ABSTRACT:

Objective:

To analyze social inequalities in the prevalence of indicators of active aging in the Brazilian older adult population.

Methods:

This is a cross-sectional study with a sample of 11,177 older adults who participated in the Brazilian National Health Survey in 2013. We estimated the prevalence of five domains of active aging (social activities, civic engagement, leisure-time physical activity, paid work, and volunteer work) according to gender, ethnicity, schooling, income, and private health insurance. Prevalence ratios and confidence intervals were calculated using Poisson regression.

Results:

The percentage of involvement in organized social activities, civic engagement, and physical activity was 25.1, 12.4, and 13.1%, respectively. Regarding work, 20.7% of the sample had a paid job, and 9.7% participated in volunteer work. Women had a higher prevalence of participation in organized social activities and volunteer work; while civic engagement and paid work were more frequent among men. White people were more likely to participate in social activities, volunteer work, and leisure-time physical activity, explained by their schooling. The strata with a higher level of schooling, income, and who had private health insurance showed a greater incidence of participation in all activities studied.

Conclusion:

The five activities analyzed are challenging for the proposed policy of active aging, as they are marked by considerable social inequality.

Keywords:
Social inequality; Health status disparities; Aging; Aged

INTRODUCTION

Currently, one of the most significant social issues we face is how to respond to the irreversible phenomenon of the aging population on a large scale, which has intensified scientific research and development of policies on the subject¹1. Timonen V. Beyond Successful and Active Ageing: A Theory of Model Ageing. Bristol: Policy Press; 2016.. Active life is one of the goals for the older adult population and has gained strength after the World Health Organization (WHO) published the Active Ageing: a Policy Framework²2. World Health Organization. Active Ageing: a Policy Framework. Genebra: World Health Organization; 2002.. WHO aimed at drawing attention to the multidimensional character of active aging in contrast to recurring approaches, which restricted this life stage to the participation in physical or economic activities. The WHO approach defines active aging as participation in social, cultural, intellectual, physical, civic, political, and economical activities²2. World Health Organization. Active Ageing: a Policy Framework. Genebra: World Health Organization; 2002.^,33. Centro Internacional de Longevidade Brasil. Envelhecimento Ativo: Um marco político em resposta à revolução da longevidade. Rio de Janeiro: Centro Internacional de Longevidade Brasil; 2015.. In 2015, the International Longevity Center - Brazil revised the mentioned policy framework in response to the emergence of a strong international movement that seeks to strengthen the rights of older adults. The document reinforces the need to examine the aging process in light of important facts such as urbanization, globalization, migration, and the growing social inequality³3. Centro Internacional de Longevidade Brasil. Envelhecimento Ativo: Um marco político em resposta à revolução da longevidade. Rio de Janeiro: Centro Internacional de Longevidade Brasil; 2015..

With respect to this last aspect, the opportunities for enjoying thriving and active aging, in addition to better health and well-being, are unevenly distributed within and among societies¹1. Timonen V. Beyond Successful and Active Ageing: A Theory of Model Ageing. Bristol: Policy Press; 2016.. Society faces the challenge of giving opportunities to all groups of older adults to age actively and with dignity, leading to an emphasis on addressing social inequalities in the context of active aging, not only by investigating the distribution of resources among different generations but by paying special attention to social inequalities in old age¹1. Timonen V. Beyond Successful and Active Ageing: A Theory of Model Ageing. Bristol: Policy Press; 2016.^,44. Ilinca S, Rodrigues R, Schmidt A, Zolyomi E. Gender and Social Class Inequalities in Active Ageing: Policy meets Theory. Viena: European Centre for Social Welfare Policy and Research; 2016..

