ABSTRACT:

Objective:

To assess the prevalence of disability and its association with social capital among community-dwelling elderly.

Methods:

The study was based on 2^nd Health Survey of Belo Horizonte Metropolitan Region - 2010, that included 1,995 community-dwelling elderly, randomly sampled. The exposure of interest was social capital, measured by confidence in neighborhood, perception of the physical environment, sense of cohesion in housing, and neighborhood perception of help. Socio-demographic variables, health conditions and use of health services were considered in the analysis with the purpose of adjustment.

Results:

Approximately one third of participants (32.6%) were unable to at least one instrumental activity of daily living (IADL) and/or basic activity of daily living (ADL); the prevalence of disability in ADL/IADL was 18.1%, and only in IADL was 14.6%. Elderly with functional disabilities had higher odds of poor social capital, but only the sense of cohesion in housing neighborhood showed to be independently associated with functional disability (OR = 1.80; 95%CI 1.12 - 2.88).

Conclusions:

Our results show the importance of social capital in research on associated factors of functional disability and indicate the need to implement public policies for social and environmental areas, since the needs of the elderly require measures beyond those typical of the health sector.

Keywords:
Disabled Persons; Social capital; Health of the elderly; Health surveys; Elderly; Epidemiology

INTRODUCTION

Aging may lead to the development of functional disability, which consists of the difficulty or need of help for the individual to perform typical self-care activities (basic activity of daily living, or ADL) or more complex ones (instrumental activity of daily living, or IADL), as well as in the impairment of physical mobility, they are important for independent living in society¹1. Alves LC, Leite IC, Machado CJ. Conceituando e mensurando a incapacidade funcional da população idosa: uma revisão de literatura. Ciênc Saúde Coletiva 2008; 13(4): 1199-207.. To Verbrugge and Jette²2. Verbrugge LM, Jette AM. The disablement process. Soc Sci Med 1997; 38(1): 1-14., the incapacitating process of the individuals may be determined by predisposing factors (sociodemographic characteristics), intraindividual (lifestyle, behavior, or diseases), and extraindividual ones (interventions from health services, use of medication, external support, in addition to physical and social environments).

Several epidemiological studies, in different populations, have been associating functional disability to predisposing (gender and age) and intraindividual characteristics (self-evaluation of health and history of diagnosis for chronic diseases, such as hypertension, diabetes, and arthritis)¹1. Alves LC, Leite IC, Machado CJ. Conceituando e mensurando a incapacidade funcional da população idosa: uma revisão de literatura. Ciênc Saúde Coletiva 2008; 13(4): 1199-207.^,33. Nikolova R, Demers L, Béland F, Giroux F. Transitions in the functional status of disabled community-living older adults over a 3-year follow-up period. Arch Gerontol Geriatr 2011; 52(1): 12-7.^,44. Giacomin KC, Peixoto SV, Uchoa E, Lima-Costa MF. Estudo de base populacional dos fatores associados à incapacidade funcional entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2008; 24(6): 1260-70.. In relation to the extraindividual factors, the role of social environment and of social relations in determining disability has been demonstrated in longitudinal⁵5. Rodrigues MA, Facchini LA, Thumé E, Maia F. Gender and incidence of functional disability in the elderly: a systematic review. Cad Saúde Pública 2009; 25(Suppl 3): S464-76. and cross-sectional⁴4. Giacomin KC, Peixoto SV, Uchoa E, Lima-Costa MF. Estudo de base populacional dos fatores associados à incapacidade funcional entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2008; 24(6): 1260-70.^,66. Oliveira PH, Mattos IE. Prevalência e fatores associados à incapacidade funcional em idosos institucionalizados no Município de Cuiabá, Estado de Mato Grosso, Brasil, 2009-2010. Epidemiol Serv Saúde 2012; 21(3): 395-496.^,77. Adib-Hajbaghery M. Evaluation of old-age disability and related factors among an Iranian elderly population. East Mediterr Health J 2011; 17(9): 671-8. studies, as the limitations in social relations may generate inequalities in health, preventing social control and hindering decision making in health.

