Desigualdades sociales en salud en población mayor: revisión de los indicadores empleados en España

Social inequalities in health among the elderly population: review of indicators used in Spain

Isabel Mosquera Mónica Machón Itziar Vergara Isabel Larrañaga Unai Martín Grupo de Determinantes Sociales de la Salud de la Sociedad Española de EpidemiologíaAcerca de los autores

RESUMEN

Objetivo

Identificar los indicadores de posición social utilizados para la evaluación de desigualdades en salud en la población de 65 y más años en España.

Método

Se llevó a cabo una búsqueda sistemática de publicaciones en inglés y español desde el año 2000 en bases de datos sanitarias y sociales. Se incluyeron estudios primarios y secundarios que analizaban dichas desigualdades en España. Se identificaron los indicadores utilizados, así como las ventajas y limitaciones señaladas por los/las autores/as. Los principales hallazgos se sintetizaron en forma de revisión de la literatura.

Resultados

Se incluyeron 87 estudios, que se describían en 89 artículos. Los indicadores socioeconómicos empleados fueron tanto individuales como de tipo ecológico. Entre los primeros, el nivel educativo fue la variable socioeconómica más analizada (n = 73). Otras variables individuales empleadas fueron la ocupación (n = 17), el nivel económico objetivo (n = 16), el nivel económico subjetivo (n = 4), la vivienda y la riqueza material del hogar (n = 6), la relación con la actividad laboral (n = 5) y medidas mixtas (n = 5). Entre los indicadores ecológicos se identificaron índices simples (n = 3) y compuestos (n = 7). Estos últimos se habían construido a partir de varios indicadores, entre los que se encontraban el nivel educativo y el desempleo. Se analizaron las desigualdades en múltiples indicadores de salud, siendo la salud percibida el único indicador evaluado en función de todos los indicadores socioeconómicos descritos.

Conclusiones

Se identifica una gran variedad de indicadores socioeconómicos para el análisis de las desigualdades sociales en salud en población mayor. No se evalúan suficientemente desde una perspectiva de género, por lo que esto constituye una línea de interés para futuras investigaciones.

Palabras clave:
Desigualdades sociales; Salud; Personas mayores; Indicadores; Búsqueda sistemática; Revisión; España

ABSTRACT

Objective

To identify the indicators of social position used to evaluate inequalities in health among the population aged 65 and over in Spain.

Method

A systematic search of the literature published in English and Spanish since 2000 in health and social databases was carried out. Primary and secondary studies analyzing these inequalities in Spain were included. The indicators used were identified, as well as the advantages and limitations pointed out by the authors. The main findings were synthesized in a review of the literature.

Results

We included 87 studies, described in 89 articles. The socioeconomic indicators employed were both individual and ecological. Among the former, educational level was the most analyzed socioeconomic variable (n = 73). Other individual variables used were occupation (n = 17), objective economic level (n = 16), subjective economic level (n = 4), housing and household material wealth (n = 6), relationship with work activity (n = 5), and mixed measures (n = 5). Among the ecological indicators, simple (n = 3) and complex indices (n = 7) were identified. The latter had been constructed based on several indicators, such as educational level and unemployment. Inequalities in multiple health indicators were analyzed, self-perceived health being the only indicator assessed according to all the socioeconomic indicators described.

Conclusions

A wide variety of indicators is identified for the evaluation of social inequalities in health among the elderly population. There have not been sufficiently assessed from a gender perspective; this is a line of interest for future research.

Keywords:
Social inequalities; Health; Older adults; Indicators; Systematic search; Review; Spain

Introducción

La población española, al igual que el resto de las poblaciones occidentales, experimenta desde hace décadas un profundo cambio en su estructura de edades, que ha tenido como consecuencia el incremento de la población de 65 y más años11. Eurostat. Proportion of population aged 65 and over. 2017. Disponible en: http://ec.europa.eu/eurostat/tgm/table.do?tab=table&init=1&plugin=1&language=en&pcode=tps00028
http://ec.europa.eu/eurostat/tgm/table.d...
. Este aumento ha provocado un mayor interés por conocer el estado de salud de este colectivo, dadas las implicaciones que tiene para los sistemas sanitarios futuros y su sostenibilidad, así como la necesidad de planificar intervenciones a él dirigidas. El conocimiento de la salud de esta población requiere asimismo conocer su distribución entre los diferentes grupos sociales, es decir, la existencia y la magnitud de las desigualdades sociales en salud.

El estudio de las desigualdades sociales en salud en el contexto español ha aumentado notablemente en los últimos años22. Borrell C, Azlor E, Rodríguez-Sanz M, et al. Trends in socioeconomic mortality inequalities in a southern European urban setting at the turn of the 21st century. J Epidemiol Community Health. 2008;62:258-66.-33. Domínguez-Berjón MF, Rodríguez-Sanz M, Marí-Dell'Olmo M, et al. Uso de indicadores socioeconómicos del área de residencia en la investigación epidemiológica: experiencia en España y oportunidades de avance. Gac Sanit. 2014;28:418-25., y se identifica un empeoramiento de la salud a medida que desciende la posición social. Sin embargo, la mayoría de los estudios se han centrado en la población general o en edad activa, lo cual supone una limitación para el conocimiento de las desigualdades en población mayor, ya que las desigualdades en salud varían notablemente a lo largo de todo el ciclo vital44. von dem Knesebeck O, Luschen G, Cockerham WC, et al. Socioeconomic status and health among the aged in the United States and Germany: a comparative cross-sectional study. Soc Sci Med. 2003;57:1643-52.. Además, la pertinencia del indicador de posición social utilizado puede variar según el grupo de edad55. Reijneveld SA, Gunning-Schepers LJ. Age, health and measurement of the socioeconomic status of individuals. Eur J Public Health. 1995;5:187-92.-66. Borrell C, Regidor E, Arias LC, et al. Inequalities in mortality according to educational level in two large Southern European cities. Int J Epidemiol. 1999;28:58-63., y puede haber características de la población mayor que hagan que indicadores extensamente utilizados en la población general no sean adecuados en dicho grupo de edad77. Dahl E, Birkelund GE. Health inequalities in later life in a social democratic welfare state. Soc Sci Med. 1997;44:871-81..

Todo ello puede llevar a que la abundante evidencia científica acerca de las desigualdades sociales en salud en la población general no sea trasladable de forma directa a la población mayor. La escasa evidencia disponible muestra, no obstante, que existen importantes desigualdades entre las personas a partir de 65 años88. Morcillo V, de Lorenzo-Cáceres A, Domínguez P, et al. Desigualdades en la salud autopercibida de la población española mayor de 65 años. Gac Sanit. 2014;28:511-21.-99. Martín U, Domínguez-Rodríguez A, Bacigalupe A. Desigualdades sociales en salud en población Mayr: una aportación desde la salud pública al debate sobre el retraso de la edad de jubilación en España. Gac Sanit. 2017, http://dx.doi.org/10.1016/j.gaceta.2017.10.010, pii: S0213-9111(17)30275-3. [Epub ahead of print].
https://doi.org/10.1016/j.gaceta.2017.10...
y que se emplean diversos indicadores de posición socioeconómica para su análisis1010. Smith GD, Shipley MJ, Rose G. Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall Study. J Epidemiol Community Health. 1990;44:265-70.

11. O'Reilly D. Standard indicators of deprivation: do they disadvantage older people? Age Ageing. 2002;31:197-202.
-1212. Collins AL, Goldman N. Perceived social position and health in older adults in Taiwan. Soc Sci Med. 2008;66:536-44..

El objetivo de este estudio es identificar los indicadores de posición social utilizados para la evaluación de desigualdades en salud en la población de 65 y más años en España, así como las ventajas y las limitaciones señaladas por los/las autores/as.

Método

Se llevó a cabo una búsqueda sistemática de publicaciones desde el año 2000 hasta octubre de 2017 en inglés y español en bases de datos sanitarias y sociales (Embase, PubMed, Scopus, Social Sciences Citation Index y Sociology database). En la búsqueda se incluyeron términos relacionados con indicadores socioeconómicos, edad y salud. La estrategia de búsqueda seguida en Social Sciences Citation Index se muestra en la Tabla 1.

Tabla 1
Estrategia de búsqueda en Social Sciences Citation Index para la revisión de desigualdades sociales en salud en población mayor en España

Se incluyeron estudios primarios y secundarios que analizaban desigualdades sociales en salud en población mayor en España. Se consideró población mayor la de 65 y más años de edad, la que formaba parte de una muestra con una edad media de 65 o más años, o si no se especificaba la edad, que el estudio aludiera de manera explícita a población mayor. Se excluyeron los resúmenes de congresos y las tesis doctorales.

Dos investigadoras revisaron los títulos o los resúmenes tras un pilotaje previo de la aplicación de los criterios de inclusión y exclusión definidos. Una vez seleccionados los estudios se encargaron de extraer de cada uno de ellos la siguiente información: primer/a autor/a, año de publicación, población/muestra, indicador/es de salud, indicador/es socioeconómico/s empleado/s, su categorización, y ventajas y limitaciones señaladas de cada uno de ellos. Los principales hallazgos se sintetizaron en forma de revisión de la literatura1313. Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26:91-108..

Resultados

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76. Castro-Monteiro E, Alhayek-Aí M, Diaz-Redondo A, et al. Quality of life of institutionalized older adults by dementia severity. Int Psychogeriatr. 2016;28:83-92.

77. Negrón-Blanco L, de Pedro-Cuesta J, Almazán J, et al. Prevalence of and factors associated with homebound status among adults in urban and rural Spanish populations. BMC Public Health. 2016;16:574.

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93. Rodríguez S, Montero P, Carmenate M, et al. Functional decline over 2 years in older Spanish adults: evidence from the Survey of Health. Ageing and Retirement in Europe. Geriatr Gerontol Int. 2014;14:403-12.

94. Vergara I, Vrotsou K, Orive M, et al. Factors related to functional prognosis in elderly patients after accidental hip fractures: a prospective cohort study. BMC Geriatr. 2014;14:124.

95. Soler-Vila H, García-Esquinas E, León-Muñoz LM, et al. Contribution of health behaviours and clinical factors to socioeconomic differences in frailty among older adults. J Epidemiol Community Health. 2016;70:354-60.

96. Vergara I, Vrotsou K, Orive M, et al. Wrist fractures and their impact in daily living functionality on elderly people: a prospective cohort study. BMC Geriatr. 2016;16:11.

97. Cadar D, Robitaille A, Clouston S, et al. An international evaluation of cognitive reserve and memory changes in early old age in 10 European countries. Neuroepidemiology. 2017;48:9-20.
-9898. Lipnicki D, Crawford J, Dutta R, et al. Age-related cognitive decline and associations with sex, education and apolipoprotein E genotype across, ethnocultural groups and geographic regions: a collaborative cohort study. PLos Med. 2017;14:e1002261. y una revisión sistemática88. Morcillo V, de Lorenzo-Cáceres A, Domínguez P, et al. Desigualdades en la salud autopercibida de la población española mayor de 65 años. Gac Sanit. 2014;28:511-21..

Figura 1
Proceso de selección de estudios en la revisión de desigualdades sociales en salud en población mayor en España.