In Brazil, few studies have explored the knowledge about social inequalities related to the profile of activity engagement, with representative data on the entire Brazilian older adult population⁵5. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Vigitel Brasil 2016: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2016. Brasil: Ministério da Saúde; 2017.^,66. Peixoto SV, Mambrini JVM, Firmo JOA, Loyola Filho AI, Souza Junior PRB, Andrade FB, et al. Prática de atividade física entre adultos mais velhos: resultados do ELSI-Brasil. Rev Saúde Pública 2018; 52(Supl. 2): 5s. http://dx.doi.org/10.11606/s1518-8787.2018052000605
http://dx.doi.org/10.11606/s1518-8787.20... ^,77. Ferreira FR, César CC, Andrade FB, Souza Junior PRB, Lima-Costa MF, Proietti FA. Aspectos da participação social e a percepção da vizinhança: ELSI-Brasil. Rev Saúde Pública 2018; 52(Supl. 2): 18s.. Thus, this study aimed to analyze the prevalent demographic and socioeconomic inequalities in indicators of active aging among the Brazilian older adult population.

METHOD

This is a cross-sectional study that used data from the National Health Survey (NHS) held in 2013. NHS is a national household-based survey, conducted by the Ministry of Health, in partnership with the Brazilian Institute of Geography and Statistics⁸8. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2014.. NHS sought to provide data on the health situation and lifestyles of the Brazilian population, as well as health care⁹9. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza Júnior PRB, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Ciên Saúde Colet 2014; 19(2): 333-42. http://dx.doi.org/10.1590/1413-81232014192.14072012
http://dx.doi.org/10.1590/1413-812320141... . In addition, the survey paid special attention to aspects related to the existing inequalities in the Brazilian population⁸8. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2014.^,1010. Malta DC, Leal MC, Costa MFL, Morais Neto OL. Inquéritos Nacionais de Saúde: experiência acumulada e proposta para o inquérito de saúde brasileiro. Rev Bras Epidemiol 2008; 11(Supl. 1): 159-67. http://dx.doi.org/10.1590/S1415-790X2008000500017
http://dx.doi.org/10.1590/S1415-790X2008... .

NHS was designed to represent Brazil, its main regions, Federation Units (FU), metropolitan areas, and state capitals. NHS used a three-stage cluster sampling, stratified by primary sampling units (PSU). The first stage selected census tracts or sets of units that constituted the PSU; the second stage consisted of choosing the households; and the third stage selected - with equal probability among all adults living in the household - a resident aged 18 years or more to answer the individual questionnaire⁸8. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2014.^,1111. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde 2015; 24(2): 207-16. http://dx.doi.org/10.5123/S1679-49742015000200003
http://dx.doi.org/10.5123/S1679-49742015... .

The NHS sample comprised 64,348 households. A total of 60,202 selected residents were interviewed on their health status, lifestyle, and chronic diseases. The other residents selected (n=4,146) had their data dismissed, as they refused to answer the specific questionnaire or provided inconsistent information¹²12. Andrade SSA, Stopa SR, Brito AS, Chueri PS, Szwarcwald CL, Malta DC. Prevalência de hipertensão arterial autorreferida na população brasileira: análise da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde 2015; 24(2): 297-304. http://dx.doi.org/10.5123/S1679-49742015000200012
http://dx.doi.org/10.5123/S1679-49742015... .

The NHS questionnaire for data collection was subdivided into three parts:

A resident of the household who knew the socioeconomic and health status of all its members answered the first two parts of the questionnaire. The resident selected answered the individual questionnaire, which included several thematic sections, such as work characteristics and social support, perceived health status, accidents and violence, lifestyle, chronic diseases, oral health, and medical care¹³13. Damacena GN, Szwarcwald CL, Malta DC, Souza Júnior PRB, Vieira MLFP, Pereira CA, et al. O processo de desenvolvimento da Pesquisa Nacional de Saúde no Brasil, 2013. Epidemiol Serv Saúde 2015; 24(2): 197-206. http://dx.doi.org/10.5123/S1679-49742015000200002
http://dx.doi.org/10.5123/S1679-49742015... . This study analyzed data about only the residents selected aged 60 years or more, comprising a sample of 11,177 individuals. Other publications⁸8. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2014.^,1111. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde 2015; 24(2): 207-16. http://dx.doi.org/10.5123/S1679-49742015000200003
http://dx.doi.org/10.5123/S1679-49742015... provide more details on the sampling process and weighting. Trained interviewers collected data using personal digital assistants (PDA)⁸8. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2014..