As for social relations, the social capital is an important outcome in health. Social capital may be defined as "characteristics of social organizations such as trust, rules, and social networking which facilitate coordinates actions and generate benefits"⁸8. Putnam R. The prosperous community: social capital and public life. Am Prospect 1993; 13: 35-42., and it can be accessed through social relations⁹9. Han S. Compositional and contextual associations of social capital and self-rated health in Seoul, South Korea: a multilevel analysis of longitudinal evidence. Soc Sci Med 2012; 80: 113-20.. Their study allows deeper understanding of the health relations of the population with the individual particularities, their ability to face the environmental challenges and the social dynamics of the community in which they are inserted⁹9. Han S. Compositional and contextual associations of social capital and self-rated health in Seoul, South Korea: a multilevel analysis of longitudinal evidence. Soc Sci Med 2012; 80: 113-20..

A discussion that permeates the social capital is the individual-collective opposition, regarding its measuring¹⁰10. Poortinga W. Social relations or social capital? Individual and community health effects of bonding social capital. Soc Sci Med 2006; 63(1): 255-70.. Those who see it as an attribute of the individual, use the individual level of analysis. In it, each person is treated as a unit of analysis and personal indexes of social capital are built and analyzed, considering their behavior, perception, and attitude in the midst of social groups or neighborhood¹¹11. Macinko J, Starfield B. The utility of social capital in research on health determinants. Milbank Q 2001; 79(3): 387-428..

The investigations about the relations between social capital and health began at the end of the last century, when Kawachi et al.¹²12. Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income inequality and mortality. Am J Public Health 1997; 87(9): 1491-8. studied the role of social capital in mortality. Since then, some researches have been offering evidence of the relation of the social capital and health conditions¹³13. Tomita A, Burns JK. A multilevel analysis of association between neighborhood social capital and depression: evidence from the first South African National Income Dynamics Study. J Affect Disord 2013; 144(1-2): 101-5.^,1414. Furuta M, Ekuni D, Takao S, Suzuki E, Morita M, Kawachi I. Social capital and self-rated oral health among young people. Community Dent Oral Epidemiol 2012; 40(2): 97-104., but the ones specifically focused on the relations between social capital and functional disability are still scarce¹⁵15. Aida J, Kondo K, Kawachi I, Subramanian SV, Ichida Y, Hirai H, et al. Does social capital affect the incidence of functional disability in older Japanese? A prospective population-based cohort study. J Epidemiol Community Health 2012; 67(1): 42-7.^,1616. Pollack CE, von dem Knesebeck O. Social capital and health among the aged: comparisons between the United States and Germany. Health Place 2004; 10(4): 383-91.. This investigation becomes, then, important as the knowledge of their determinants may reduce the negative aspects of the limitations or dependencies, such as expenses and overload of the health system and also about the community and the elderly individuals or caregiver.

Considering what was exposed so far, this study had the objective of estimating the prevalence of functional disability and investigating the association between social capital among community-dwelling elderly.

METHODS

AREA AND POPULATION OF STUDY

The study was carried out in the Metropolitan Region of Belo Horizonte (RMBH), state of Minas Gerais, in Southeastern Brazil, which is the third greatest urban concentration in the country, with a population of 4.9 million inhabitants, of which 10% are 60 years old or older¹⁷17. Instituto Brasileiro de Geografia e Estatística. Indicadores sociais municipais: uma análise dos resultados do universo do Censo Demográfico 2010. Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/censo2010/indicadores_sociais_municipais/default_indicadores_sociais_municipais.shtm (Acessado em: 12 de dezembro de 2013).
http://www.ibge.gov.br/home/estatistica/... . It is based on the data collected in the Second Health Survey of RMBH, conducted between May 1st and July 31st 2010, a supplementary questionnaire to the Job and Unemployment Survey in RMBH (Pesquisa de Emprego e Desemprego da RMBH: PED-RMBH), which is coordinated by the João Pinheiro Foundation, a government agency of the state of Minas Gerais¹⁸18. Fundação João Pinheiro. Pesquisa de Emprego e Desemprego na Região Metropolitana de Belo Horizonte (PED/RMBH). Belo Horizonte: Sistema Nacional de Emprego; 2010.. The investigation was approved by the Research Ethics Committee René Rachou, Oswaldo Cruz Foundation, protocol number 10/2009.