En su mayoría son de ámbito estatal, si bien se identificaron también estudios multipaís1919. Huisman M, Kunst A, Mackenbach J. Socioeconomic inequalities in morbidity among the elderly; a European overview. Soc Sci Med. 2003;57:861-73.-2020. Nikula S, Jylhä M, Bardage C, et al. Are IADLs comparable across countries? Sociodemographic associates of harmonized IADL measures. Aging Clin Exp Res. 2003;15:451-9.,2020. Nikula S, Jylhä M, Bardage C, et al. Are IADLs comparable across countries? Sociodemographic associates of harmonized IADL measures. Aging Clin Exp Res. 2003;15:451-9.,2323. Huisman M, Kunst AE, Andersen O, et al. Socioeconomic inequalities in mortality among elderly people in 11 European populations. J Epidemiol Community Health. 2004;58:468-75.,3939. Santos-Eggimann B, Cuénoud P, Spagnoli J, et al. Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. J Gerontol A Biol Sci Med Sci. 2009;64:675-81.,5454. Fokkema T, Gierveld J, Dykstra P. Cross-national differences in older adult loneliness. J Psychol. 2012;146:201-28.,9797. Cadar D, Robitaille A, Clouston S, et al. An international evaluation of cognitive reserve and memory changes in early old age in 10 European countries. Neuroepidemiology. 2017;48:9-20.-9898. Lipnicki D, Crawford J, Dutta R, et al. Age-related cognitive decline and associations with sex, education and apolipoprotein E genotype across, ethnocultural groups and geographic regions: a collaborative cohort study. PLos Med. 2017;14:e1002261., en varias comunidades autónomas3333. Costa-Font J. Housing assets and the socio-economic determinants of health and disability in old age. Health Place. 2008;14:478-91.,4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.-4343. Oliva-Moreno J, Zozaya N, López-Valcárcel BG. Opposite poles: a comparison between two Spanish regions in health-related quality of life, with implications for health policy. BMC Public Health. 2010;10:576.,5252. Fernández-Martínez B, Prieto-Flores ME, Forjaz MJ, et al. Self-perceived health status in older adults: regional and sociodemographic inequalities in Spain. Rev Saude Publica. 2012;46:310-9.,5858. Rueda S. Health inequalities among older adults in Spain: the importance of gender, the socioeconomic development of the region of residence, and social support. Womens Health Issues. 2012;22:e483-90.,7676. Castro-Monteiro E, Alhayek-Aí M, Diaz-Redondo A, et al. Quality of life of institutionalized older adults by dementia severity. Int Psychogeriatr. 2016;28:83-92.,8080. Contador I, Stern Y, Bermejo-Pareja F, et al. Is educational attainment associated with increased risk of mortality in people with dementia? A population-based study. Curr Alzheimer Res. 2017;14:571-6.,8989. Zuluaga M, Guallar-Castillón P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161: 950-5.,9191. Quintana JM, García S, Aguirre U, et al. Relationship of sociodemographic variables with outcomes after cataract surgery. Eye (London, England). 2013;27: 698-707., en una o más provincias de una comunidad autónoma1717. Regidor E, Calle M, Domínguez V, et al. Mortalidad según características sociales y económicas: estudio de mortalidad de la Comunidad Autónoma de Madrid. Med Clin. 2001;116:726-31.,3636. Prieto-Flores ME, Fernández-Mayoralas G, Rojo-Pérez F, et al. Factores sociodemográficos y de salud en el bienestar emocional como dominio de calidad de vida de las personas mayores en la Comunidad de Madrid, 2005. Rev Esp Salud Pública. 2008;82:301-13.,3838. Rueda S, Artazcoz L. Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support. Ageing Soc. 2009;29:625-47.,4545. Brugulat-Guiteras P, Puig-Oriol X, Mompart-Penina A, et al. Dependencia para la realización de actividades de la vida diaria en las personas mayores de Cataluña. Med Clin. 2011;137:32-6.-4646. García-García FJ, Gutiérrez AG, Alfaro-Acha A, et al. The prevalence of frailty syndrome in an older population from Spain. The Toledo Study for Healthy Aging. J Nutr Health Aging. 2011;15:852-6.,5151. Rodríguez-Rodríguez V, Rojo-Pérez F, Fernández-Mayoralas G, et al. Recursos económicos y calidad de vida en la población mayor. Rev Int Sociol. 2011;69:195-227.,5353. Ferra A, Bibiloni MM, Zapata ME, et al. Body mass index, life-style, and healthy status in free living elderly people in menorca island. J Nutr Health Aging. 2012;16:298-305.,5757. Rodríguez S, Nilsson C, Lund R, et al. Social inequality in dynamic balance performance in an early old age Spanish population: the role of health and lifestyle associated factors. Arch Gerontol Geriatr. 2012;54:E139-45.,5959. Cornejo M, Pérez G, de Lima K-C, et al. Oral health-related quality of life in institutionalized elderly in (Spain) Barcelona. Med Oral Patol Oral Cir Bucal. 2013;18:e285-92.

60. Eustaquio-Raga M, Montiel-Company J, Almerich-Silla J. Factors associated with edentulousness in an elderly population in Valencia (Spain). Gac Sanit. 2013;27:123-7.
-6161. Orueta JF, Nuño-Solinís R, García-Álvarez A, et al. Prevalence of multimorbidity according to the deprivation level among the elderly in the Basque Country. BMC Public Health. 2013;13:918.,6363. Artacho R, Lujano C, Sánchez-Vico AB, et al. Nutritional status in chronicallyill elderly patients. Is it related to quality of life? J Nutr Health Aging. 2014;18:192-7.-6464. Orueta JF, García-Álvarez A, García-Goñi M, et al. Prevalence and costs of multimorbidity by deprivation levels in the Basque Country: a population based study using health administrative databases. PLoS One. 2014;9:e89787.,6767. Violán C, Foguet-Boreu Q, Roso-Llorach A, et al. Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study. BMC Public Health. 2014;14:530.,8686. Ceresuela A, Rubio S, Rodríguez B, et al. Desigualdades sociales y cambios en la calidad de vida de los ancianos en el medio rural de Cuenca entre 1994 y 2002. Rev Esp Geriatr Gerontol. 2008;43:221-8.,9494. Vergara I, Vrotsou K, Orive M, et al. Factors related to functional prognosis in elderly patients after accidental hip fractures: a prospective cohort study. BMC Geriatr. 2014;14:124.,9696. Vergara I, Vrotsou K, Orive M, et al. Wrist fractures and their impact in daily living functionality on elderly people: a prospective cohort study. BMC Geriatr. 2016;16:11., y en una o varias ciudades1515. Lasheras C, Patterson AM, Casado C, et al. Effects of education on the quality of life, diet, and cardiovascular risk factors in an elderly Spanish community population. Exp Aging Res. 2001;27:257-70.-1616. Martínez-Sánchez E, Gutiérrez-Fisac JL, Gispert R, et al. Educational differences in health expectancy in Madrid and Barcelona. Health Policy. 2001;55:227-31.,1818. Borrell C, Rodríguez M, Ferrando J, et al. Role of individual and contextual effects in injury mortality: new evidence from small area analysis. Inj Prev. 2002;8:297-302.,2525. Borrell C, Marí-Dell'Olmo M, Rodríguez-Sanz M, et al. Socioeconomic position and excess mortality during the heat wave of 2003 in Barcelona. Eur J Epidemiol. 2006;21:633-40.,2727. Pizarro V, Ferrer M, Domingo-Salvany A, et al. Dental health differences by social class in home-dwelling seniors of Barcelona, Spain. J Public Health Dent. 2006;66:288-91.,2929. Varas-Fabra F, Castro E, Pérula LA, et al. Caídas en ancianos de la comunidad: prevalencia, consecuencias y factores asociados. Aten Primaria. 2006;38:450-5.,3131. Lázaro A, Aranda E, Sánchez A, et al. Functional capacity for daily living activities among senior citizens attending community centers in the city of Zaragoza, Spain, 2005. Rev Esp Salud Pública. 2007;81:625-36.,3434. Damián J, Pastor-Barriuso R, Valderrama-Gama E. Factors associated with selfrated health in older people living in institutions. BMC Geriatr. 2008;8:5.-3535. Lobo-Escolar A, Saz P, Marcos G, et al. Somatic and psychiatric comorbidity in the general elderly population: results from the ZARADEMP Project. J Psychosom Res. 2008;65:347-55.,4040. Castell MV, Otero A, Sánchez MT, et al. Prevalencia de fragilidad en una población urbana de mayores de 65 años y su relación con comorbilidad y discapacidad. Aten Primaria. 2010;42:520-7.-4141. Espelt A, Font-Ribera L, Rodríguez-Sanz M, et al. Disability among older people in a Southern European city in 2006: trends in gender and socioeconomic inequalities. J Womens Health. 2010;19:927-33.,4444. Párraga I, Navarro B, Andrés F, et al. Miedo a las caídas en las personas mayores no institucionalizadas. Gac Sanit. 2010;24:453-9.,4747. Jürschik P, Escobar MA, Nuin C, et al. Criterios de fragilidad del adulto mayor. Estudio piloto. Aten Primaria. 2011;43:190-6.,5050. Montejo P, Montenegro M, Fernández M, et al. Subjective memory complaints in the elderly: prevalence and influence of temporal orientation, depression and quality of life in a population-based study in the city of Madrid. Aging Ment Health. 2011;15:85-96.,6262. Rodríguez-Fonseca M, Palència L, Marí-Dell'Olmo M, et al. Evolution of socioeconomic inequalities in mortality in small geographical areas of the two largest cities in Spain (Barcelona and Madrid), 1996-2007. Public Health. 2013;127:916-21.,7777. Negrón-Blanco L, de Pedro-Cuesta J, Almazán J, et al. Prevalence of and factors associated with homebound status among adults in urban and rural Spanish populations. BMC Public Health. 2016;16:574.,7979. Sáez-Prado B. Haya-Fernández M-C, Sanz-García M-T. Oral health and quality of life in the municipal senior citizen's social clubs for people over 65 of Valencia, Spain. Med Oral Patol Oral Cir Bucal. 2016;21:21305.,8383. Suárez-Gómez A, Sánchez-Vega J, Suárez-González F, et al. Estado nutricional de la población mayor de 65 años de edad de la ciudad de Badajoz. Semergen. 2017;43:80-4.

84. Orfila F, Ferrer M, Lamarca R, et al. Evolution of self-rated health status in the elderly: cross-sectional vs. longitudinal estimates. J Clin Epidemiol. 2000;53:563-70.
-8585. Zunzunegui MV, Núñez O, Durban M, et al. Decreasing prevalence of disability in activities of daily living, functional limitations and poor self-rated health: a 6-year follow-up study in Spain. Aging Clin Exp Res. 2006;18:352-8.,8888. Sánchez-Santos M, Zunzunegui M, Otero-Puime A, et al. Self-rated health and mortality risk in relation to gender and education: a time-dependent covariate analysis. Eur J Ageing. 2011;8:281-9.,9999. Dalmau-Bueno A, García-Altés A, Marí-Dell'Olmo M, et al. Veintidós años de evolución de las desigualdades socioeconómicas en la mortalidad en la ciudad de Barcelona. Gac Sanit. 2010;24:20-7.-100100. Izco N, Etxeberria J, Delfrade J, et al. Desigualdades socioeconómicas en la mortalidad en Pamplona y Logroño en el periodo 1996-2007. An Sist Sanit Navar. 2013;36:229-40..

