saúde Pública 2013; 29:1572-82.. However, these studies were not homogeneous with regard to how to analyze race/skin color, and some studies only analyzed the iniquity between Whites versus non-Whites ¹⁴14. Szwarcwald CL, Damacena GN, Souza Júnior PRB, Almeida WS, Lima LTM, Malta DC, et al. Determinantes da autoavaliação de saúde no Brasil e a influência dos comportamentos saudáveis: resultados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18:33-44. and Blacks/Browns (negroes) versus Whites ¹³13. Barata RB, Almeida MF, Montero CV, Silva ZP. Health inequalities based on ethnicity in individuals aged 15 to 64, Brazil, 1998. Cad Saúde Pública 2007; 23:305-13.. Despite allowing the effects of power relationships between marginalized and privileged groups to be assessed, this approach makes it difficult to understand the breadth and nuances of racial iniquity in health in Brazil. Most studies that separately analyzed the distinctions of each of the races/skin color in self-rated health ¹¹11. Rodrigues CG, Maia AG. Como a posição social influencia a auto-avaliação do estado de saúde? Uma análise comparativa entre 1998 e 2003. Cad Saúde Pública 2010; 26:762-74.^,1212. Dachs JNW. Determinantes das desigualdades na auto-avaliação do estado de saúde no Brasil: análise dos dados da PNAD/1998. Ciênc Saúde Colet 2002; 7:641-57.^,1515. Chiavegatto Filho ADP, Laurenti R. Disparidades étnico-raciais em saúde autoavaliada: análise multinível de 2.697 indivíduos residentes em 145 municípios brasileiros. Cad Saúde Pública 2013; 29:1572-82., as in this study, as well as most of those that dichotomized race/color for analysis ¹³13. Barata RB, Almeida MF, Montero CV, Silva ZP. Health inequalities based on ethnicity in individuals aged 15 to 64, Brazil, 1998. Cad Saúde Pública 2007; 23:305-13.^,1414. Szwarcwald CL, Damacena GN, Souza Júnior PRB, Almeida WS, Lima LTM, Malta DC, et al. Determinantes da autoavaliação de saúde no Brasil e a influência dos comportamentos saudáveis: resultados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18:33-44., found that the association between race/color and self-rated health was independent of socioeconomic status indicators, such as education, income, or occupation. However, in one of these studies, this association was fully explained by the level of income and education ¹²12. Dachs JNW. Determinantes das desigualdades na auto-avaliação do estado de saúde no Brasil: análise dos dados da PNAD/1998. Ciênc Saúde Colet 2002; 7:641-57.. It should be pointed out that socioeconomic position indicators do not meet confounding variable criteria for an analysis of the association between race/skin color and health outcomes. In this association the socioeconomic position indicators meet the criteria of mediation. This happens because race/skin color is an intrinsic characteristic of the individual, a fundamental cause that temporally precedes the socioeconomic position one reaches in adult life, and generates differences in educational opportunities, income, and occupation ³⁶36. Kawachi I, Daniels N, Robinson DE. Health disparities by race and class: why both matter. Health Aff (Millwood) 2005; 24:343-52.^,3737. Phelan JC, Link BG. Is racism a fundamental cause of inequalities in health? Annu Rev Sociol 2015; 41:311-30.. Nevertheless, previous studies investigating the association between race/skin color and self-rated health did not identify racism as a fundamental cause of racial differences in socioeconomic status indicators. Consequently, there is room for misinterpretations that the root of racial iniquity is social iniquity and not racism.

This study found that more than 50% of the racial iniquity in poor self-rated health was mediated by social mobility among Black and Brown individuals alike. Thus, our findings suggest that both the current socioeconomic position and the socioeconomic position of origin are important to understanding the country’s racial health iniquities. The socioeconomic position of origin among individuals of different races/skin colors is strongly influenced by the accumulation of discriminatory actions throughout history that have the potential to “transmit” racial disadvantages across generations through the propagation of social iniquity ²⁷27. Telles E, Flores RD, Urrea-Giraldo F. Pigmentocracies: educational inequality, skin color and census ethnoracial identification in eight Latin American countries. Res Soc Stratif Mobil 2015; 40:39-58.. Furthermore, racial iniquity persists even in cases where Blacks, Browns, and Whites have the same social position of origin. A recent study showed that, regardless of the socioeconomic position of origin, Whites have advantages over Browns and Browns over Blacks with respect to the level of education ²⁵25. Ribeiro CAC. Classe, raça e mobilidade social no Brasil. Dados 2006; 49:833-73.. Additionally, there is evidence that the socioeconomic position of origin may interact with race/color to determine an individual’s current social position. For example, using Brazilian National Household Sample Survey (PNAD) data, it was shown that there is no racial iniquity in the opportunity for social mobility among individuals born in the lower classes ²⁵25. Ribeiro CAC. Classe, raça e mobilidade social no Brasil. Dados 2006; 49:833-73.. However, among individuals with origins in the upper classes, Whites are more likely to remain at the top of the class hierarchy, while Blacks and Browns are more likely to have downward social mobility ²⁵25. Ribeiro CAC. Classe, raça e mobilidade social no Brasil. Dados 2006; 49:833-73.. This finding might be explained by the greater presence of racial discrimination in the higher social positions, a fact well described in the literature ³⁸38. Burgard S, Castiglione DP, Lin KY, Nobre AA, Aquino EML, Pereira AC, et al. Differential reporting of discriminatory experiences in Brazil and the United States. Cad Saúde Pública 2017; 33 Suppl 1:e00110516. and a probable consequence of the greater coexistence that Blacks with a high socioeconomic status have with Whites in their daily lives ²⁴24. Assari S. Race, intergenerational social mobility and stressful life events. Behav Sci (Basel) 2018; 8:86.. The presence of such discrimination at the top of the hierarchy would make it more difficult for Blacks and Browns from a high socioeconomic position to remain there, favoring downward mobility.