The participants were selected through probabilistic cluster sampling, using the census tracts of the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística: IBGE) as a primary selection unit, and the households, the sampling units, of the urban area of the 34 municipalities in the RMBH. The sample of the survey was based on 7,500 households, with about 24,000 residents. All the individuals aged 20 years or older (n = 7,778), living in the sample households, took part in the interview. Of those, 2,271 of them were aged 60 years or older¹⁹19. Lima-Costa MF. Saúde dos Adultos em Belo Horizonte. Belo Horizonte: Núcleo de Estudos em Saúde Pública e Envelhecimento da Fundação Oswaldo Cruz e Universidade Federal de Minas Gerais; 2012.. and were eligible for this study.

VARIABLES OF THE STUDY

The dependent variable was the functional disability of the elderly, measured by the answer to the question "What degree of difficulty do you have to perform the following activities? " formulated for each of the six ADL and the five IADL researched. The first ones included feeding, transferring from bed to chair, getting dressed, walking between two rooms on the same floor, using the toilet, and taking a shower; the last ones covered preparing their own meal, taking care of their own money, performing household chores, taking medicine, and shopping. The possible answers were: no difficulty, some difficulty, a lot of difficulty, and not able to perform it without help. Elderly who reported any degree of difficulty to perform at least one of the activities mentioned were considered incapable seniors. According to the answers provided, the elderly were classified into one of the three categories:

All elderly who reported difficulty in performing any ADL also did so in relation to an IADL and, as a result, were placed in the same group.

The exposure of interest was the social capital, measured by four indicators: trust in the neighborhood, perception of the physical environment, sense of cohesion to the house, and perception of help²⁰20. Luz TC, Loyola Filho AI, Lima-Costa MF. Social capital and under-utilization of medication for financial reasons among elderly women: evidence from two Brazilian health surveys. Ciênc Saúde Coletiva 2013; 18(12): 3721-3730., were built by seven questions of the questionnaire. Given the dichotomous nature of these seven questions, the matrix of tetrachoric correlation to evaluate the correlation between them was used, an analysis which justified the definition of the composition of each one of the indicators, as described below.

To compose the indicator "trust in the neighborhood," the participant was asked whether they could or could not trust most people, and for the composition of "help perception," it was asked whether or not the elderly thought their neighbors helped each other. In each of these questions, the negative answer characterized, respectively, low trust in the neighborhood and absence of perception of help. The indicator "perception of the physical environment" consisted of two questions: "Are you satisfied with the way your block is taken care of?" and "Do you think your neighborhood is good for children and teenagers?" The negative answer to at least one of these questions characterized worse perception of the physical environment. The composition of the "sense of cohesion to the neighborhood" was based on three questions, being, whether or not they felt comfortable in the neighborhood where they live, whether or not they liked their neighborhood, and if they would like to stay in the place where they live. Similarly, the worse sense of cohesion was determined by the negative answer to at least one of these questions. As well as in other studies²⁰20. Luz TC, Loyola Filho AI, Lima-Costa MF. Social capital and under-utilization of medication for financial reasons among elderly women: evidence from two Brazilian health surveys. Ciênc Saúde Coletiva 2013; 18(12): 3721-3730.^,2121. Baron-Epel O, Weinstein R, Haviv-Mesika A, Garty-Sandalon N, Green S. Individual-level analysis of social capital and health: a comparison of Arab and Jewish Israelis. Soc Sci Med 2008; 66(4): 900-910., the low trust in the neighborhood, the absence of help perception, and worse perception of the physical environment and sense of cohesion indicate low levels of social capital.