Regarding the study variables, we selected five indicators of active aging among the questions available, belonging to three dimensions:

We estimated the prevalence of each indicator of active aging according to the following variables: gender (female and male); ethnicity (white and black, the latter consisting of individuals who declared being black or multiracial); level of schooling (illiterate or with less than one year of study; incomplete or complete elementary school; incomplete or complete high school; incomplete or complete higher education); household income in minimum wages per capita (mwpc) (< 0.5; 0.5 to 1.0; 1.0 to 3.0; > 3.0); and having private health insurance (yes and no).

We analyzed the differences between proportions using Pearson’s χ² test, considering those with a p-value<0.05 statistically significant. Prevalence ratios (PR) of each indicator of active aging, as well as their respective 95% confidence intervals (95%CI), were calculated using Poisson regression and adjusted for gender, age, and geographic region of residence. Analyses according to gender and ethnicity were also adjusted for level of schooling. We considered the complex sample design effect in all analyses, using the survey module of the software Stata 14.0 (Stata Corp., College Station, United States).

The National Committee for Ethics in Research (Comissão Nacional de Ética em Pesquisa - CONEP) of the National Health Council (NHC), Ministry of Health, approved the NHS. The individuals selected for the interview expressed their agreement by signing the Informed Consent Form.

RESULTS

The estimates analyzed in this study are based on responses from 11,177 individuals aged 60 years or more. Considering the appropriate sample weights, 56.4% of the interviewees were females and aged 60 to 69 years, the age of 13.6% was greater than or equal to 80 years, 53.6% declared being white and 44.9%, black or multiracial. Regarding schooling, 32.1% were illiterate or had less than one year of study, while 45.6 and 12.2% had completed at least a year of elementary or high school, respectively. The proportion of older adults with complete or incomplete higher education in the study population was 10.2%. With respect to family income, 43.0% earned less than 0.5 mwpc, 24.2% belonged to the stratum with > 1.0 and < 3.0 mwpc, and the proportion of older adults with 3 or more mwpc was 6.9%. The total of older adults who reported having private health insurance was 32.0%.

Table 1 presents the prevalence of indicators of active aging in the total population and according to gender. The percentage of involvement in social activities was 25.1%, being 30% more prevalent among women, while 12.4% of older adults reported civic engagement, with a higher incidence among men (PR=1.27). Concerning the physical activity dimension, only 13.1% declared practicing leisure-time physical activity within the recommended levels, without differences between genders. The percentage of older adults who stated having a paid job was 20.7%, being higher among men (PR=2.34), while 9.7% of the population reported participating in volunteer work, with prevalence 25% higher among women.

In the evaluation according to ethnicity (Table 2), the frequency of participation in social activities and volunteer work was higher among individuals who declared being white, when compared to the black population (RP=1.14 and 1.46, respectively). The frequency of white people considered physically active during leisure time was also higher (PR=1.33). On the other hand, the prevalence of civic engagement and paid work according to ethnicity was similar. After adjustment for level of schooling, all differences found lost their statistical significance.

The analysis of the active aging profile according to level of schooling (Table 3) revealed that all activities investigated were significantly more prevalent in segments with higher schooling, particularly for participation in leisure-time physical activity within the recommended levels and volunteer work, whose prevalence quadrupled compared to the lower stratus (PR=4.42 and 4.43, respectively).

In the analysis according to income (Table 4), interviewees with a higher status (three or more mwpc) showed a higher prevalence of participation in all activities assessed, with differences of greater magnitude for the practice of leisure-time physical activity (PR=4.12) and volunteer work (PR=3.07).

Table 5 presents the prevalence of indicators of active aging according to private health insurance. Older adults with private health insurance had a greater prevalence of involvement in all activities analyzed in this study when compared to those who depended solely on the public health system (Sistema Único de Saúde - SUS). The greatest difference between these groups concerned the practice of leisure-time physical activity (PR=2.21).