En la mayor parte de los estudios, la población o la muestra estaba compuesta por personas mayores residentes en la comunidad, excepto tres que incluyeron solo personas institucionalizadas3434. Damián J, Pastor-Barriuso R, Valderrama-Gama E. Factors associated with selfrated health in older people living in institutions. BMC Geriatr. 2008;8:5.,5959. Cornejo M, Pérez G, de Lima K-C, et al. Oral health-related quality of life in institutionalized elderly in (Spain) Barcelona. Med Oral Patol Oral Cir Bucal. 2013;18:e285-92.,7676. Castro-Monteiro E, Alhayek-Aí M, Diaz-Redondo A, et al. Quality of life of institutionalized older adults by dementia severity. Int Psychogeriatr. 2016;28:83-92. y siete que contaron con ambos tipos de población1515. Lasheras C, Patterson AM, Casado C, et al. Effects of education on the quality of life, diet, and cardiovascular risk factors in an elderly Spanish community population. Exp Aging Res. 2001;27:257-70.,2424. Sagardui-Villamor J, Guallar-Castillón P, García-Ferruelo M, et al. Trends in disability and disability-free life expectancy among elderly people in Spain: 1986-1999. J Gerontol A Biol Sci Med Sci. 2005;60:1028-34.,3535. Lobo-Escolar A, Saz P, Marcos G, et al. Somatic and psychiatric comorbidity in the general elderly population: results from the ZARADEMP Project. J Psychosom Res. 2008;65:347-55.,4646. García-García FJ, Gutiérrez AG, Alfaro-Acha A, et al. The prevalence of frailty syndrome in an older population from Spain. The Toledo Study for Healthy Aging. J Nutr Health Aging. 2011;15:852-6.,6060. Eustaquio-Raga M, Montiel-Company J, Almerich-Silla J. Factors associated with edentulousness in an elderly population in Valencia (Spain). Gac Sanit. 2013;27:123-7.,8080. Contador I, Stern Y, Bermejo-Pareja F, et al. Is educational attainment associated with increased risk of mortality in people with dementia? A population-based study. Curr Alzheimer Res. 2017;14:571-6.,8484. Orfila F, Ferrer M, Lamarca R, et al. Evolution of self-rated health status in the elderly: cross-sectional vs. longitudinal estimates. J Clin Epidemiol. 2000;53:563-70..

Los estudios analizaron desigualdades sociales en múltiples resultados en salud: estado funcional, morbilidad, salud percibida, salud mental y emocional, calidad de vida, mortalidad y esperanza de vida. El estado funcional (n = 29) y la morbilidad (n = 19) fueron los más examinados.

Indicadores socioeconómicos

La mayoría de los estudios analizaron las desigualdades sociales en salud en población mayor empleando un único indicador socioeconómico. En 36 estudios se utilizó más de un indicador88. Morcillo V, de Lorenzo-Cáceres A, Domínguez P, et al. Desigualdades en la salud autopercibida de la población española mayor de 65 años. Gac Sanit. 2014;28:511-21.,1414. Martínez JA, Chavida F, Sánchez-Seco Higuera P, et al. Epidemiology of cognitive impairment in Spain. Eur J Gen Pract. 2000;6:52-6.,1919. Huisman M, Kunst A, Mackenbach J. Socioeconomic inequalities in morbidity among the elderly; a European overview. Soc Sci Med. 2003;57:861-73.,2828. Regidor E, Gutiérrez-Fisac J, Banegas J, et al. Association of adult socioeconomic position with hypertension in older people. J Epidemiol Community Health. 2006;60:74-80.

29. Varas-Fabra F, Castro E, Pérula LA, et al. Caídas en ancianos de la comunidad: prevalencia, consecuencias y factores asociados. Aten Primaria. 2006;38:450-5.
-3030. Álvarez-Gutiérrez FJ, Miravitlles M, Calle M, et al. Impacto de la EPOC en la vida diaria de los pacientes. Resultados del estudio multicéntrico EIME. Arch Bronconeumol. 2007;43:64-72.,3333. Costa-Font J. Housing assets and the socio-economic determinants of health and disability in old age. Health Place. 2008;14:478-91.,3636. Prieto-Flores ME, Fernández-Mayoralas G, Rojo-Pérez F, et al. Factores sociodemográficos y de salud en el bienestar emocional como dominio de calidad de vida de las personas mayores en la Comunidad de Madrid, 2005. Rev Esp Salud Pública. 2008;82:301-13.

37. Jiménez-García R, de Miguel-Díez J, Rejas-Gutiérrez J, et al. Health, treatment and health care resources consumption profile among Spanish adults with diabetes and chronic obstructive pulmonary disease. Prim Care Diabetes. 2009;3:141-8.
-3838. Rueda S, Artazcoz L. Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support. Ageing Soc. 2009;29:625-47.,4040. Castell MV, Otero A, Sánchez MT, et al. Prevalencia de fragilidad en una población urbana de mayores de 65 años y su relación con comorbilidad y discapacidad. Aten Primaria. 2010;42:520-7.,4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.,4444. Párraga I, Navarro B, Andrés F, et al. Miedo a las caídas en las personas mayores no institucionalizadas. Gac Sanit. 2010;24:453-9.

45. Brugulat-Guiteras P, Puig-Oriol X, Mompart-Penina A, et al. Dependencia para la realización de actividades de la vida diaria en las personas mayores de Cataluña. Med Clin. 2011;137:32-6.

46. García-García FJ, Gutiérrez AG, Alfaro-Acha A, et al. The prevalence of frailty syndrome in an older population from Spain. The Toledo Study for Healthy Aging. J Nutr Health Aging. 2011;15:852-6.

47. Jürschik P, Escobar MA, Nuin C, et al. Criterios de fragilidad del adulto mayor. Estudio piloto. Aten Primaria. 2011;43:190-6.

48. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65.

49. Miravitlles M, Naberan K, Cantoni J, et al. Socioeconomic status and healthrelated quality of life of patients with chronic obstructive pulmonary disease. Respiration. 2011;82:402-8.
-5050. Montejo P, Montenegro M, Fernández M, et al. Subjective memory complaints in the elderly: prevalence and influence of temporal orientation, depression and quality of life in a population-based study in the city of Madrid. Aging Ment Health. 2011;15:85-96.,5151. Rodríguez-Rodríguez V, Rojo-Pérez F, Fernández-Mayoralas G, et al. Recursos económicos y calidad de vida en la población mayor. Rev Int Sociol. 2011;69:195-227.

52. Fernández-Martínez B, Prieto-Flores ME, Forjaz MJ, et al. Self-perceived health status in older adults: regional and sociodemographic inequalities in Spain. Rev Saude Publica. 2012;46:310-9.

53. Ferra A, Bibiloni MM, Zapata ME, et al. Body mass index, life-style, and healthy status in free living elderly people in menorca island. J Nutr Health Aging. 2012;16:298-305.

54. Fokkema T, Gierveld J, Dykstra P. Cross-national differences in older adult loneliness. J Psychol. 2012;146:201-28.
-5555. Girón P. Is age associated with self-rated health among older people in Spain? Cent Eur J Public Health. 2012;20:185-90.,5757. Rodríguez S, Nilsson C, Lund R, et al. Social inequality in dynamic balance performance in an early old age Spanish population: the role of health and lifestyle associated factors. Arch Gerontol Geriatr. 2012;54:E139-45.,6363. Artacho R, Lujano C, Sánchez-Vico AB, et al. Nutritional status in chronicallyill elderly patients. Is it related to quality of life? J Nutr Health Aging. 2014;18:192-7.,6565. Pino L, González-Vélez A, Prieto-Flores M, et al. Self-perceived health and quality of life by activity status in community-dwelling older adults. Geriatr Gerontol Int. 2014;14:464-73.-6666. Rodríguez-Laso A, Abellán A, Sancho M, et al. Perceived economic situation, but not education level, is associated with disability prevalence in the Spanish elderly: observational study. BMC Geriatr. 2014;14:60.,6868. Abellán A, Rodríguez-Laso A, Pujol R, et al. A higher level of education amplifies the inverse association between income and disability in the Spanish elderly. Aging Clin Exp Res. 2015;27:903-9.,7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.

74. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.
-7575. Reques L, Santos J, Belza M, et al. Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level. Eur J Public Health. 2015;25:990-5.,8181. González M, Facal D, Juncos-Rabadan O, et al. Socioeconomic, emotional, and physical execution variables as predictors of cognitive performance in a Spanish sample of middle-aged and older community-dwelling participants. Int Psychogeriatr. 2017;29:1669-80.-8282. Pérez-Hernández B, García-Esquinas E, Graciani A, et al. Desigualdades sociales en los factores de riesgo cardiovascular de los adultos mayores de España: estudio ENRICA-Seniors. Rev Esp Cardiol. 2017;70:145-54.,9090. Regidor E, Kunst A, Rodríguez-Artalejo F, et al. Small socio-economic differences in mortality in Spanish older people. Eur J Public Health. 2012;22:80-5.-9191. Quintana JM, García S, Aguirre U, et al. Relationship of sociodemographic variables with outcomes after cataract surgery. Eye (London, England). 2013;27: 698-707.,9595. Soler-Vila H, García-Esquinas E, León-Muñoz LM, et al. Contribution of health behaviours and clinical factors to socioeconomic differences in frailty among older adults. J Epidemiol Community Health. 2016;70:354-60.,9797. Cadar D, Robitaille A, Clouston S, et al. An international evaluation of cognitive reserve and memory changes in early old age in 10 European countries. Neuroepidemiology. 2017;48:9-20.. Los indicadores empleados para el análisis de las citadas desigualdades sociales en España fueron tanto de tipo individual como de tipo ecológico (véase la tabla I del Apéndice online). A continuación, se describen los indicadores individuales:

Nivel educativo: esta variable es la que más se ha empleado para evaluar las desigualdades socioeconómicas, concretamente en 73 estudios88. Morcillo V, de Lorenzo-Cáceres A, Domínguez P, et al. Desigualdades en la salud autopercibida de la población española mayor de 65 años. Gac Sanit. 2014;28:511-21.,1414. Martínez JA, Chavida F, Sánchez-Seco Higuera P, et al. Epidemiology of cognitive impairment in Spain. Eur J Gen Pract. 2000;6:52-6.

15. Lasheras C, Patterson AM, Casado C, et al. Effects of education on the quality of life, diet, and cardiovascular risk factors in an elderly Spanish community population. Exp Aging Res. 2001;27:257-70.

16. Martínez-Sánchez E, Gutiérrez-Fisac JL, Gispert R, et al. Educational differences in health expectancy in Madrid and Barcelona. Health Policy. 2001;55:227-31.

17. Regidor E, Calle M, Domínguez V, et al. Mortalidad según características sociales y económicas: estudio de mortalidad de la Comunidad Autónoma de Madrid. Med Clin. 2001;116:726-31.