The model used to evaluate the association between social capital and functional disability took into account, for the purpose of adjustment, three sets of variables, namely: sociodemographic characteristics, health conditions, and use of health services. The sociodemographic characteristics included gender, age (in years), education (in years), marital status (married, widowed, or single/divorced), and if they lived alone. For the set of health conditions, the number of chronic diseases (0, 1, 2, and 3 or more), based on the report of medical diagnosis for the following diseases: arthritis, cancer, hypertension, asthma, diabetes, coronary diseases, stroke, depression, and kidney and spine diseases was considered. Also among health conditions, the health self-evaluation (very good/good, fair, and poor/very poor) was used. As for the describing variables of the use of health services, the number of medical appointments (0 to 1, 2 to 4, and 5 or more) and the history of hospitalization within the last 12 months, in addition to the coverage by health insurance, were the variables chosen.

DATA ANALYSIS

The incapable seniors for IADL and the incapable ones for both ADL and IADL were compared, simultaneously, with those who do not have difficulties in ADL nor in IADL (capable seniors), by the χ² test of Pearson, in relation to all the aforementioned covariables.

The multivariate analysis of the association between social capital and functional disability was performed using the model of multinomial logistic regression, which estimates the odds ratios (OR) and the respective 95%confidence interval (95% CI). The final multivariate model includes the four indicators of social capital. For the selection of the covariates to be included in the multivariate model, the statistical significance level p < 0.20 was adopted, considering that the significance level p < 0.05 is the criterion to identify the independent variables associated to functional disability. The appropriateness of the adjustment of the multivariate model was evaluated through the generalized Hosmer-Lemeshow test.

The analyses were conducted using the Stata^(r) software, version 13 (Stata Corp), considering the technical procedures adopted for populational surveys with complex sample designs.

ETHICAL CONSIDERATIONS

The Adult Health Survey of the metropolitan area of Belo Horizonte in 2010, protocol number 10/2009, was approved by the Research Ethics Committee of the Institute René Rachou, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais.

RESULTS

One thousand nine hundred and ninety-five elderly took part in the study with the complete information on all the variables included in the study. The elderly excluded (n = 276) were no different from the participants in relation to the functional disability (p = 0.345) and to all indicators of social capital (p > 0.05). Most of the participants were females (61.7%) and belonged to the age range from 60 to 69 years of age (55.8%). A little more than 6 among every 10 participants (64.1%) had education of less than 8 years, half (49.9%) of them were married and 15.4% lived alone. In relation to health conditions, 72.2% of them had at least one chronic disease and more than half of them (58.1%) evaluated health as good or very good. The characterization of the population of the study and the results of the univariate analysis of the characteristics associated to functional disability may be seen in details in Table 1. With the exception of living alone and coverage by health insurance, the remaining variables were associated to functional disability, with p < 0.05.

Every one-third of the participants (32.7%) were incapable of at least one IADL and/or ADL; the prevalence of disability for ADL was 18.1% and the exclusive disability for IADL was 14.6%, considering that the elderly with disability for ADL were also incapable of at least one IADL. Considering that the indicators which dimensions the social capital, the proportion of elderly who did not notice help from the neighborhood, is case they needed, and with worse sense of cohesion to the neighborhood reached approximately 14%. With more elevated proportions, the ones with worse perception of the environment reached 21.8%, and 39.5% had low trust in the people of the neighborhood.

In Table 2, it is possible to see the results of the univariate analysis of the association between the social capitals and functional disability. The elderly incapable of IADL and incapable of both IADL and ADL showed higher proportions of worse social capital, but only the perception of the physical environment and the sense of cohesion of the neighborhood were significantly associated to the functional disability (p < 0.05).

The final results of the multivariate analysis of the factors associated with functional disability are presented in Table 3. Only the indicator of sense of cohesion to the neighborhood kept a significant and independent association of the variables of adjustment, with OR = 1.80 (95%CI 1.12 - 2.88) for exclusive inability of IADL and OR = 1.99 (95%CI 1.17 - 3.41) for association of disability of ADL/IADL, indicating that elderly with worse perception of their neighborhood have higher chances of disability of IADL/ADL.

