ABSTRACT:

Objectives:

To estimate the magnitude of gender differences in disability among adults aged 60 and older and to evaluate whether they can be associated with social gender inequality and socioeconomic contextual factors at the level of Brazilian federative units.

Methods:

This is a multilevel study that used data from 23,575 older adults of 27 federative units who participated in the 2013 Brazilian Health Survey. The activity limitation index was developed from the item response theory, using activities of daily living and instrumental activities of daily living variables. The association of individual and contextual variables with disability was estimated by assessing the magnitude of differences between genders, using cross-level interaction effects in multilevel generalized linear models, including only the variables that were statistically significant in the final model.

Results:

The prevalence of disability was higher among women (37.6%) than among men (26.5%), totaling 32.7% of the older adults. In the adjusted multilevel analysis, disability was influenced by income inequality (γ_gini = 0.022, p < 0.001) among federative units. In addition, gender differences in disability were associated with social gender inequalities (γ_mgiiXsex = 0.020, p = 0.004).

Conclusion:

Women had higher disability disadvantages compared to men, and those differences were associated with social gender inequalities among the Brazilian federative units influenced by income inequality.

Keywords:
Health of the Disabled; Aging; Health Status Disparities; Multilevel analysis

RESUMO:

Objetivos:

Estimar a magnitude das diferenças de gênero na incapacidade entre adultos com 60 anos ou mais e avaliar se elas podem estar associadas à desigualdade social de gênero e aos fatores contextuais socioeconômicos no nível das unidades federativas brasileiras.

Métodos:

Estudo multinível que utilizou dados de 23.575 adultos mais velhos das 27 unidades federativas que participaram da Pesquisa Nacional de Saúde de 2013. O índice de limitação de atividades foi desenvolvido a partir da teoria de resposta ao item, utilizando-se variáveis de atividades básicas e instrumentais da vida diária. Foram estimadas as associações das variáveis individuais e contextuais com a incapacidade, avaliando-se a magnitude das diferenças entre os gêneros, ao utilizar efeitos de interação de nível cruzado em modelos lineares generalizados multiníveis, incluindo-se apenas as variáveis que foram estatisticamente significantes no modelo final.

Resultados:

A prevalência de incapacidade foi mais elevada entre as mulheres (37,6%) do que entre os homens (26,5%), totalizando 32,7% dos adultos mais velhos. Na análise multinível ajustada, a incapacidade foi influenciada pela desigualdade de renda (γ_gini = 0,022, p < 0,001) entre as unidades federativas. Além disso, as diferenças de gênero na incapacidade foram associadas com as desigualdades sociais de gênero (γ_mgiiXsex = 0,020, p = 0,004).

Conclusões:

As mulheres tiveram desvantagens maiores de incapacidade quando comparadas aos homens, e estas diferenças foram associadas às desigualdades sociais de gênero entre unidades federativas brasileiras, influenciadas pelas desigualdades de renda.

Palavras-chave:
Saúde da Pessoa com Incapacidade; Envelhecimento; Disparidades nos Níveis de Saúde; Análise multinível

INTRODUCTION

Activity limitations are difficulties an individual may experience performing physical tasks. They are considered negative aspects of functionality and constitute an important part of an individual’s disability status¹1. Stineman MG, Henry-Sánchez JT, Kurichi JE, Pan Q, Xie D, Saliba D, et al. Staging activity limitation and participation restriction in elderly community-dwelling persons according to difficulties in self-care and domestic life functioning. Am J Phys Med Rehabil 2012; 91(2): 126-40. http://doi.org/10.1097/PHM.0b013e318241200d
https://doi.org/http://doi.org/10.1097/P... ^,22. World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization, 2001., which is defined within the context of health as the person’s feature directly caused by disease, trauma or other health condition that requires medical care provided in the form of individual treatment by professionals (medical model)²2. World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization, 2001.. However, a person’s disability is also affected by the environmental characteristics of his/her surroundings (social model)³3. Sadana R, Blas E, Budhwani S, Koller T, Paraje G. Healthy ageing: Raising awareness of inequalities, determinants, and what could be done to improve health equity. Gerontologist 2016; 56(Suppl. 2): S178-93. http://doi.org/10.1093/geront/gnw034
https://doi.org/http://doi.org/10.1093/g... .