DISCUSSION

This study presented the NHS results on the prevalence of participation of older adults in five activities relating to social, physical activity, and work dimensions. The findings reveal significant social inequalities in the aging process of the Brazilian older adult population according to gender, ethnicity, level of schooling, per capita household income, and private health insurance.

Regarding the social dimension, the frequency of involvement in organized social activities (25.1%) was higher than that estimated for civic engagement (12.4%), in line with the perspective that the participation rate is lower when a certain activity requires more individual resources and shared skills¹⁵15. Bukov A, Maas I, Lampert T. Social Participation in Very Old Age: Cross-Sectional and Longitudinal Findings From BASE. J Gerontol B Psychol Sci Soc Sci 2002; 57(6): P510-7. https://doi.org/10.1093/geronb/57.6.p510
https://doi.org/10.1093/geronb/57.6.p510... .

Involvement in the social dimension presented significant variations among the social segments analyzed. For instance, we found a clear gender bias, in which women reported greater participation in organized social activities, while men were more active in civic engagements. A possible explanation for this contrast is the greater male resistance to engaging in more cultural, educational, and playful activities, which predominate in spaces like community centers for older adults and community groups¹⁶16. Barreto KML, Carvalho EMF, Falcão IV, Lessa FJD, Leite VMM. Perfil sócio-epidemiológico demográfico das mulheres idosas da Universidade Aberta à Terceira Idade no estado de Pernambuco. Rev Bras Saúde Matern Infant 2003; 3: 339-54.^,1717. Borges PLC, Bretas RP, Azevedo SF, Barbosa JMM. Perfil dos idosos frequentadores de grupos de convivência em Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2008; 24(12): 2798-808. http://dx.doi.org/10.1590/S0102-311X2008001200008
http://dx.doi.org/10.1590/S0102-311X2008... . On the other hand, the under-representation of women in civic engagement, but that also extends to other decision-making areas¹⁸18. Almeida C, Lüchmann L, Ribeiro E. Associativismo e representação política feminina no Brasil. Rev Bras Ciênc Polít 2012; (8): 237-63. http://dx.doi.org/10.1590/S0103-33522012000200009
http://dx.doi.org/10.1590/S0103-33522012... ^,1919. World Economic Forum. The Global Gender Gap Report. Genebra: World Economic Forum; 2017., demonstrated in this study reveals, above all, a qualitative injustice, since it signals the precedence of certain topics, groups, and interests in decision-making arenas at the expense of others¹⁸18. Almeida C, Lüchmann L, Ribeiro E. Associativismo e representação política feminina no Brasil. Rev Bras Ciênc Polít 2012; (8): 237-63. http://dx.doi.org/10.1590/S0103-33522012000200009
http://dx.doi.org/10.1590/S0103-33522012... . These findings indicate that society still strongly differentiates activities and behaviors considered typically feminine and masculine. Several activities are used as a resource in gender structuring and reconstruction, such as social activities, work, domestic chores, and sports²⁰20. Courtenay WH. Constructions of masculinity and their influence on men’s well-being: a theory of gender and health. Soc Sci Med 2000; 50(10): 1385-401.. As to social dimension differences according to ethnicity, the results showed that white people participated in organized social activities more often than the black population. This difference was explained by schooling, reinforcing the idea that access to social resources throughout life favors social participation³3. Centro Internacional de Longevidade Brasil. Envelhecimento Ativo: Um marco político em resposta à revolução da longevidade. Rio de Janeiro: Centro Internacional de Longevidade Brasil; 2015.. However, these groups did not differ regarding civic engagement. This finding suggests that ethnicity might not substantially affect the propensity to act politically. In Brazil, socioeconomic factors, such as income and schooling, are clearly more relevant in boosting this type of participation than the direct effect of ethnicity²¹21. Bueno NS. Raça e comportamento político: participação, ativismo e recursos em Belo Horizonte. Lua Nova 2012; (85): 187-226. http://dx.doi.org/10.1590/S0102-64452012000100006
http://dx.doi.org/10.1590/S0102-64452012... . So much so that higher schooling and income strata were more active in the social dimension, corroborating other studies⁴4. Ilinca S, Rodrigues R, Schmidt A, Zolyomi E. Gender and Social Class Inequalities in Active Ageing: Policy meets Theory. Viena: European Centre for Social Welfare Policy and Research; 2016.^,1515. Bukov A, Maas I, Lampert T. Social Participation in Very Old Age: Cross-Sectional and Longitudinal Findings From BASE. J Gerontol B Psychol Sci Soc Sci 2002; 57(6): P510-7. https://doi.org/10.1093/geronb/57.6.p510
https://doi.org/10.1093/geronb/57.6.p510... .