All the variables included in the final model for adjustment are presented independently associated with the exclusive inability of IADL and/or inability of ADL/IADL. Female elderly, older widowers, in worse health conditions (with three or more chronic diseases or who evaluated negatively their own health) and who used more health services (five or more medical appointments and history of hospitalization within the last 12 months) had more chances of presenting one of the disabilities, whereas among the elderly with education equal to or longer than 8 years, the chances of disability were lower.

DISCUSSION

Our results showed that one-third of the elderly presented themselves incapable to perform at least one IADL and/or ADL, and that the chances of functional disability were higher among elderly with lower level of social capital, although among the indicators of this later one, only the perception of cohesion to the neighborhood was independently associated with disability.

The prevalence of disability observed in this study (32.7%) was slightly lower than the one detected (35.8%) in a study carried out among elderly living in the RMBH in 2003²²22. Fialho CB, Lima-Costa MF, Giacomin KC, Loyola Filho AI. Capacidade funcional e uso de serviços de saúde por idosos da Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil: um estudo de base populacional. Cad Saúde Pública 2014; 30(3): 599-610., which measured the functional disability with identical criteria to the ones used here. When compared with other studies, it was proven to be higher than the 22.7% verified among Brazilian elderly participating in the National Survey by Household Sample (Pesquisa Nacional por Amostras de Domicílio: PNAD) 2003²³23. Parahyba MI, Veras R. Diferenciais sociodemográficos no declínio funcional em mobilidade física entre os idosos no Brasil. Ciênc Saúde Coletiva 2008; 13(4): 1257-64. and to the 25% observed among Iranian elderly⁷7. Adib-Hajbaghery M. Evaluation of old-age disability and related factors among an Iranian elderly population. East Mediterr Health J 2011; 17(9): 671-8.. However, in the study of the PNAD²³23. Parahyba MI, Veras R. Diferenciais sociodemográficos no declínio funcional em mobilidade física entre os idosos no Brasil. Ciênc Saúde Coletiva 2008; 13(4): 1257-64., the measure of functional disability restricted themselves to the activity of walking about 100 m and the inability of ADL, among the Iranians, was evaluated. The prevalence was lower, however, than the one found among Spanish elderly (71.7%)²⁴24. Guallar-Castillón P, Sagardui-Villamor J, Banegas JR, Graciani A, Fornés NS, López García EL, et al. Waist circumference as a predictor of disability among older adults. Obesity 2007; 15(1): 233-44., but in this study the measure of disability was broader, covering not only the ADL and IADL, but also activities of mobility. Therefore, the prevalence of disability among the elderly in the RMBH was higher than the one observed in studies in which its operation was proven to be more restricted in terms of activities, and lower than the studies in which a broader criterion to measure disability was adopted.

In our study, the disability of IADL was more frequent than the inability of ADL, results of which are considered consistent with other literatures³3. Nikolova R, Demers L, Béland F, Giroux F. Transitions in the functional status of disabled community-living older adults over a 3-year follow-up period. Arch Gerontol Geriatr 2011; 52(1): 12-7.^,66. Oliveira PH, Mattos IE. Prevalência e fatores associados à incapacidade funcional em idosos institucionalizados no Município de Cuiabá, Estado de Mato Grosso, Brasil, 2009-2010. Epidemiol Serv Saúde 2012; 21(3): 395-496.^,2424. Guallar-Castillón P, Sagardui-Villamor J, Banegas JR, Graciani A, Fornés NS, López García EL, et al. Waist circumference as a predictor of disability among older adults. Obesity 2007; 15(1): 233-44.. The ADL is related to the survival and it requires the need of caregivers, whereas the IADL involves greater complexity degree for implementation and precedes the ADL³3. Nikolova R, Demers L, Béland F, Giroux F. Transitions in the functional status of disabled community-living older adults over a 3-year follow-up period. Arch Gerontol Geriatr 2011; 52(1): 12-7.. The measuring of the IADL allows scaling at populational level, the functional disability in the early stages, and facilitating the early detection of the problem. From the perspective of health services, this investigative option favors the targeting of their actions for the limitation of the advance of the less severe disability, reducing the potential for future growth of a severe disability, and reducing costly consequences about the health system and about the quality of life of the individual and their family²⁵25. Ferreira OGL, Maciel SC, Silva AO, Santos WS, Moreira MASP. O envelhecimento ativo sob o olhar de idosos funcionalmente independentes. Rev Esc Enferm USP 2010; 44(4): 1065-9.. From the perspective of the objective of our study, considering the IADL along with the ADL in the estimates of functional disability was particularly relevant, as the variable of exposure of interest was the social capital and the instrumental activities are strongly connected to the social participation and to the life outside the household.