It is now argued that, as life expectancy continues to increase around the world, life will mean, on average, a longer period wasted by suffering due to frailty, disability, and age-related illness (e.g., cardiovascular diseases, cancer, diabetes mellitus, osteoporosis, among others)⁴4. Kirkwood TBL. Healthy old age. Nature 2008; 455: 739-40. http://doi.org/10.1038/455739a
https://doi.org/http://doi.org/10.1038/4... ^,55. Veras RP. Estratégias para o enfrentamento das doenças crônicas: um modelo em que todos ganham [Strategies for coping with chronic diseases: a model where everyone wins]. Rev Bras Geriatr e Gerontol 2011; 14(4): 779-86. http://doi.org/10.1590/S1809-98232011000400017
https://doi.org/http://doi.org/10.1590/S... ^,66. Jaul E, Barron J. Age-Related Diseases and Clinical and Public Health Implications for the 85 Years Old and Over Population. Front Public Health 2017; 5: 335. http://doi.org/10.3389/fpubh.2017.00335
https://doi.org/http://doi.org/10.3389/f... . In Brazil, the population pyramid is in the process of contraction, resulting from a constant decrease of fertility rates, from 6.3 children per woman, in 1960, to 1.9 children per woman, in 2010. This is already below the replacement level, set as 2.1 children per woman⁷7. Anderson JSN, Schneider S. Brazilian Demographic Transition and the Strategic Role of Youth. Espace populations sociétés 2014; (2-3). http://doi.org/10.4000/eps.5774
https://doi.org/http://doi.org/10.4000/e... . At the same time, the epidemiological transition occurs differently from the model experienced by industrialized countries (e.g., Canada, the USA, Spain, Germany, England) and even by other nearby locations, such as Chile, Cuba, and Costa Rica. In Brazil, there is coexistence of old and new health problems, in which despite the predominance of chronic and degenerative diseases, the communicable ones still play an important role⁸8. Schramm JMA, Oliveira AF, Leite IC, Valente JG, Gadelha AMJ, Portela MC, et al. Transição epidemiológica e o estudo de carga de doença no Brasil [Epidemiological transition and the study of burden of disease in Brazil]. Ciên Saúde Colet 2004; 9(4): 897-908. http://doi.org/10.1590/S1413-81232004000400011
https://doi.org/http://doi.org/10.1590/S... .

In Brazil, social inequalities are prevalent in older adults due to the continuing inequitable distribution of resources among groups living under different socioeconomic conditions⁹9. Braga LS, Lima-Costa MF, César CC, Macinko J. Social inequalities on selected determinants of active aging and health status indicators in a large Brazilian city (2003-2010). J Aging Health 2016; 28(1): 180-96. http://doi.org/10.1177/0898264315589575
https://doi.org/http://doi.org/10.1177/0... . Social inequality plays an important role in the prevalence of disability among older adults¹⁰10. Melzer D, Parahyba MI. Socio-demographic correlates of mobility disability in older Brazilians: Results of the first national survey. Age Ageing 2004; 33(3): 253-9. http://doi.org/10.1093/ageing/afh075
https://doi.org/http://doi.org/10.1093/a... , especially among women¹¹11. World Health Organization. Active ageing: A policy framework. A contribution of the World Health Organization to the Second United Nations World Assembly on Ageing, Madrid, Spain, 2002 [Internet]. Geneva: World Health Organization ; 2002 [cited on June 13, 2018]. Available from: Available from: https://extranet.who.int/agefriendlyworld/wp-content/uploads/2014/06/WHO-Active-Ageing-Framework.pdf
https://extranet.who.int/agefriendlyworl... . It is likely that individuals living in areas with better socioeconomic conditions have greater access to medical goods and services and, consequently, are capable of maintaining good health conditions and functional capacity over time¹²12. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: A multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78. http://doi.org/10.1590/S0034-89102010005000009
https://doi.org/http://doi.org/10.1590/S... . Those cumulative disadvantages mean that women are more likely than men to become poor and suffer from disabilities at an old age¹³13. Zunzunegui MV, Alvarado BE, Guerra R, Gómez JF, Ylli A, Guralnik JM, et al. The mobility gap between older men and women: The embodiment of gender. Arch Gerontol Geriatr 2015; 61(2): 140-8. http://doi.org/10.1016/j.archger.2015.06.005
https://doi.org/http://doi.org/10.1016/j... .