18. Borrell C, Rodríguez M, Ferrando J, et al. Role of individual and contextual effects in injury mortality: new evidence from small area analysis. Inj Prev. 2002;8:297-302.
-1919. Huisman M, Kunst A, Mackenbach J. Socioeconomic inequalities in morbidity among the elderly; a European overview. Soc Sci Med. 2003;57:861-73.,2222. Graciani A, Banegas J, López-García E, et al. Prevalence of disability and associated social and health-related factors among the elderly in Spain: a population-based study. Maturitas. 2004;48:381-92.

23. Huisman M, Kunst AE, Andersen O, et al. Socioeconomic inequalities in mortality among elderly people in 11 European populations. J Epidemiol Community Health. 2004;58:468-75.

24. Sagardui-Villamor J, Guallar-Castillón P, García-Ferruelo M, et al. Trends in disability and disability-free life expectancy among elderly people in Spain: 1986-1999. J Gerontol A Biol Sci Med Sci. 2005;60:1028-34.

25. Borrell C, Marí-Dell'Olmo M, Rodríguez-Sanz M, et al. Socioeconomic position and excess mortality during the heat wave of 2003 in Barcelona. Eur J Epidemiol. 2006;21:633-40.
-2626. Graciani A, Banegas J, Guallar-Castillon P, et al. Cognitive assessment of the nondemented elderly community dwellers in Spain. Dement Geriatr Cogn Disord. 2006;21:104-12.,2828. Regidor E, Gutiérrez-Fisac J, Banegas J, et al. Association of adult socioeconomic position with hypertension in older people. J Epidemiol Community Health. 2006;60:74-80.

29. Varas-Fabra F, Castro E, Pérula LA, et al. Caídas en ancianos de la comunidad: prevalencia, consecuencias y factores asociados. Aten Primaria. 2006;38:450-5.

30. Álvarez-Gutiérrez FJ, Miravitlles M, Calle M, et al. Impacto de la EPOC en la vida diaria de los pacientes. Resultados del estudio multicéntrico EIME. Arch Bronconeumol. 2007;43:64-72.
-3131. Lázaro A, Aranda E, Sánchez A, et al. Functional capacity for daily living activities among senior citizens attending community centers in the city of Zaragoza, Spain, 2005. Rev Esp Salud Pública. 2007;81:625-36.,3333. Costa-Font J. Housing assets and the socio-economic determinants of health and disability in old age. Health Place. 2008;14:478-91.

34. Damián J, Pastor-Barriuso R, Valderrama-Gama E. Factors associated with selfrated health in older people living in institutions. BMC Geriatr. 2008;8:5.

35. Lobo-Escolar A, Saz P, Marcos G, et al. Somatic and psychiatric comorbidity in the general elderly population: results from the ZARADEMP Project. J Psychosom Res. 2008;65:347-55.

36. Prieto-Flores ME, Fernández-Mayoralas G, Rojo-Pérez F, et al. Factores sociodemográficos y de salud en el bienestar emocional como dominio de calidad de vida de las personas mayores en la Comunidad de Madrid, 2005. Rev Esp Salud Pública. 2008;82:301-13.

37. Jiménez-García R, de Miguel-Díez J, Rejas-Gutiérrez J, et al. Health, treatment and health care resources consumption profile among Spanish adults with diabetes and chronic obstructive pulmonary disease. Prim Care Diabetes. 2009;3:141-8.

38. Rueda S, Artazcoz L. Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support. Ageing Soc. 2009;29:625-47.

39. Santos-Eggimann B, Cuénoud P, Spagnoli J, et al. Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. J Gerontol A Biol Sci Med Sci. 2009;64:675-81.

40. Castell MV, Otero A, Sánchez MT, et al. Prevalencia de fragilidad en una población urbana de mayores de 65 años y su relación con comorbilidad y discapacidad. Aten Primaria. 2010;42:520-7.

41. Espelt A, Font-Ribera L, Rodríguez-Sanz M, et al. Disability among older people in a Southern European city in 2006: trends in gender and socioeconomic inequalities. J Womens Health. 2010;19:927-33.

42. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.

43. Oliva-Moreno J, Zozaya N, López-Valcárcel BG. Opposite poles: a comparison between two Spanish regions in health-related quality of life, with implications for health policy. BMC Public Health. 2010;10:576.

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28. Regidor E, Gutiérrez-Fisac J, Banegas J, et al. Association of adult socioeconomic position with hypertension in older people. J Epidemiol Community Health. 2006;60:74-80.
-2929. Varas-Fabra F, Castro E, Pérula LA, et al. Caídas en ancianos de la comunidad: prevalencia, consecuencias y factores asociados. Aten Primaria. 2006;38:450-5.,4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.,4444. Párraga I, Navarro B, Andrés F, et al. Miedo a las caídas en las personas mayores no institucionalizadas. Gac Sanit. 2010;24:453-9.-4545. Brugulat-Guiteras P, Puig-Oriol X, Mompart-Penina A, et al. Dependencia para la realización de actividades de la vida diaria en las personas mayores de Cataluña. Med Clin. 2011;137:32-6.,4949. Miravitlles M, Naberan K, Cantoni J, et al. Socioeconomic status and healthrelated quality of life of patients with chronic obstructive pulmonary disease. Respiration. 2011;82:402-8.-5050. Montejo P, Montenegro M, Fernández M, et al. Subjective memory complaints in the elderly: prevalence and influence of temporal orientation, depression and quality of life in a population-based study in the city of Madrid. Aging Ment Health. 2011;15:85-96.,7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.-7474. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.,8282. Pérez-Hernández B, García-Esquinas E, Graciani A, et al. Desigualdades sociales en los factores de riesgo cardiovascular de los adultos mayores de España: estudio ENRICA-Seniors. Rev Esp Cardiol. 2017;70:145-54.,9090. Regidor E, Kunst A, Rodríguez-Artalejo F, et al. Small socio-economic differences in mortality in Spanish older people. Eur J Public Health. 2012;22:80-5.,9595. Soler-Vila H, García-Esquinas E, León-Muñoz LM, et al. Contribution of health behaviours and clinical factors to socioeconomic differences in frailty among older adults. J Epidemiol Community Health. 2016;70:354-60., y entre ellos uno analizó también la ocupación del padre8282. Pérez-Hernández B, García-Esquinas E, Graciani A, et al. Desigualdades sociales en los factores de riesgo cardiovascular de los adultos mayores de España: estudio ENRICA-Seniors. Rev Esp Cardiol. 2017;70:145-54.. Los estudios no señalaron en todos los casos a qué ocupación se referían. Entre los que lo hicieron, tres aludían a la ocupación desempeñada durante más tiempo2020. Nikula S, Jylhä M, Bardage C, et al. Are IADLs comparable across countries? Sociodemographic associates of harmonized IADL measures. Aging Clin Exp Res. 2003;15:451-9.,4444. Párraga I, Navarro B, Andrés F, et al. Miedo a las caídas en las personas mayores no institucionalizadas. Gac Sanit. 2010;24:453-9.,4949. Miravitlles M, Naberan K, Cantoni J, et al. Socioeconomic status and healthrelated quality of life of patients with chronic obstructive pulmonary disease. Respiration. 2011;82:402-8. y dos a la última ocupación8282. Pérez-Hernández B, García-Esquinas E, Graciani A, et al. Desigualdades sociales en los factores de riesgo cardiovascular de los adultos mayores de España: estudio ENRICA-Seniors. Rev Esp Cardiol. 2017;70:145-54.,9090. Regidor E, Kunst A, Rodríguez-Artalejo F, et al. Small socio-economic differences in mortality in Spanish older people. Eur J Public Health. 2012;22:80-5.. Varios/as autores/as asignaron a las mujeres la ocupación de su marido2828. Regidor E, Gutiérrez-Fisac J, Banegas J, et al. Association of adult socioeconomic position with hypertension in older people. J Epidemiol Community Health. 2006;60:74-80.,9090. Regidor E, Kunst A, Rodríguez-Artalejo F, et al. Small socio-economic differences in mortality in Spanish older people. Eur J Public Health. 2012;22:80-5.,9595. Soler-Vila H, García-Esquinas E, León-Muñoz LM, et al. Contribution of health behaviours and clinical factors to socioeconomic differences in frailty among older adults. J Epidemiol Community Health. 2016;70:354-60., mientras que Izquierdo, et al.4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421. optaron por excluir a las mujeres amas de casa por considerar que esta información no era válida para la categorización de su clase social. Los estudios agruparon a las personas en un número de categorías que oscilaba de dos2020. Nikula S, Jylhä M, Bardage C, et al. Are IADLs comparable across countries? Sociodemographic associates of harmonized IADL measures. Aging Clin Exp Res. 2003;15:451-9.,4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.,4444. Párraga I, Navarro B, Andrés F, et al. Miedo a las caídas en las personas mayores no institucionalizadas. Gac Sanit. 2010;24:453-9.,8282. Pérez-Hernández B, García-Esquinas E, Graciani A, et al. Desigualdades sociales en los factores de riesgo cardiovascular de los adultos mayores de España: estudio ENRICA-Seniors. Rev Esp Cardiol. 2017;70:145-54.,9595. Soler-Vila H, García-Esquinas E, León-Muñoz LM, et al. Contribution of health behaviours and clinical factors to socioeconomic differences in frailty among older adults. J Epidemiol Community Health. 2016;70:354-60. a siete7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.-7474. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48..