The results of this study suggest that promoting upward social mobility among Blacks and Browns could attenuate racial health iniquity among Blacks and Browns. However, a rise in upward mobility may have a less than expected effect without a simultaneous curtailment of the structural racism that is deeply rooted in Brazilian society and permeates its institutions, not to mention being strongly present in our culture. For instance, several studies have indicated that upward social mobility and current high socioeconomic status among Blacks and other racial minorities exert a less protective effect on health than that observed among Whites ²⁴24. Assari S. Race, intergenerational social mobility and stressful life events. Behav Sci (Basel) 2018; 8:86.^,3939. Assari S, Thomas A, Caldwell CH, Mincy RB. Blacks' diminished health return of family structure and socioeconomic status: 15 years of follow-up of a national urban sample of youth. J Urban Health 2018; 95:21-35.^,4040. Assari S. The benefits of higher income in protecting against chronic medical conditions are smaller for African Americans than Whites. Healthcare (Basel) 2018; 6:2.. This may be due to the stress generated by racial discrimination ³⁵35. Breen R, Luijkx R, Müller W, Pollak R. Nonpersistent inequality in educational attainment: evidence from eight European countries. Am J Sociol 2009; 114:1475-521., since, as mentioned earlier, racial discrimination is more prevalent among Blacks with high socioeconomic status ³⁸38. Burgard S, Castiglione DP, Lin KY, Nobre AA, Aquino EML, Pereira AC, et al. Differential reporting of discriminatory experiences in Brazil and the United States. Cad Saúde Pública 2017; 33 Suppl 1:e00110516.. Additionally, structural racism interferes with the placement of individuals in the labor market, as well as access to housing, quality education, and various goods and services, meaning that, even if Brown and Black individuals attain the same level of education observed in Whites, they still tend to have less prestigious occupations and positions and lower income levels than Whites ¹⁷17. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389:1453-63.. Consequently, although education is one of the main drivers of social mobility and significant advances in the access of Blacks and Browns to higher education in Brazil since 2002, as a reflection of affirmative action policies in higher education ⁴¹41. Heringer R. Democratização da educação superior no Brasil: das metas de inclusão ao sucesso acadêmico. Revista Brasileira de Orientação Profissional 2018; 19:7-17., this is not enough to promote racial equality, as Whites are much more efficient at converting experience and education into monetary returns due to the privileges they have accumulated throughout life ¹⁸18. Hasenbalg C, Silva NV. Educação e diferenças raciais na mobilidade ocupacional no Brasil. In: XXII Encontro Anual da ANPOCS - GT Desigualdades Sociais. https://www.anpocs.com/index.php/encontros/papers/22-encontro-anual-da-anpocs/gt-20/gt03-6/5050-chasenbalg-ndovalle-educacao/file (acessado em Fev/2020).
https://www.anpocs.com/index.php/encontr... . Thus, affirmative action policies need to be accompanied by policies that act continuously on the different mechanisms in which racism operates ⁴²42. Jones CP. Confronting institutionalized racism. Phylon 2003; 50:7-22., curtailing the economic and social injustices that lead to marginalizing Blacks and Browns to substandard schools, jobs, and housing; disproportionate exposure to occupational hazards; lower wages; lower rates of promotion; mass incarceration; police violence; and unequal health care ¹⁷17. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389:1453-63.. Therefore, confronting racism requires a transformation and dismantling of the policies and various institutions that sustain the racial hierarchy in Brazil. To accomplish this, greater Black representation is imperative in the political arena in order to bring about much-needed change in the historically constructed values that have glorified the belief in White superiority and Black inferiority, compromising the life and health of Blacks and Browns throughout the generations ¹⁷17. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389:1453-63.^,4242. Jones CP. Confronting institutionalized racism. Phylon 2003; 50:7-22..