In a previous study, 33% of older Brazilian adults had limitations to perform Activities of Daily Living (ADL) (37% of women and 27% of men). In the Northeast, this prevalence affected 39%, followed by the North and Midwest with 35% each, the South with 32% and the Southeast with 29%¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde [Health National Survey] 2013, Brazil [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística [Brazilian Institute of Geography and Statistics]; 2013 [cited on February 15, 2018]. Available from: Available from: https://www.pns.icict.fiocruz.br/arquivos/Novos/Questionario%20PNS.pdf
https://www.pns.icict.fiocruz.br/arquivo... . The prevalence of disability is significantly higher among users of the public system (32%) than those of the private health system (25%)¹⁵15. Silva AMM, Mambrini DM, Peixoto SV, Malta DC, Lima-Costa MF. Uso de serviços de saúde por idosos brasileiros com e sem limitação funcional [Use of health services by Brazilian elderly with and without functional limitation]. Rev Saúde Pública 2017; 51(Suppl. 1): 5s. http://doi.org/10.1590/s1518-8787.2017051000243
https://doi.org/http://doi.org/10.1590/s... . The older adults who lived in Federative Units with higher Gini index were more likely to present higher level of disabilities compared to the older adults who lived in states with lower economic disadvantages¹²12. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: A multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78. http://doi.org/10.1590/S0034-89102010005000009
https://doi.org/http://doi.org/10.1590/S... ^,1616. Lima ALB, Lima KC. Activity limitation in the elderly people and inequalities in Brazil. Open Access Library Journal 2014; 1: e739. http://doi.org/10.4236/oalib.1100739
https://doi.org/http://doi.org/10.4236/o... .

Many important studies provide an overview of the disabilities in Brazilian older adults, including gender differences and their determinants¹⁷17. Barbosa AR, Souza JMP, Lebrão ML, Laurenti R, Marucci MFN. Functional limitations of Brazilian elderly by age and gender differences: Data from SABE survey. Cad Saúde Pública 2005; 21(4): 1177-85. http://doi.org/10.1590/S0102-311X2005000400020
https://doi.org/http://doi.org/10.1590/S... ^,1818. Andrade FCD, Guevara PE, Lebrão ML, Duarte YAO, Santos JLF. Gender differences in life expectancy and disability-free life expectancy among older adults in Sao Paulo, Brazil. Womens Health Issues 2011; 21(1): 64-70. http://doi.org/10.1016/j.whi.2010.08.007
https://doi.org/http://doi.org/10.1016/j... ^,1919. Alexandre T, Corona LP, Nunes DP, Santos JLF, de Oliveira Duarte YA, Lebrão ML. Gender differences in incidence and determinants of disability in activities of daily living among elderly individuals: SABE study. Arch Gerontol Geriatr 2012; 55(2): 431-7. http://doi.org/10.1016/j.archger.2012.04.001
https://doi.org/http://doi.org/10.1016/j... ^,2020. Campos ACV, Albala C, Lera L, Sánchez H, Vargas AMD, Ferreira e Ferreira F. Gender differences in predictors of self-rated health among older adults in Brazil and Chile. BMC Public Health 2015; 15: 365-76. http://doi.org/10.1186/s12889-015-1666-9
https://doi.org/http://doi.org/10.1186/s... ^,2121. Lima-Costa MF, Mambrini JVM, Peixoto SV, Malta DC, Macinko J. Socioeconomic inequalities in activities of daily living limitations and in the provision of informal and formal care for noninstitutionalized older Brazilians: National Health Survey. Int J Equity Health 2016; 15: 137-45. http://doi.org/10.1186/s12939-016-0429-2
https://doi.org/http://doi.org/10.1186/s... . Other previous studies have measured the functionality of older adults in Brazil, where disabilities were associated with demographic (sex, age), socioeconomic (occupation, level of schooling, income), and health factors (chronic diseases)¹²12. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: A multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78. http://doi.org/10.1590/S0034-89102010005000009
https://doi.org/http://doi.org/10.1590/S... ^,2222. Beltrão KI, Teixeira MP, Parahyba MI, Fletcher P. Capacidade funcional dos idosos: Uma análise dos suplementos Saúde da PNAD com a teoria de resposta ao item [Functional capacity of the elderly: An analysis of the PNAD Health supplements with the item response theory] [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística [Brazilian Institute of Geography and Statistics] ; 2013 [cited on July 21, 2018]. Available from: Available from: http://biblioteca.ibge.gov.br/visualizacao/livros/liv65318.pdf
http://biblioteca.ibge.gov.br/visualizac... ^,2323. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza-Júnior PRBD, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação [National Health Survey in Brazil: design and methodology of application]. Ciênc Saúde Coletiva [Science and Collective Health] 2014; 19(2): 333-42. http://doi.org/10.1590/1413-81232014192.14072012
https://doi.org/http://doi.org/10.1590/1... . Differently of those previous investigations, this study uses the item response theory to aggregate two dimensions of functionality, i.e. ADL and Instrumental ADL (IADL), in a latent trait and estimate cross-level interaction analysis using multilevel modelling. We can, therefore, estimate the contextual effect (aggregate level) of an ecological exposure on individual risk (individual level). The aims of this study were to estimate the magnitude of gender differences in disability among older adults aged 60 and older in Brazil in 2013 and to examine whether those differences could be associated with social gender inequalities and socioeconomic contextual factors at the level of federative units.