In this study, the functional disability was shown positively associated to the low level of social capital. Our results corroborate findings of international studies carried out in the higher income countries¹⁵15. Aida J, Kondo K, Kawachi I, Subramanian SV, Ichida Y, Hirai H, et al. Does social capital affect the incidence of functional disability in older Japanese? A prospective population-based cohort study. J Epidemiol Community Health 2012; 67(1): 42-7.^,2626. Andrew MK. Social capital, health, and care home residence among older adults: a secondary analysis of the Health Survey for England 2000. Eur J Ageing 2005; 2(2): 137-48.^,2727. Avlund K, Lund R, Holstein BE, Due P. Social relations as determinant of onset of disability in aging. Arch Gerontol Geriatr 2004; 38(1): 85-99.. In addition to that, our results showed that not all elements of the social capital are associated to the functional disability, as its association was restricted to the indicator of cohesion to the household. Also in this aspect, our results are consistent with the literature. For example, among Japanese elderly women, the association between social capital and functional disability was limited to two elements of the former, in this case, trust and social participation¹⁵15. Aida J, Kondo K, Kawachi I, Subramanian SV, Ichida Y, Hirai H, et al. Does social capital affect the incidence of functional disability in older Japanese? A prospective population-based cohort study. J Epidemiol Community Health 2012; 67(1): 42-7.. In England²⁶26. Andrew MK. Social capital, health, and care home residence among older adults: a secondary analysis of the Health Survey for England 2000. Eur J Ageing 2005; 2(2): 137-48., in a sample of elderly aged 65 years or older, the social support and participation in groups were the dimensions of the social capital, which were statistically associated with the functional disability. In the cities of Denmark, the indicators of social capital significantly associated with the disability were the diversity in social relations, the social participation, and the social support²⁷27. Avlund K, Lund R, Holstein BE, Due P. Social relations as determinant of onset of disability in aging. Arch Gerontol Geriatr 2004; 38(1): 85-99.. In Brazil, Ferreira et al.²⁸28. Ferreira FF, César CC, Camargos VP, Lima-Costa MF, Proietti FA. Aging and urbanization: the neighborhood perception and functional performance of elderly persons in Belo Horizonte metropolitan area, Brazil. J Urban Health 2010; 87(1): 54-66. observed that only the component called perception of the physical environment was associated with the functional disability of elderly in the RMBH, Minas Gerais.

It is highlighted that the indicator of perception of cohesion to the neighborhood portrays the sense of comfort with the place of residence and whether the individuals think that a specific neighborhood is a good place to live. Probably, the elderly with high perception of cohesion to their neighborhood adopt healthier behaviors, even regarding their prevention of the onset of disabilities and they benefit from the effects of belonging to a community that shares the same interests and feelings, cultural activities, and recreation²⁹29. Luz TC, Loyola Filho AI, Lima-Costa MF. Perceptions of social capital and cost-related non-adherence to medication among the elderly. Cad Saúde Pública 2011; 27(2): 269-76.. Given the lack of studies on specific effects of cohesion perception about the functional disability and even about other health events, new investigations on this theme are necessary. In general, it is possible that the high level of social capital interferes in the health of the individuals by improving the possibilities of access to several kinds of resources, dissemination of information, organizations of the community, social control, satisfaction, and quality of life, influencing the health of the members of the society and the health actions brought before these individuals in a positive way³⁰30. Borgonovi F. A life-cycle approach to the analysis of the relationship between social capital and health in Britain. Soc Sci Med 2010; 71(11): 1927-34..