Nivel económico objetivo: 16 estudios emplearon este indicador de desigualdad 88. Morcillo V, de Lorenzo-Cáceres A, Domínguez P, et al. Desigualdades en la salud autopercibida de la población española mayor de 65 años. Gac Sanit. 2014;28:511-21.,1414. Martínez JA, Chavida F, Sánchez-Seco Higuera P, et al. Epidemiology of cognitive impairment in Spain. Eur J Gen Pract. 2000;6:52-6.,1919. Huisman M, Kunst A, Mackenbach J. Socioeconomic inequalities in morbidity among the elderly; a European overview. Soc Sci Med. 2003;57:861-73.,3030. Álvarez-Gutiérrez FJ, Miravitlles M, Calle M, et al. Impacto de la EPOC en la vida diaria de los pacientes. Resultados del estudio multicéntrico EIME. Arch Bronconeumol. 2007;43:64-72.,3333. Costa-Font J. Housing assets and the socio-economic determinants of health and disability in old age. Health Place. 2008;14:478-91.,4040. Castell MV, Otero A, Sánchez MT, et al. Prevalencia de fragilidad en una población urbana de mayores de 65 años y su relación con comorbilidad y discapacidad. Aten Primaria. 2010;42:520-7.,4747. Jürschik P, Escobar MA, Nuin C, et al. Criterios de fragilidad del adulto mayor. Estudio piloto. Aten Primaria. 2011;43:190-6.-4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65.,5555. Girón P. Is age associated with self-rated health among older people in Spain? Cent Eur J Public Health. 2012;20:185-90.,5757. Rodríguez S, Nilsson C, Lund R, et al. Social inequality in dynamic balance performance in an early old age Spanish population: the role of health and lifestyle associated factors. Arch Gerontol Geriatr. 2012;54:E139-45.,6363. Artacho R, Lujano C, Sánchez-Vico AB, et al. Nutritional status in chronicallyill elderly patients. Is it related to quality of life? J Nutr Health Aging. 2014;18:192-7.,6868. Abellán A, Rodríguez-Laso A, Pujol R, et al. A higher level of education amplifies the inverse association between income and disability in the Spanish elderly. Aging Clin Exp Res. 2015;27:903-9.,7979. Sáez-Prado B. Haya-Fernández M-C, Sanz-García M-T. Oral health and quality of life in the municipal senior citizen's social clubs for people over 65 of Valencia, Spain. Med Oral Patol Oral Cir Bucal. 2016;21:21305.,8181. González M, Facal D, Juncos-Rabadan O, et al. Socioeconomic, emotional, and physical execution variables as predictors of cognitive performance in a Spanish sample of middle-aged and older community-dwelling participants. Int Psychogeriatr. 2017;29:1669-80.,9797. Cadar D, Robitaille A, Clouston S, et al. An international evaluation of cognitive reserve and memory changes in early old age in 10 European countries. Neuroepidemiology. 2017;48:9-20.. De estos, 13 utilizaron los ingresos como indicador88. Morcillo V, de Lorenzo-Cáceres A, Domínguez P, et al. Desigualdades en la salud autopercibida de la población española mayor de 65 años. Gac Sanit. 2014;28:511-21.,1414. Martínez JA, Chavida F, Sánchez-Seco Higuera P, et al. Epidemiology of cognitive impairment in Spain. Eur J Gen Pract. 2000;6:52-6.,1919. Huisman M, Kunst A, Mackenbach J. Socioeconomic inequalities in morbidity among the elderly; a European overview. Soc Sci Med. 2003;57:861-73.,1919. Huisman M, Kunst A, Mackenbach J. Socioeconomic inequalities in morbidity among the elderly; a European overview. Soc Sci Med. 2003;57:861-73.,3333. Costa-Font J. Housing assets and the socio-economic determinants of health and disability in old age. Health Place. 2008;14:478-91.,4040. Castell MV, Otero A, Sánchez MT, et al. Prevalencia de fragilidad en una población urbana de mayores de 65 años y su relación con comorbilidad y discapacidad. Aten Primaria. 2010;42:520-7.,4747. Jürschik P, Escobar MA, Nuin C, et al. Criterios de fragilidad del adulto mayor. Estudio piloto. Aten Primaria. 2011;43:190-6.-4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65.,5555. Girón P. Is age associated with self-rated health among older people in Spain? Cent Eur J Public Health. 2012;20:185-90.,5757. Rodríguez S, Nilsson C, Lund R, et al. Social inequality in dynamic balance performance in an early old age Spanish population: the role of health and lifestyle associated factors. Arch Gerontol Geriatr. 2012;54:E139-45.,6363. Artacho R, Lujano C, Sánchez-Vico AB, et al. Nutritional status in chronicallyill elderly patients. Is it related to quality of life? J Nutr Health Aging. 2014;18:192-7.,6868. Abellán A, Rodríguez-Laso A, Pujol R, et al. A higher level of education amplifies the inverse association between income and disability in the Spanish elderly. Aging Clin Exp Res. 2015;27:903-9.,7979. Sáez-Prado B. Haya-Fernández M-C, Sanz-García M-T. Oral health and quality of life in the municipal senior citizen's social clubs for people over 65 of Valencia, Spain. Med Oral Patol Oral Cir Bucal. 2016;21:21305.,9797. Cadar D, Robitaille A, Clouston S, et al. An international evaluation of cognitive reserve and memory changes in early old age in 10 European countries. Neuroepidemiology. 2017;48:9-20., dos el nivel económico (sin especificar cómo se calculó)3030. Álvarez-Gutiérrez FJ, Miravitlles M, Calle M, et al. Impacto de la EPOC en la vida diaria de los pacientes. Resultados del estudio multicéntrico EIME. Arch Bronconeumol. 2007;43:64-72.,5353. Ferra A, Bibiloni MM, Zapata ME, et al. Body mass index, life-style, and healthy status in free living elderly people in menorca island. J Nutr Health Aging. 2012;16:298-305. y uno los gastos totales del hogar8181. González M, Facal D, Juncos-Rabadan O, et al. Socioeconomic, emotional, and physical execution variables as predictors of cognitive performance in a Spanish sample of middle-aged and older community-dwelling participants. Int Psychogeriatr. 2017;29:1669-80.. Hubo una gran diversidad en la clasificación, desde dos4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.,4747. Jürschik P, Escobar MA, Nuin C, et al. Criterios de fragilidad del adulto mayor. Estudio piloto. Aten Primaria. 2011;43:190-6.,5353. Ferra A, Bibiloni MM, Zapata ME, et al. Body mass index, life-style, and healthy status in free living elderly people in menorca island. J Nutr Health Aging. 2012;16:298-305.,6868. Abellán A, Rodríguez-Laso A, Pujol R, et al. A higher level of education amplifies the inverse association between income and disability in the Spanish elderly. Aging Clin Exp Res. 2015;27:903-9. hasta 10 grupos9797. Cadar D, Robitaille A, Clouston S, et al. An international evaluation of cognitive reserve and memory changes in early old age in 10 European countries. Neuroepidemiology. 2017;48:9-20., incluyendo un estudio en el que la renta individual se presentaba como variable continua 4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65..

Nivel económico subjetivo: con este indicador se pretende incluir dimensiones de posición económica actual que no se recogen al medir los ingresos6666. Rodríguez-Laso A, Abellán A, Sancho M, et al. Perceived economic situation, but not education level, is associated with disability prevalence in the Spanish elderly: observational study. BMC Geriatr. 2014;14:60.. Este indicador se utilizó en cuatro estudios5252. Fernández-Martínez B, Prieto-Flores ME, Forjaz MJ, et al. Self-perceived health status in older adults: regional and sociodemographic inequalities in Spain. Rev Saude Publica. 2012;46:310-9.,5454. Fokkema T, Gierveld J, Dykstra P. Cross-national differences in older adult loneliness. J Psychol. 2012;146:201-28.,6666. Rodríguez-Laso A, Abellán A, Sancho M, et al. Perceived economic situation, but not education level, is associated with disability prevalence in the Spanish elderly: observational study. BMC Geriatr. 2014;14:60.,8181. González M, Facal D, Juncos-Rabadan O, et al. Socioeconomic, emotional, and physical execution variables as predictors of cognitive performance in a Spanish sample of middle-aged and older community-dwelling participants. Int Psychogeriatr. 2017;29:1669-80.. Se evaluaron la posición económica percibida5252. Fernández-Martínez B, Prieto-Flores ME, Forjaz MJ, et al. Self-perceived health status in older adults: regional and sociodemographic inequalities in Spain. Rev Saude Publica. 2012;46:310-9., la satisfacción con los ingresos, los recursos o la situación económica general8181. González M, Facal D, Juncos-Rabadan O, et al. Socioeconomic, emotional, and physical execution variables as predictors of cognitive performance in a Spanish sample of middle-aged and older community-dwelling participants. Int Psychogeriatr. 2017;29:1669-80., y las dificultades percibidas con los ingresos actuales o para llegar a fin de mes5454. Fokkema T, Gierveld J, Dykstra P. Cross-national differences in older adult loneliness. J Psychol. 2012;146:201-28.,6666. Rodríguez-Laso A, Abellán A, Sancho M, et al. Perceived economic situation, but not education level, is associated with disability prevalence in the Spanish elderly: observational study. BMC Geriatr. 2014;14:60..

Vivienda y riqueza material del hogar: seis estudios emplearon este tipo de indicadores3030. Álvarez-Gutiérrez FJ, Miravitlles M, Calle M, et al. Impacto de la EPOC en la vida diaria de los pacientes. Resultados del estudio multicéntrico EIME. Arch Bronconeumol. 2007;43:64-72.,3333. Costa-Font J. Housing assets and the socio-economic determinants of health and disability in old age. Health Place. 2008;14:478-91.,3838. Rueda S, Artazcoz L. Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support. Ageing Soc. 2009;29:625-47.,7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.

74. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.
-7575. Reques L, Santos J, Belza M, et al. Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level. Eur J Public Health. 2015;25:990-5.,8989. Zuluaga M, Guallar-Castillón P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161: 950-5.. Dos de ellos se referían a la vivienda, recogiendo en un caso si la vivienda era propia o no3030. Álvarez-Gutiérrez FJ, Miravitlles M, Calle M, et al. Impacto de la EPOC en la vida diaria de los pacientes. Resultados del estudio multicéntrico EIME. Arch Bronconeumol. 2007;43:64-72., y en otro, el valor real de la vivienda3333. Costa-Font J. Housing assets and the socio-economic determinants of health and disability in old age. Health Place. 2008;14:478-91.. Por su parte, cuatro estudios emplearon un indicador de riqueza material del hogar3838. Rueda S, Artazcoz L. Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support. Ageing Soc. 2009;29:625-47.,7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.

74. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.
-7575. Reques L, Santos J, Belza M, et al. Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level. Eur J Public Health. 2015;25:990-5.,8989. Zuluaga M, Guallar-Castillón P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161: 950-5.. Estos indicadores se estudiaron de manera individual7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.

74. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.
-7575. Reques L, Santos J, Belza M, et al. Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level. Eur J Public Health. 2015;25:990-5.,8989. Zuluaga M, Guallar-Castillón P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161: 950-5. o como una variable conjunta3838. Rueda S, Artazcoz L. Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support. Ageing Soc. 2009;29:625-47.. Se utilizaron, entre otros, tener ducha/bañera, agua caliente, ascensor, lavadora3838. Rueda S, Artazcoz L. Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support. Ageing Soc. 2009;29:625-47.,8989. Zuluaga M, Guallar-Castillón P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161: 950-5., teléfono8989. Zuluaga M, Guallar-Castillón P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161: 950-5., calefacción o aire acondicionado3838. Rueda S, Artazcoz L. Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support. Ageing Soc. 2009;29:625-47.,7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.-7474. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.,8989. Zuluaga M, Guallar-Castillón P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161: 950-5., disponibilidad de una segunda vivienda para las vacaciones o fines de semana7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.-7474. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48., y número de coches en el hogar7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.

74. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.
-7575. Reques L, Santos J, Belza M, et al. Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level. Eur J Public Health. 2015;25:990-5..

Relación con la actividad laboral: fueron cinco los estudios que analizaron la posición social en relación con la actividad laboral. Jiménez-García et al.3737. Jiménez-García R, de Miguel-Díez J, Rejas-Gutiérrez J, et al. Health, treatment and health care resources consumption profile among Spanish adults with diabetes and chronic obstructive pulmonary disease. Prim Care Diabetes. 2009;3:141-8. diferenciaron personas activas e inactivas, mientras que dos estudios las clasificaron en tres categorías. Pino Domínguez et al.7878. Pino-Domínguez L, Navarro-Gil P, González-Vélez AE, et al. Self-perceived health status, gender, and work status. J Women Aging. 2016;28:386-94. agruparon a las personas en hombres jubilados, mujeres jubiladas y amas de casa, y Quintana et al.9191. Quintana JM, García S, Aguirre U, et al. Relationship of sociodemographic variables with outcomes after cataract surgery. Eye (London, England). 2013;27: 698-707. establecieron las categorías de empleado, labores del hogar y jubilado. Por su parte, Álvarez-Gutiérrez et al.3030. Álvarez-Gutiérrez FJ, Miravitlles M, Calle M, et al. Impacto de la EPOC en la vida diaria de los pacientes. Resultados del estudio multicéntrico EIME. Arch Bronconeumol. 2007;43:64-72. y Pino et al.6565. Pino L, González-Vélez A, Prieto-Flores M, et al. Self-perceived health and quality of life by activity status in community-dwelling older adults. Geriatr Gerontol Int. 2014;14:464-73. agruparon a las personas en cuatro categorías; en el primer caso, las categorías fueron en paro, baja laboral, pensionista y activo, y en el segundo, trabajando, jubilado/a, ama de casa y pensionista (receptor/a de pensiones de viudedad, invalidez u otras no contributivas).