With respect to the physical activity dimension, the present study analyzed the leisure domain given its more expressive beneficial effects on health compared to physical activity in other domains²²22. Abu-Omar K, Rütten A. Relation of leisure time, occupational, domestic, and commuting physical activity to health indicators in Europe. Prev Med 2008; 47(3): 319-23. https://doi.org/10.1016/j.ypmed.2008.03.012
https://doi.org/10.1016/j.ypmed.2008.03.... . The national prevalence of older adults physically active during leisure time (13.1%) is lower than that estimated for the global older adult population (45%) in 2010²³23. World Health Organization. Global Status Report on noncommunicable diseases 2014. Genebra: World Health Organization; 2014. and the one observed in the population aged 65 years or more who live in Brazilian state capitals (22.3%)⁵5. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Vigitel Brasil 2016: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2016. Brasil: Ministério da Saúde; 2017..

Despite the low prevalence, we emphasize that we found no differences between genders, contrary to findings of a systematic review that identified a higher incidence of leisure-time physical activity among men²⁴24. Notthoff N, Reisch P, Gerstorf D. Individual Characteristics and Physical Activity in Older Adults: A Systematic Review. Gerontology 2017; 63(5): 443-59. https://doi.org/10.1159/000475558
https://doi.org/10.1159/000475558... . This study also showed that the adjustment for schooling explained all differences found between black and white people regarding the practice of physical activity. Also, the magnitude of inequalities in leisure-time physical activity was similar in the variables related to socioeconomic status (schooling and income), suggesting that both effects could be equally important²⁵25. Beenackers MA, Kamphuis CBM, Giskes K, Brug J, Kunst AE, Burdorf A, et al. Socioeconomic inequalities in occupational, leisure-time, and transport related physical activity among European adults: A systematic review. Int J Behav Nutr Phys Act 2012; 9: 116. https://doi.org/10.1186/1479-5868-9-116
https://doi.org/10.1186/1479-5868-9-116... . The causes for inequalities in the involvement in leisure-time physical activity could be associated with the effect of schooling on the knowledge about the positive consequences of this practice for health and/or the financial conditions for this kind of activity²⁵25. Beenackers MA, Kamphuis CBM, Giskes K, Brug J, Kunst AE, Burdorf A, et al. Socioeconomic inequalities in occupational, leisure-time, and transport related physical activity among European adults: A systematic review. Int J Behav Nutr Phys Act 2012; 9: 116. https://doi.org/10.1186/1479-5868-9-116
https://doi.org/10.1186/1479-5868-9-116... ^,2626. Del Duca GF, Rombaldi AJ, Knuth AG, Azevedo MR, Nahas MV, Hallal PC. Associação entre nível econômico e inatividade física em diferentes domínios. Rev Bras Ativ Fís Saúde 2009; 14(2): 123-31. https://doi.org/10.12820/rbafs.v.14n2p123-131
https://doi.org/10.12820/rbafs.v.14n2p12... .

Concerning the work dimension, this study revealed that the prevalence of paid work was 20.7%. This estimate could be considered low and follows the decreasing trend that this indicator has been showing in Brazil. In 2005, the occupation level of the Brazilian older adult population was 30.2%, decreasing to 26.3% in 2015²⁷27. Instituto Brasileiro de Geografia e Estatística. Síntese de indicadores sociais: uma análise das condições de vida da população brasileira 2016. Rio de Janeiro: IBGE; 2016.. In contrast, 9.7% of the interviewees declared participating in volunteer work, representing twice the percentage reported in another national survey, which estimated a prevalence of 4.6% for this activity in Brazil, considering the population aged 50 years or more²⁸28. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios Contínua 2016: Outras formas de trabalho. Rio de Janeiro: IBGE ; 2017..