An important part of racial iniquity in poor self-rated health in this study was not mediated by intergenerational social mobility. In addition to having less access to educational, economic, and occupational resources and, consequently, less social mobility, Blacks and Browns also have less access to quality housing, live in more economically segregated neighborhoods, have less social and political capital, have less access to health services, are more often exposed to stressful work, and are subjected to psychosocial stress due to racial discrimination ⁴³43. Krieger N. Discrimination and health inequities. In: Berkman LF, Kawachi I, Glymour MM, editors. Social epidemiology. 2nd Ed. New York: Oxford University Press; 2014. p. 63-125.. All these exposures restrict life and work options in healthy environments, are associated with greater adherence to risky behaviors, and increase physiological adaptations in the nervous, endocrine, and immune systems, triggering metabolic changes that increase the risk of illness and death ⁴⁴44. Krieger N. Methods for the scientific study of discrimination and health: an ecosocial approach. Am J Public Health 2012; 102:936-44.^,4545. McEwen BS. Brain on stress: how the social environment gets under the skin. Proc Natl Acad Sci U S A 2012;109 Suppl 2:17180-5.. Thus, as defended by Nancy Krieger ⁴³43. Krieger N. Discrimination and health inequities. In: Berkman LF, Kawachi I, Glymour MM, editors. Social epidemiology. 2nd Ed. New York: Oxford University Press; 2014. p. 63-125.^,4444. Krieger N. Methods for the scientific study of discrimination and health: an ecosocial approach. Am J Public Health 2012; 102:936-44. in her ecosocial theory, individuals exposed to structural and interpersonal racism tend to biologically “incorporate” the exposures arising from the ecological and social context in which they live, leading to racial iniquities in health.

This study has limitations that should be considered. The ELSA-Brasil cohort is made up of public servants from Brazilian educational and research institutions who have a higher average income and level of education than that found in the general Brazilian population; therefore, our prevalence measurements are not representative of the population as a whole. The non-inclusion of very poor and unemployed individuals in the cohort could possibly explain the lower prevalence of poor self-related health in the ELSA-Brasil as compared to that observed in the 2013 Brazilian National Health Survey (PNS) (19.7% versus 33.9 %, respectively) ⁴⁶46. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014.. It is also worth noting that the population at the top of the Brazilian social hierarchy is underrepresented in the ELSA-Brasil population. By excluding those individuals who occupy the extreme ends of the social hierarchy, the heterogeneity in social mobility variables may have been reduced. Therefore, the mediating effect of social mobility on the relationship between race/skin color and self-rated poor health in Brazil may be greater than that pointed out in this study. However, racial iniquity in self-rated health in the ELSA-Brasil was greater than that observed in the PNS: while in ELSA-Brasil 15% of the Whites, 24% of the Browns, and 28% of the Blacks rated their health as poor, these percentages in the PNS were 30%, 38%, and 38% for Whites, Browns, and Blacks, respectively ⁴⁶46. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014.. Finally, despite the small percentage of missing data for educational mobility (2.3%), these losses were differential with regard to the explanatory variable and the outcome, suggesting the associations may have been underestimated. Conversely, although the loss of information for occupational mobility was almost three times higher (6.4%), it was not related to self-rated health, suggesting a lesser impact on the associations.

The strengths of this study include the large size of the ELSA-Brasil cohort, the inclusion of participants from three Brazilian regions, racial heterogeneity, and the existence of normally uncommon information in epidemiological studies on intergenerational mobility. These characteristics allowed us to examine and estimate the extent to which intergenerational social mobility (educational and socio-occupational) mediates racial iniquities in poor self-rated health.

In conclusion, our results reiterate the inordinate racial iniquity in self-rated health in the Brazilian context and confirm our hypothesis that intergenerational social mobility contributes significantly to mediating this iniquity. Considering that the propagation of racial iniquity in social mobility from one generation to another not only contributes to maintaining it over time, but also to expanding it, it is imperative to promote public policies with a focus on curtailing structural racism to mitigate the profound racial iniquity in health found in the country.

Acknowledgments

The authors would like to thank all ELSA-Brasil participants for their valuable contribution to this study. This study was funded by the Brazilian Ministry of Health, Brazilian Ministry of Science, Technology and Innovation and the Brazilian National Research Council (CNPq). S. M. Barreto, D. Chor, L. Giatti and R. H. Griep are CNPq productivity fellows. S. M. Barreto is a research fellow from the Minas Gerais State Research Foundation (FAPEMIG). L. V. Camelo and C. G. Coelho received financial support from the Federal University of Minas Gerais (Institutional Program for Research Assistance for Newly Hired Doctors).

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