Medidas mixtas: en cinco estudios3232. Regidor E, Gutiérrez-Fisac J, Banegas J, et al. Influencia a lo largo de la vida de las circunstancias socioeconómicas, de la inactividad física y de la obesidad sobre la presencia de síndrome metabólico. Rev Esp Salud Pública. 2007;81: 25-31.,3636. Prieto-Flores ME, Fernández-Mayoralas G, Rojo-Pérez F, et al. Factores sociodemográficos y de salud en el bienestar emocional como dominio de calidad de vida de las personas mayores en la Comunidad de Madrid, 2005. Rev Esp Salud Pública. 2008;82:301-13.,4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65.,5151. Rodríguez-Rodríguez V, Rojo-Pérez F, Fernández-Mayoralas G, et al. Recursos económicos y calidad de vida en la población mayor. Rev Int Sociol. 2011;69:195-227.,8181. González M, Facal D, Juncos-Rabadan O, et al. Socioeconomic, emotional, and physical execution variables as predictors of cognitive performance in a Spanish sample of middle-aged and older community-dwelling participants. Int Psychogeriatr. 2017;29:1669-80. se combinaron medidas para categorizar a la población mayor. Se distinguieron estas combinaciones: clase social generada a partir de nivel educativo y condición socioeconómica3636. Prieto-Flores ME, Fernández-Mayoralas G, Rojo-Pérez F, et al. Factores sociodemográficos y de salud en el bienestar emocional como dominio de calidad de vida de las personas mayores en la Comunidad de Madrid, 2005. Rev Esp Salud Pública. 2008;82:301-13., combinación entre relación con la actividad laboral y la ocupación4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65.,8181. González M, Facal D, Juncos-Rabadan O, et al. Socioeconomic, emotional, and physical execution variables as predictors of cognitive performance in a Spanish sample of middle-aged and older community-dwelling participants. Int Psychogeriatr. 2017;29:1669-80., recursos económicos (resultado de considerar cuatro indicadores de nivel económico objetivo y subjetivo)5151. Rodríguez-Rodríguez V, Rojo-Pérez F, Fernández-Mayoralas G, et al. Recursos económicos y calidad de vida en la población mayor. Rev Int Sociol. 2011;69:195-227. e índice de exposición acumulativa a lo largo de la vida combinando cinco indicadores de riesgo. Estos indicadores fueron la clase social baja en la infancia, el nivel de estudios bajo, la clase social baja de adulto, la inactividad física y la obesidad general en la vida adulta3232. Regidor E, Gutiérrez-Fisac J, Banegas J, et al. Influencia a lo largo de la vida de las circunstancias socioeconómicas, de la inactividad física y de la obesidad sobre la presencia de síndrome metabólico. Rev Esp Salud Pública. 2007;81: 25-31..

Los indicadores citados aportan información individual, pero varios estudios complementaron o sustituyeron esta información por aquella relativa al entorno. Por ello, en varios proyec tos se optó por utilizar indicadores ecológicos, ya fuera de tipo educativo, económico, laboral o una combinación de varios tipos4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.,4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65.,5858. Rueda S. Health inequalities among older adults in Spain: the importance of gender, the socioeconomic development of the region of residence, and social support. Womens Health Issues. 2012;22:e483-90.,6161. Orueta JF, Nuño-Solinís R, García-Álvarez A, et al. Prevalence of multimorbidity according to the deprivation level among the elderly in the Basque Country. BMC Public Health. 2013;13:918.-6262. Rodríguez-Fonseca M, Palència L, Marí-Dell'Olmo M, et al. Evolution of socioeconomic inequalities in mortality in small geographical areas of the two largest cities in Spain (Barcelona and Madrid), 1996-2007. Public Health. 2013;127:916-21.,6464. Orueta JF, García-Álvarez A, García-Goñi M, et al. Prevalence and costs of multimorbidity by deprivation levels in the Basque Country: a population based study using health administrative databases. PLoS One. 2014;9:e89787.,6767. Violán C, Foguet-Boreu Q, Roso-Llorach A, et al. Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study. BMC Public Health. 2014;14:530.,7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.-7474. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.,9999. Dalmau-Bueno A, García-Altés A, Marí-Dell'Olmo M, et al. Veintidós años de evolución de las desigualdades socioeconómicas en la mortalidad en la ciudad de Barcelona. Gac Sanit. 2010;24:20-7.,100100. Izco N, Etxeberria J, Delfrade J, et al. Desigualdades socioeconómicas en la mortalidad en Pamplona y Logroño en el periodo 1996-2007. An Sist Sanit Navar. 2013;36:229-40.. Los indicadores que se emplearon fueron estos:

  • Índices simples: tres estudios utilizaron estos indicadores. Karlsdotter et al.4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65. evaluaron la desigualdad económica mediante el índice de Gini (como variable continua). Por su parte, Regidor et al.7474. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48. emplearon dicho índice (clasificado en cuatro categorías) y los ingresos per cápita. También se analizaron el nivel económico objetivo empleando los ingresos familiares de la municipalidad disponibles per cápita4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421., la tasa de desempleo y la inversión en capital humano, medida como el porcentaje de población a partir de 25 años con educación universitaria7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50..

  • Índices compuestos: en siete estudios4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65.,5858. Rueda S. Health inequalities among older adults in Spain: the importance of gender, the socioeconomic development of the region of residence, and social support. Womens Health Issues. 2012;22:e483-90.,6161. Orueta JF, Nuño-Solinís R, García-Álvarez A, et al. Prevalence of multimorbidity according to the deprivation level among the elderly in the Basque Country. BMC Public Health. 2013;13:918.-6262. Rodríguez-Fonseca M, Palència L, Marí-Dell'Olmo M, et al. Evolution of socioeconomic inequalities in mortality in small geographical areas of the two largest cities in Spain (Barcelona and Madrid), 1996-2007. Public Health. 2013;127:916-21.,6464. Orueta JF, García-Álvarez A, García-Goñi M, et al. Prevalence and costs of multimorbidity by deprivation levels in the Basque Country: a population based study using health administrative databases. PLoS One. 2014;9:e89787.,6767. Violán C, Foguet-Boreu Q, Roso-Llorach A, et al. Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study. BMC Public Health. 2014;14:530.,9999. Dalmau-Bueno A, García-Altés A, Marí-Dell'Olmo M, et al. Veintidós años de evolución de las desigualdades socioeconómicas en la mortalidad en la ciudad de Barcelona. Gac Sanit. 2010;24:20-7.-100100. Izco N, Etxeberria J, Delfrade J, et al. Desigualdades socioeconómicas en la mortalidad en Pamplona y Logroño en el periodo 1996-2007. An Sist Sanit Navar. 2013;36:229-40. se utilizaron índices construidos a partir de varios indicadores. Dalmau-Bueno et al.9999. Dalmau-Bueno A, García-Altés A, Marí-Dell'Olmo M, et al. Veintidós años de evolución de las desigualdades socioeconómicas en la mortalidad en la ciudad de Barcelona. Gac Sanit. 2010;24:20-7. crearon un índice con indicadores de desempleo e instrucción insuficiente, mientras que en estudios llevados a cabo en Cataluña6767. Violán C, Foguet-Boreu Q, Roso-Llorach A, et al. Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study. BMC Public Health. 2014;14:530., el País Vasco6161. Orueta JF, Nuño-Solinís R, García-Álvarez A, et al. Prevalence of multimorbidity according to the deprivation level among the elderly in the Basque Country. BMC Public Health. 2013;13:918.,6464. Orueta JF, García-Álvarez A, García-Goñi M, et al. Prevalence and costs of multimorbidity by deprivation levels in the Basque Country: a population based study using health administrative databases. PLoS One. 2014;9:e89787. y varias ciudades6262. Rodríguez-Fonseca M, Palència L, Marí-Dell'Olmo M, et al. Evolution of socioeconomic inequalities in mortality in small geographical areas of the two largest cities in Spain (Barcelona and Madrid), 1996-2007. Public Health. 2013;127:916-21.,100100. Izco N, Etxeberria J, Delfrade J, et al. Desigualdades socioeconómicas en la mortalidad en Pamplona y Logroño en el periodo 1996-2007. An Sist Sanit Navar. 2013;36:229-40. se empleó el índice MEDEA, que tiene en cuenta desempleo, bajo nivel educativo, bajo nivel de educación en jóvenes, trabajadores/as manuales y trabajadores/as eventuales en la sección censal de residencia de las personas fallecidas102102. Domínguez-Berjón MF, Borrell C, Cano-Serral G, et al. Construcción de un índice de privación a partir de datos censales en grandes ciudades españolas (Proyecto MEDEA). Gac Sanit. 2008;22:179-87.. Karlsdotter et al.4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65. utilizaron como indicador de desigualdad económica el bienestar per cápita regional, que combina la renta per cápita y la desigualdad de renta medida con el índice de Theil. Por otro lado, Rueda5858. Rueda S. Health inequalities among older adults in Spain: the importance of gender, the socioeconomic development of the region of residence, and social support. Womens Health Issues. 2012;22:e483-90. analizó la situación en cuatro comunidades autónomas (el País Vasco, Navarra, Andalucía y Murcia) seleccionadas por su nivel de desarrollo socioeconómico; no señalaba el indicador empleado para su categorización, si bien aportaba datos de analfabetismo y producto interior bruto per cápita en las cuatro regiones.

Los indicadores de tipo individual se emplearon para analizar las desigualdades en todos los indicadores de salud considerados, esto es, en estado funcional1919. Huisman M, Kunst A, Mackenbach J. Socioeconomic inequalities in morbidity among the elderly; a European overview. Soc Sci Med. 2003;57:861-73.

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41. Espelt A, Font-Ribera L, Rodríguez-Sanz M, et al. Disability among older people in a Southern European city in 2006: trends in gender and socioeconomic inequalities. J Womens Health. 2010;19:927-33.

42. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.

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46. García-García FJ, Gutiérrez AG, Alfaro-Acha A, et al. The prevalence of frailty syndrome in an older population from Spain. The Toledo Study for Healthy Aging. J Nutr Health Aging. 2011;15:852-6.