METHODS

SAMPLE AND DATA COLLECTION

This was a cross-sectional study based on data from the Brazilian Health Survey 2013 (BNHS)²³23. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza-Júnior PRBD, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação [National Health Survey in Brazil: design and methodology of application]. Ciênc Saúde Coletiva [Science and Collective Health] 2014; 19(2): 333-42. http://doi.org/10.1590/1413-81232014192.14072012
https://doi.org/http://doi.org/10.1590/1... . The BNHS selected 81,187 households randomly, and individuals aged 18 years or older were interviewed. One individual from each household was selected in a complex sampling plan. Thus, 64,348 interviews were collected in the households, resulting in a non-response rate of 8.1%²⁴24. Claro RM, Santos MAS, Oliveira TP, Pereira CA, Szwarcwald CL, Malta DC. Unhealthy food consumption related to chronic noncommunicable diseases in Brazil: National Health Survey, 2013. Epidemiol Serv Saúde 2015; 24(2): 257-65. http://doi.org/10.5123/S1679-49742015000200008
https://doi.org/http://doi.org/10.5123/S... . In total, 60,202 people participated in individual interviews²⁵25. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Sampling Design for the National Health Survey, Brazil 2013. Epidemiol Serv Saúde 2015; 24(2): 207-16. http://doi.org/10.5123/S1679-49742015000200003
https://doi.org/http://doi.org/10.5123/S... , in which 23,815 were older adults¹⁵15. Silva AMM, Mambrini DM, Peixoto SV, Malta DC, Lima-Costa MF. Uso de serviços de saúde por idosos brasileiros com e sem limitação funcional [Use of health services by Brazilian elderly with and without functional limitation]. Rev Saúde Pública 2017; 51(Suppl. 1): 5s. http://doi.org/10.1590/s1518-8787.2017051000243
https://doi.org/http://doi.org/10.1590/s... . A selected population of the study was composed by 23,575 older adults aged 60 or older living in 27 Brazilian federative units. Calibrated individual weights were established in order to address participants’ non-response and sample attrition²⁶26. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde: Percepção de estado de saúde, estilo de vida e doenças crônicas [National Health Survey: Perception of health status, lifestyle and chronic diseases], Brazil [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística [Brazilian Institute of Geography and Statistics] ; 2014 [cited on July 12, 2018]. [181 p.]. Available from: Available from: http://biblioteca.ibge.gov.br/visualizacao/livros/liv91110.pdf
http://biblioteca.ibge.gov.br/visualizac... . Response rates ranged from 84% in Pará to 96% in Bahia. A small number (1,8%) of individuals was excluded from the study due to lack of data for individual variables or because they were born with physical, hearing, cognitive, or visual impairments. Considering that the data used in this study are anonymous and available in the public domain, submission to the Ethics Committee was not required in accordance with the recommendations of the National Research Ethics Committee of Brazil²⁷27. Brazil. Conselho Nacional de Saúde [Health National Council]. Resolução [Resolution] nº 510, April 7, 2016 [Internet]. Brazil: Conselho Nacional de Saúde; 2016 [cited on July 12, 2018]. Available from: Available from: http://conselho.saude.gov.br/resolucoes/2016/Reso510.pdf
http://conselho.saude.gov.br/resolucoes/... .

The National Health Survey is a household-based nationwide survey carried out by the Brazilian Department of Health in partnership with the Brazilian Institute of Geography and Statistics (IBGE). The scope of the survey is to establish the health status and lifestyles of the population - as well as how they look after their health - with regard to access and use of services, preventive actions, continuity of care, and health care financing.