The work dimension also revealed gender bias. Men were more active in paid work, while women were more involved in volunteer work. The higher frequency of men in the labor market has been mainly associated with the traditional patterns of division of labor and cultural influences⁴4. Ilinca S, Rodrigues R, Schmidt A, Zolyomi E. Gender and Social Class Inequalities in Active Ageing: Policy meets Theory. Viena: European Centre for Social Welfare Policy and Research; 2016.^,1919. World Economic Forum. The Global Gender Gap Report. Genebra: World Economic Forum; 2017.^,2929. He W, Goodkind D, Kowal P. Census Bureau (US), International Population Reports P95/16-1: An Aging World: 2015. Washington, D.C.: Department of Commerce (US); 2016.. Another factor that could influence the permanence of older men in the labor market is the need to complement the household income, even after retirement, to meet their own financial demands and those of dependent family members, due to circumstances such as economic crisis, unemployment, divorce, and drug addiction, especially in lower-income strata³⁰30. Oliveira MB, Silva NM. Participação de aposentados nas transferências de recursos nas famílias. Rev Ciênc Hum 2012; 12(1): 135-44.. On the other hand, gender differences in volunteer work contrast with those found in the literature⁴4. Ilinca S, Rodrigues R, Schmidt A, Zolyomi E. Gender and Social Class Inequalities in Active Ageing: Policy meets Theory. Viena: European Centre for Social Welfare Policy and Research; 2016.^,3131. Principi A, Chiatti C, Lamura G, Frerichs F. The Engagement of Older People in Civil Society Organizations. Educ Gerontol 2012; 38(2): 83-106. https://doi.org/10.1080/03601277.2010.515898
https://doi.org/10.1080/03601277.2010.51... and could be correlated to distinct income levels and work experiences between men and women, besides cultural aspects⁴4. Ilinca S, Rodrigues R, Schmidt A, Zolyomi E. Gender and Social Class Inequalities in Active Ageing: Policy meets Theory. Viena: European Centre for Social Welfare Policy and Research; 2016.^,3131. Principi A, Chiatti C, Lamura G, Frerichs F. The Engagement of Older People in Civil Society Organizations. Educ Gerontol 2012; 38(2): 83-106. https://doi.org/10.1080/03601277.2010.515898
https://doi.org/10.1080/03601277.2010.51... . The work dimension analysis according to ethnicity revealed a difference between white and black people only regarding volunteer work, explained by schooling. The relevance of stratification by ethnicity in studies about volunteer work is related to its potential in identifying differences concerning quality of life measures that make volunteer work possible, such as schooling and income, or revealing the direct effect of racism on the unequal access to this activity³²32. Dannefer D. Cumulative Advantage/Disadvantage and the Life Course: Cross-Fertilizing Age and Social Science Theory. J Gerontol B Psychol Sci Soc 2003; 58(6): S327-37. https://doi.org/10.1093/geronb/58.6.s327
https://doi.org/10.1093/geronb/58.6.s327... ^,3333. Tang F, Copeland VC, Wexler S. Racial Differences in Volunteer Engagement by Older Adults: An Empowerment Perspective. Social Work Res 2012; 36(2): 89-100. http://dx.doi.org/10.1093/swr/svs009
http://dx.doi.org/10.1093/swr/svs009... . With respect to differences in socioeconomic status, the present study indicated that older adults who had higher schooling and income participated more often in paid and volunteer work. A possible explanation for the distinction in paid work is that individuals with lower socioeconomic status usually have worse health conditions and work on more physically demanding and less fulfilling positions, favoring their early exit from the labor market³⁴34. Reinhardt JD, Wahrendorf M, Siegrist J. Socioeconomic position, psychosocial work environment and disability in an ageing workforce: a longitudinal analysis of SHARE data from 11 European countries. Occup Environ Med 2013; 70(3): 156-63. https://doi.org/10.1136/oemed-2012-100924
https://doi.org/10.1136/oemed-2012-10092... . As to volunteer work, the prevalence found could be considered low when compared to other regions in the world⁴4. Ilinca S, Rodrigues R, Schmidt A, Zolyomi E. Gender and Social Class Inequalities in Active Ageing: Policy meets Theory. Viena: European Centre for Social Welfare Policy and Research; 2016.^,3131. Principi A, Chiatti C, Lamura G, Frerichs F. The Engagement of Older People in Civil Society Organizations. Educ Gerontol 2012; 38(2): 83-106. https://doi.org/10.1080/03601277.2010.515898
https://doi.org/10.1080/03601277.2010.51... , suggesting a potential lack of opportunity or incentive to a “volunteering culture”³3. Centro Internacional de Longevidade Brasil. Envelhecimento Ativo: Um marco político em resposta à revolução da longevidade. Rio de Janeiro: Centro Internacional de Longevidade Brasil; 2015..