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Artacho R, Lujano C, Sánchez-Vico AB, et al. Nutritional status in chronicallyill elderly patients. Is it related to quality of life? J Nutr Health Aging. 2014;18:192-7.,6565. Pino L, González-Vélez A, Prieto-Flores M, et al. Self-perceived health and quality of life by activity status in community-dwelling older adults. Geriatr Gerontol Int. 2014;14:464-73.,7676. Castro-Monteiro E, Alhayek-Aí M, Diaz-Redondo A, et al. Quality of life of institutionalized older adults by dementia severity. Int Psychogeriatr. 2016;28:83-92.,7979. Sáez-Prado B. Haya-Fernández M-C, Sanz-García M-T. Oral health and quality of life in the municipal senior citizen's social clubs for people over 65 of Valencia, Spain. Med Oral Patol Oral Cir Bucal. 2016;21:21305.,8686. Ceresuela A, Rubio S, Rodríguez B, et al. Desigualdades sociales y cambios en la calidad de vida de los ancianos en el medio rural de Cuenca entre 1994 y 2002. Rev Esp Geriatr Gerontol. 2008;43:221-8., mortalidad 1717. Regidor E, Calle M, Domínguez V, et al. Mortalidad según características sociales y económicas: estudio de mortalidad de la Comunidad Autónoma de Madrid. Med Clin. 2001;116:726-31.-1818. Borrell C, Rodríguez M, Ferrando J, et al. Role of individual and contextual effects in injury mortality: new evidence from small area analysis. Inj Prev. 2002;8:297-302.,2323. Huisman M, Kunst AE, Andersen O, et al. Socioeconomic inequalities in mortality among elderly people in 11 European populations. J Epidemiol Community Health. 2004;58:468-75.,2525. Borrell C, Marí-Dell'Olmo M, Rodríguez-Sanz M, et al. Socioeconomic position and excess mortality during the heat wave of 2003 in Barcelona. Eur J Epidemiol. 2006;21:633-40.,4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.,7272. Miqueléiz E, Lostao L, Reques L, et al. Desigualdades en mortalidad total y por causa de muerte según el nivel de estudios en Navarra: hallazgos de un estudio longitudinal 2001-2008. Rev Esp Salud Pública. 2015;89:295-306.

73. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.

74. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.
-7575. Reques L, Santos J, Belza M, et al. Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level. Eur J Public Health. 2015;25:990-5.,8080. Contador I, Stern Y, Bermejo-Pareja F, et al. Is educational attainment associated with increased risk of mortality in people with dementia? A population-based study. Curr Alzheimer Res. 2017;14:571-6.,8787. Regidor E, Guallar-Castillón P, Gutiérrez-Fisac J, et al. Socioeconomic variation in the magnitude of the association between self-rated health and mortality. Ann Epidemiol. 2010;20:395-400.,8989. Zuluaga M, Guallar-Castillón P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161: 950-5.,9090. Regidor E, Kunst A, Rodríguez-Artalejo F, et al. Small socio-economic differences in mortality in Spanish older people. Eur J Public Health. 2012;22:80-5. y esperanza de vida1616. Martínez-Sánchez E, Gutiérrez-Fisac JL, Gispert R, et al. Educational differences in health expectancy in Madrid and Barcelona. Health Policy. 2001;55:227-31..

Por su parte, los indicadores de tipo ecológico se utilizaron en el estudio de desigualdades en morbilidad 6161. Orueta JF, Nuño-Solinís R, García-Álvarez A, et al. Prevalence of multimorbidity according to the deprivation level among the elderly in the Basque Country. BMC Public Health. 2013;13:918.,6464. Orueta JF, García-Álvarez A, García-Goñi M, et al. Prevalence and costs of multimorbidity by deprivation levels in the Basque Country: a population based study using health administrative databases. PLoS One. 2014;9:e89787.,6767. Violán C, Foguet-Boreu Q, Roso-Llorach A, et al. Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study. BMC Public Health. 2014;14:530., salud percibida4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65.,5858. Rueda S. Health inequalities among older adults in Spain: the importance of gender, the socioeconomic development of the region of residence, and social support. Womens Health Issues. 2012;22:e483-90., salud mental y emocional5858. Rueda S. Health inequalities among older adults in Spain: the importance of gender, the socioeconomic development of the region of residence, and social support. Womens Health Issues. 2012;22:e483-90., mortalidad 4242. Izquierdo C, Oviedo M, Ruiz L, et al. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health. 2010;10:421.,6262. Rodríguez-Fonseca M, Palència L, Marí-Dell'Olmo M, et al. Evolution of socioeconomic inequalities in mortality in small geographical areas of the two largest cities in Spain (Barcelona and Madrid), 1996-2007. Public Health. 2013;127:916-21.,7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50.,7474. Regidor E, Vallejo F, Giráldez-García C, et al. Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality. Eur J Epidemiol. 2015;30:637-48.,9999. Dalmau-Bueno A, García-Altés A, Marí-Dell'Olmo M, et al. Veintidós años de evolución de las desigualdades socioeconómicas en la mortalidad en la ciudad de Barcelona. Gac Sanit. 2010;24:20-7.-100100. Izco N, Etxeberria J, Delfrade J, et al. Desigualdades socioeconómicas en la mortalidad en Pamplona y Logroño en el periodo 1996-2007. An Sist Sanit Navar. 2013;36:229-40. y esperanza de vida100100. Izco N, Etxeberria J, Delfrade J, et al. Desigualdades socioeconómicas en la mortalidad en Pamplona y Logroño en el periodo 1996-2007. An Sist Sanit Navar. 2013;36:229-40.. La salud percibida fue el único indicador de salud estudiado en el que se evaluaron las desigualdades en función de todos los tipos de indicadores descritos1515. Lasheras C, Patterson AM, Casado C, et al. Effects of education on the quality of life, diet, and cardiovascular risk factors in an elderly Spanish community population. Exp Aging Res. 2001;27:257-70.,1919. Huisman M, Kunst A, Mackenbach J. Socioeconomic inequalities in morbidity among the elderly; a European overview. Soc Sci Med. 2003;57:861-73.,2121. Gonzalo E, Pasarin MI. La salud de las personas Mayres. Gac Sanit. 2004;18:69-80.,3333. Costa-Font J. Housing assets and the socio-economic determinants of health and disability in old age. Health Place. 2008;14:478-91.-3434. Damián J, Pastor-Barriuso R, Valderrama-Gama E. Factors associated with selfrated health in older people living in institutions. BMC Geriatr. 2008;8:5.,3838. Rueda S, Artazcoz L. Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support. Ageing Soc. 2009;29:625-47.,4848. Karlsdotter K, Martín JJ, López del Amo MP. Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007. Gac Sanit. 2011;25:59-65.,8484. Orfila F, Ferrer M, Lamarca R, et al. Evolution of self-rated health status in the elderly: cross-sectional vs. longitudinal estimates. J Clin Epidemiol. 2000;53:563-70.-8585. Zunzunegui MV, Núñez O, Durban M, et al. Decreasing prevalence of disability in activities of daily living, functional limitations and poor self-rated health: a 6-year follow-up study in Spain. Aging Clin Exp Res. 2006;18:352-8.,8787. Regidor E, Guallar-Castillón P, Gutiérrez-Fisac J, et al. Socioeconomic variation in the magnitude of the association between self-rated health and mortality. Ann Epidemiol. 2010;20:395-400..

Discusión

Esta revisión ha permitido identificar una gran variedad de indicadores de posición social empleados en la medida de desigualdades en salud en población mayor en España. La mayoría de los estudios utilizaron el nivel educativo como indicador de posición socioeconómica, posiblemente por la facilidad de su obtención5757. Rodríguez S, Nilsson C, Lund R, et al. Social inequality in dynamic balance performance in an early old age Spanish population: the role of health and lifestyle associated factors. Arch Gerontol Geriatr. 2012;54:E139-45..

La educación puede condicionar las oportunidades de empleo e ingresos, y consecuentemente la pensión durante la jubilación2525. Borrell C, Marí-Dell'Olmo M, Rodríguez-Sanz M, et al. Socioeconomic position and excess mortality during the heat wave of 2003 in Barcelona. Eur J Epidemiol. 2006;21:633-40.,2828. Regidor E, Gutiérrez-Fisac J, Banegas J, et al. Association of adult socioeconomic position with hypertension in older people. J Epidemiol Community Health. 2006;60:74-80.,5151. Rodríguez-Rodríguez V, Rojo-Pérez F, Fernández-Mayoralas G, et al. Recursos económicos y calidad de vida en la población mayor. Rev Int Sociol. 2011;69:195-227.,9292. Mejía-Lancheros C, Estruch R, Martínez-González MA, et al. Impact of psychosocial factors on cardiovascular morbimortality: a prospective cohort study. BMC Cardiovasc Disord. 2014;14:135.. Además, es un mediador directo de la salud a lo largo de toda la vida en cuanto que condiciona el conocimiento y la actitud ante diversos hábitos de riesgo1616. Martínez-Sánchez E, Gutiérrez-Fisac JL, Gispert R, et al. Educational differences in health expectancy in Madrid and Barcelona. Health Policy. 2001;55:227-31.,7070. Cámara A, Zueras P, Blanes A, et al. Componentes generacionales y socioeconómicos de la discapacidad entre los mayores españoles. Rev Esp Investig Sociol. 2015;151:23-43.,9292. Mejía-Lancheros C, Estruch R, Martínez-González MA, et al. Impact of psychosocial factors on cardiovascular morbimortality: a prospective cohort study. BMC Cardiovasc Disord. 2014;14:135. y la utilización de servicios de salud103103. Fernández-Olano C, López-Torres J, Cerdà-Díaz R, et al. Factors associated with health care utilization by the elderly in a public health care system. Health Policy. 2006;75:131-9..

El nivel educativo tiende a permanecer estable a lo largo de la vida1616. Martínez-Sánchez E, Gutiérrez-Fisac JL, Gispert R, et al. Educational differences in health expectancy in Madrid and Barcelona. Health Policy. 2001;55:227-31.,7070. Cámara A, Zueras P, Blanes A, et al. Componentes generacionales y socioeconómicos de la discapacidad entre los mayores españoles. Rev Esp Investig Sociol. 2015;151:23-43.,9292. Mejía-Lancheros C, Estruch R, Martínez-González MA, et al. Impact of psychosocial factors on cardiovascular morbimortality: a prospective cohort study. BMC Cardiovasc Disord. 2014;14:135., pero en la población mayor en España puede no reflejar adecuadamente la posición socioeconómica, puesto que estas personas abandonaron la escuela a una edad temprana, habiendo finalizado o no los estudios primarios, y es infrecuente la formación universitaria1515. Lasheras C, Patterson AM, Casado C, et al. Effects of education on the quality of life, diet, and cardiovascular risk factors in an elderly Spanish community population. Exp Aging Res. 2001;27:257-70.,2222. Graciani A, Banegas J, López-García E, et al. Prevalence of disability and associated social and health-related factors among the elderly in Spain: a population-based study. Maturitas. 2004;48:381-92.,2828. Regidor E, Gutiérrez-Fisac J, Banegas J, et al. Association of adult socioeconomic position with hypertension in older people. J Epidemiol Community Health. 2006;60:74-80.