The functional capacity is one of the most relevant issues in public health, because of its dimensional aspect and for allowing aging with quality of life; its study and understanding are configured as one of the main objectives of health professionals and health services. The identification of associated factors that causes functional disability of elderly provides relevant elements for the prevention and for the intervention strategies and it is essential to avoid or lessen the damages to the individuals, the family, and the society. From what is known, few studies have been examining social factors as the determinants of functional disability¹⁵15. Aida J, Kondo K, Kawachi I, Subramanian SV, Ichida Y, Hirai H, et al. Does social capital affect the incidence of functional disability in older Japanese? A prospective population-based cohort study. J Epidemiol Community Health 2012; 67(1): 42-7.^,2727. Avlund K, Lund R, Holstein BE, Due P. Social relations as determinant of onset of disability in aging. Arch Gerontol Geriatr 2004; 38(1): 85-99..

In addition to that, considering the social capital proves particularly important, as it provides opportunities for better understanding the reason why inequalities in health are manifested, especially the functional disability, and how they may be better addressed, directing the focus of health professionals, policies, and the community members themselves, in favor of aging with quality of health³¹31. Pattussi MP, Moysés SJ, Junges JR, Sheiham A. Capital social e a agenda de pesquisa em epidemiologia. Cad Saúde Pública 2006; 22(8): 1525-46..

The multiple definitions, the different options of measuring, and the data analysis hamper the research of the social capital in populational studies. Thus, recognizing their diverse and multidimensional nature, we use measures of social capital that are able to express the degree of interpersonal relation and the satisfaction with the place of residence and with neighbors, which are also used in other investigations performed with elderly living in the RMBH²⁹29. Luz TC, Loyola Filho AI, Lima-Costa MF. Perceptions of social capital and cost-related non-adherence to medication among the elderly. Cad Saúde Pública 2011; 27(2): 269-76.. Another difficulty arises from the absence of a consensus on which would be the appropriate level of social capital, if either the individual or aggregate one³²32. Rostila M. The facets of social capital. J Theory Soc Behav 2010; 41(3): 308-26.. In relation to the unit of analysis, we have chosen to measure the social capital at an individual level, once it was originally considered and defined as a good thing of the individual and not inducing to ecological fallacy³³33. Portes A. Social capital: its origins and applications in modern sociology. Annu Rev Sociol 1998; 24(1): 1-24.^,3434. Lillbacka R. Measuring social capital: assessing construct stability of various operationalizations of social capital in a Finnish sample. Acta Sociol 2006; 49(2): 201-20..

An important limitation of this study is its cross-sectional design, which makes it impossible to establish a distinction, in time, between exposure end events. It sets up then, the possibility of occurrence of reverse causality, that is, the low level of social capital being a consequence of functional disability. On the other hand, the study shows qualities that reinforce it, such as being population based, allowing the inference of its results for one of the most populous metropolitan areas in Brazil, in addition to the methodological rigor in its conduction, which support its internal validity.

CONCLUSION

In conclusion, our study showed high prevalence of functional disability, especially in the group of IADL and their association with the social capital. Elderly with low levels of social capital had more chances of presenting some kind of difficulty in performing the IADL/ADL, particularly regarding the perception of cohesion of their neighborhood. The future populational researches on functional disability should not neglect the role of the social context for a broader understanding of this complex and dynamic phenomenon. It is also expected that coping with the disability is not limited to specific health actions, but it also contemplates the implementation of other public policies, in social and environmental areas, once the needs of elderly demand measures beyond those specific to the health field.

ACKNOWLEDGMENT

We thank Professor Maria Fernanda Furtado Lima e Costa, coordinator of the "Health Survey of Belo Horizonte - 2010 (Inquérito de Saúde de Belo Horizonte - 2010)," for the kindness of granting access to the database of the referred survey, whose analysis resulted in this article.

References

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