The study also revealed that the population with private health insurance was more active in the social, physical activity, and work dimensions. This analysis was not adjusted for income or schooling to reveal the profile of involvement in activities among the population who depended solely on SUS. In this scenario, the study confirms, among other aspects, the role and importance of SUS in encouraging social participation, given its potential to promote physical and mental health in older adults³⁵35. Douglas H, Georgiou A, Westbrook J. Social participation as an indicator of successful aging: an overview of concepts and their associations with health. Aust Health Rev 2017; 41(4): 455-62. https://doi.org/10.1071/AH16038
https://doi.org/10.1071/AH16038... . Another characteristic evidenced by the study was the inequality in the practice of physical activity among the population with and without health insurance. This finding emphasizes the need to expand the access to body practices and physical activity with programs such as Health Gym, and the effective action in Family Health Support Centers, considered important allies in reducing physical inactivity among older adults, as well as the inequality in this practice³⁶36. Sá GBAR, Dornelles GC, Cruz KG, Amorim RCA, Andrade SSCA, Oliveira TP, et al. O Programa Academia da Saúde como estratégia de promoção da saúde e modos de vida saudáveis: cenário nacional de implementação. Ciênc Saúde Colet 2016; 21(6): 1849-60. http://dx.doi.org/10.1590/1413-81232015216.09562016
http://dx.doi.org/10.1590/1413-812320152... ^,3737. Carvalho FFB, Nogueira JAD. Práticas corporais e atividades físicas na perspectiva da Promoção da Saúde na Atenção Básica. Ciênc Saúde Colet 2016; 21(6): 1829-38. http://dx.doi.org/10.1590/1413-81232015216.07482016
http://dx.doi.org/10.1590/1413-812320152... .

This study has a cross-sectional design, which can lead to survival bias, regarded as a logical error when studying older adults who survived early mortality - more common among people with higher risk exposure throughout life. The strengths of this study are the sample size, which allowed us to estimate most indicators of active aging with a good level of accuracy in the strata investigated, the quality of the data collected, and the use of indicators less explored in the Brazilian older adult population.

CONCLUSION

The study highlighted five activities that are still challenging for the proposed policy of active aging, both for their low prevalence among Brazilian older adults and for being marked by considerable social inequality. The data showed that participating in different activities in old age could be related to traditional gender roles, assimilated throughout life. The study also identified that older adults with higher levels of income and schooling are more involved in social, physical, and productive activities, reinforcing the importance of fighting educational and income inequality as a way to promote active aging. We also underline the possibilities for SUS to contribute in establishing active aging in Brazil, be it by promoting health-specific actions that favor an active life, or by encouraging the participation of older adults in activities that can improve their health.

These findings strengthen the idea that confronting social inequalities is an important part of the strategy to implement active aging, providing adapted and appropriate solutions for different groups of older adults and avoiding the imposition of less feasible goals.

ACKNOWLEDGMENTS

The authors thank the Ministry of Health for funding the project under the grant No. 817122/2015 and the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq) for the productivity scholarship to M. B. A. Barros (grant No. 309073/2015-4).

References

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