29. Varas-Fabra F, Castro E, Pérula LA, et al. Caídas en ancianos de la comunidad: prevalencia, consecuencias y factores asociados. Aten Primaria. 2006;38:450-5.
-3030. Álvarez-Gutiérrez FJ, Miravitlles M, Calle M, et al. Impacto de la EPOC en la vida diaria de los pacientes. Resultados del estudio multicéntrico EIME. Arch Bronconeumol. 2007;43:64-72.,3535. Lobo-Escolar A, Saz P, Marcos G, et al. Somatic and psychiatric comorbidity in the general elderly population: results from the ZARADEMP Project. J Psychosom Res. 2008;65:347-55.,5151. Rodríguez-Rodríguez V, Rojo-Pérez F, Fernández-Mayoralas G, et al. Recursos económicos y calidad de vida en la población mayor. Rev Int Sociol. 2011;69:195-227.,6868. Abellán A, Rodríguez-Laso A, Pujol R, et al. A higher level of education amplifies the inverse association between income and disability in the Spanish elderly. Aging Clin Exp Res. 2015;27:903-9.,7272. Miqueléiz E, Lostao L, Reques L, et al. Desigualdades en mortalidad total y por causa de muerte según el nivel de estudios en Navarra: hallazgos de un estudio longitudinal 2001-2008. Rev Esp Salud Pública. 2015;89:295-306.,7575. Reques L, Santos J, Belza M, et al. Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level. Eur J Public Health. 2015;25:990-5.,8383. Suárez-Gómez A, Sánchez-Vega J, Suárez-González F, et al. Estado nutricional de la población mayor de 65 años de edad de la ciudad de Badajoz. Semergen. 2017;43:80-4.,9292. Mejía-Lancheros C, Estruch R, Martínez-González MA, et al. Impact of psychosocial factors on cardiovascular morbimortality: a prospective cohort study. BMC Cardiovasc Disord. 2014;14:135.. Ello explica que en siete estudios se considerase la educación primaria el punto de corte, si bien la categorización no fue uniforme.

Otras limitaciones del nivel educativo como indicador socioeconómico son su incapacidad para referirse a grupos sociales que surgen de relaciones económicas interdependientes, su significado no universal por estar ligado a edad, sexo, raza, cohorte de nacimiento y posición de clase, y su menor capacidad de predecir la posesión de bienes que la posición de clase1818. Borrell C, Rodríguez M, Ferrando J, et al. Role of individual and contextual effects in injury mortality: new evidence from small area analysis. Inj Prev. 2002;8:297-302..

Por otro lado, en cuanto al sexo, Cámara et al.7070. Cámara A, Zueras P, Blanes A, et al. Componentes generacionales y socioeconómicos de la discapacidad entre los mayores españoles. Rev Esp Investig Sociol. 2015;151:23-43. sugieren la existencia de una vinculación más directa entre la educación y el estatus socioeconómico en la población femenina. Una revisión apunta que, en las mujeres mayores que han tenido una escasa inclusión en el mercado laboral, el nivel educativo se comporta más como un indicador de privación material88. Morcillo V, de Lorenzo-Cáceres A, Domínguez P, et al. Desigualdades en la salud autopercibida de la población española mayor de 65 años. Gac Sanit. 2014;28:511-21..

Otro de los indicadores más utilizados en los estudios identificados fue la ocupación. Girón5555. Girón P. Is age associated with self-rated health among older people in Spain? Cent Eur J Public Health. 2012;20:185-90. la señala como la medida más adecuada para la población mayor, si bien Regidor et al.7373. Regidor E, Vallejo F, Reques L, et al. Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: heterogeneous findings depending on the level of geographic aggregation. Soc Sci Med. 2015;141:142-50. destacan la gran limitación que supone su uso en una población con tasas de inactividad superiores al 90%. Generalmente se atribuye la última ocupación desempeñada por la persona mayor, pero esta puede no reflejar las ocupaciones que ha tenido a lo largo de su vida laboral104104. Borrell C, Ferrando J. Desigualdades en salud en la población anciana. JANO. 2003;64:25-33.. Además, en la población mayor no resulta adecuado, puesto que la ocupación previa no parece relacionarse directamente con las desigualdades en salud77. Dahl E, Birkelund GE. Health inequalities in later life in a social democratic welfare state. Soc Sci Med. 1997;44:871-81.. Por otro lado, en el caso de las mujeres no es apropiado, dadas sus bajas tasas de actividad entre las generaciones mayores105105. Arber S, Ginn J. Gender and inequalities in health in later life. Soc Sci Med. 1993;36:33-46.. Con frecuencia, a las mujeres que no han tenido un empleo remunerado se les asigna la ocupación de su marido106106. Borrell C, Rohlfs I, Artazcoz L, et al. Desigualdades en salud según la clase social en las mujeres ¿Cómo influye el tipo de medida de la clase social? Gac Sanit. 2004;18:75-82.. Asimismo, la clasificación de la ocupación se basa en los trabajos desempeñados por los hombres y no parece adecuada para categorizar a las mujeres, que se concentran más en ciertos sectores107107. Galobardes B, Lynch J, Smith GD. Measuring socioeconomic position in health research. Br Med Bull. 2007;81-82:21-37..

Muy relacionados con la ocupación están los ingresos; si bien se trata de una información sensible, que la población puede ser reacia a dar5151. Rodríguez-Rodríguez V, Rojo-Pérez F, Fernández-Mayoralas G, et al. Recursos económicos y calidad de vida en la población mayor. Rev Int Sociol. 2011;69:195-227.. Además, puede no ser una medida precisa de los recursos económicos totales disponibles para una persona mayor6666. Rodríguez-Laso A, Abellán A, Sancho M, et al. Perceived economic situation, but not education level, is associated with disability prevalence in the Spanish elderly: observational study. BMC Geriatr. 2014;14:60.. Cuando los ingresos estudiados son los familiares es preciso tener en cuenta que estos ingresos pueden proceder de una única persona o de más, por lo que son un indicador no inequívoco de la posición social actual5757. Rodríguez S, Nilsson C, Lund R, et al. Social inequality in dynamic balance performance in an early old age Spanish population: the role of health and lifestyle associated factors. Arch Gerontol Geriatr. 2012;54:E139-45..

Por otro lado, es necesario considerar que los ingresos reflejan los recursos disponibles en periodos determinados de tiempo, mientras que la riqueza refleja el acúmulo de esos recursos y su potencial efecto longitudinal a lo largo del curso vital. La riqueza incluye, además de los ingresos, recursos financieros y físicos, tales como el valor de la vivienda, coche o inversiones107107. Galobardes B, Lynch J, Smith GD. Measuring socioeconomic position in health research. Br Med Bull. 2007;81-82:21-37.. Los indicadores de riqueza han sido menos empleados que los ingresos, a pesar de haberse sugerido que la riqueza se relaciona más con el estado de salud que los ingresos108108. Park BH, Jung M, Lee TJ. Associations of income and wealth with health status in the Korean elderly. J Prev Med Public Health. 2009;42:275-82.. Varios estudios centraron el análisis de las desigualdades en un aspecto concreto de la riqueza: el de la riqueza material del hogar7575. Reques L, Santos J, Belza M, et al. Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level. Eur J Public Health. 2015;25:990-5.,8989. Zuluaga M, Guallar-Castillón P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161: 950-5.. Estos aspectos son relativamente fáciles de recoger, si bien resulta difícil la comparación de los hallazgos en salud cuando el contexto es diferente107107. Galobardes B, Lynch J, Smith GD. Measuring socioeconomic position in health research. Br Med Bull. 2007;81-82:21-37..

En los estudios en que se emplearon indicadores de nivel económico subjetivo, relación con la actividad laboral y medidas mixtas no se señalaban sus respectivas ventajas y limitaciones, como tampoco se hizo en los estudios que utilizaron indicadores ecológicos.

El único estudio secundario incluido en esta revisión88. Morcillo V, de Lorenzo-Cáceres A, Domínguez P, et al. Desigualdades en la salud autopercibida de la población española mayor de 65 años. Gac Sanit. 2014;28:511-21. sugiere la conveniencia de emplear varios indicadores para la evaluación de desigualdades, algo ya señalado en estudios previos1010. Smith GD, Shipley MJ, Rose G. Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall Study. J Epidemiol Community Health. 1990;44:265-70.,109109. Grundy E, Holt G. The socioeconomic status of older adults: how should we measure it in studies of health inequalities? J Epidemiol Community Health. 2001;55:895-904.

110. Kunst A, Bos V, Mackenbach J, et al. Measuring socio-economic inequalities in health in the European Union: guidelines and illustrations. A report for the Health Monitoring Program of the European Commission. Rotterdam, The Netherlands: Erasmus University; 2001.
-111111. Avlund K, Holstein BE, Osler M, et al. Social position and health in old age: the relevance of different indicators of social position. Scand J Public Health. 2003;31:126-36.. Para Morcillo et al.88. Morcillo V, de Lorenzo-Cáceres A, Domínguez P, et al. Desigualdades en la salud autopercibida de la población española mayor de 65 años. Gac Sanit. 2014;28:511-21. parece necesario que uno de los indicadores considerados deba indicar la clase social, y entre ellos, el que puede obtenerse más fácilmente y plantea menos problemas en la categorización de las mujeres mayores es el nivel educativo. Sin embargo, teniendo en cuenta las limitaciones de este indicador, entre otras el efecto cohorte, se ha sugerido complementar su uso con el de un indicador de privación individual109109. Grundy E, Holt G. The socioeconomic status of older adults: how should we measure it in studies of health inequalities? J Epidemiol Community Health. 2001;55:895-904., que aporta información en cuanto a la posición social a lo largo de la vida. La elección del indicador o indicadores empleados no es baladí, puesto que es preciso tener en cuenta que los indicadores determinan el patrón y la magnitud de las desigualdades observadas110110. Kunst A, Bos V, Mackenbach J, et al. Measuring socio-economic inequalities in health in the European Union: guidelines and illustrations. A report for the Health Monitoring Program of the European Commission. Rotterdam, The Netherlands: Erasmus University; 2001.,112112. Acheson D, Barker D, Chambers J, et al. Independent inquiry into inequalities in health. The Stationery Office;1998..

Como fortalezas de esta revisión cabe mencionar la búsqueda sistemática en bases de datos tanto del ámbito social como del sanitario, así como el amplio periodo de tiempo considerado. Entre sus limitaciones es preciso citar la no inclusión de literatura gris, por no estar revisada por pares, y que no se ha evaluado la calidad metodológica de los estudios incluidos. No obstante, la inclusión de los estudios sometidos a revisión externa ha permitido cumplir el objetivo de identificar los indicadores empleados en el contexto español. Además, por razones de espacio, este estudio solo discute algunos indicadores en relación con su aplicabilidad en hombres y mujeres.

En conclusión, son numerosos los indicadores socioeconómicos empleados para el análisis de las desigualdades sociales en salud en la población mayor, destacando especialmente el nivel educativo. Es limitada la evidencia que aportan los/las autores/as en cuanto a las limitaciones y las ventajas del uso de los distintos indicadores. Además, no se analiza suficientemente este tema desde una perspectiva de género, por lo que esta constituye una línea de interés para futuras investigaciones.

Anexo   Material adicional

Se puede consultar material adicional a este artículo en su versión electrónica disponible en doi: 10.1016/j.gaceta.2018.11.002.

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  • Financiación

    Este artículo ha sido realizado en el marco del Grupo de Trabajo de Determinantes Sociales de la Salud de la Sociedad Española de Epidemiología, que ha financiado los costes de publicación.

Fechas de Publicación

  • Publicación en esta colección
    11 Set 2020
  • Fecha del número
    May-Jun 2020
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