ETHICAL APPROVAL

This study was exempted from submission to an ethics committee in accordance with the recommendations of the Brazilian National Committee for Ethics in Research, as the data used in this study are anonymous and available in the public domain.

DEPENDENT VARIABLE

The construct of the activity limitation index (ALI), which is used as a proxy to measure disability, was based on 12 questions in the BNHS. They were divided into two functionality dimensions: ADL (k1, k4, k7, k10, k13, k16 and k19)¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde [Health National Survey] 2013, Brazil [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística [Brazilian Institute of Geography and Statistics]; 2013 [cited on February 15, 2018]. Available from: Available from: https://www.pns.icict.fiocruz.br/arquivos/Novos/Questionario%20PNS.pdf
https://www.pns.icict.fiocruz.br/arquivo... and IADL (k22, k25, k28, k31 and k34)¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde [Health National Survey] 2013, Brazil [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística [Brazilian Institute of Geography and Statistics]; 2013 [cited on February 15, 2018]. Available from: Available from: https://www.pns.icict.fiocruz.br/arquivos/Novos/Questionario%20PNS.pdf
https://www.pns.icict.fiocruz.br/arquivo... , but they were united in a single latent trait. The self-reported response categories in ADL were:

The items related to the IADL were transformed into a dichotomous scale (0: “no difficulty”; 1: “has little difficulty, great difficulty, or cannot”) due to the scarce number of responses in some categories.

INDIVIDUAL INDEPENDENT VARIABLES

The main individual independent variable was sex. The following individual variables were also included in the analysis: age in years; restriction of usual activities during the last two weeks as a result of health problems (yes, no); self-perceived health (very good or good; fair, poor or very poor); medical health insurance plan (yes, no); participation in organized social activities (yes, no); educational level (illiterate or primary study; secondary or tertiary studies); Brazilian economic classification criteria, adapted and based in the sum of scores (by number of color television, bathroom, car, washing machine, DVD player, refrigerator, microwave), educational level and housekeeper (no = 0; yes = 4), as proposed by CCEB²⁸28. Associação Brasileira de Empresas de Pesquisa [Research Companies Brazilian Association]. Critério de Classificação Econômica Brasil [Brazil Economic Classification Criteria] 2008 [Internet]. Brazil: Associação Brasileira de Empresas de Pesquisa; 2008 [cited on July 12, 2018]. Available from: Available from: http://www.abep.org/Servicos/Download.aspx?id=05
http://www.abep.org/Servicos/Download.as... . Thus, the social classes were categorized as follows: 0-13 (E and D); 14-50 (A, B and C) (Fiocruz, Rio de Janeiro, 2016, unpublished data).

CONTEXTUAL INDEPENDENT VARIABLES

The following contextual factors at federative unit level were used as additional independent variables:

STATISTICAL ANALYSIS

This study used a hybrid model (generalized partial credit model and two logistic parameters) of item response theory ((2LP)/GPCM IRT) to construct the ALI for each individual respondent. Despite the fact that the θ scale ranged from -∞ to +∞, it was transformed and restricted in continuous values between 0 (no activity limitation) and 1 (maximum activity limitation) for practical purposes, and thus allowing regression for nonnegative positively skewed dependent variable.

The second level of multilevel analysis considered those variables related to federative units, and the evaluation of ALI behavior at first level was seen as a function of the predictor variables for both levels. The coefficients of ALI and gender differences therein, as well as the 95% confidence intervals (95%CI) were estimated for each federative unit. To estimate the association between contextual variables and gender differences in disability, cross-level interaction effects were used in multilevel generalized linear models for non-normal (log-linked GLM Gamma) and zero-inflated (logit-linked GLM Binomial), with robust variance responses. Model I included activity limitation by sex, and there was no control for other individual variables. Model II, level 1, included all the individual and contextual variables; Model III (final) comprised all variables that were statistically significant in the multivariate analysis in model II. Intercept and sex factor were considered to be random effects on all models, fitted using gllamm command, using a statistical significance level of 0.05. The statistical analysis was performed using STATA 14.1 IC statistical software (Stata Corporation, College Station, TX).

RESULTS

GENDER DIFFERENCES IN DISABILITY

Among the 23,575 participants in the sample, 32.7% (95%CI 32.1 - 33.3) presented some difficulty in performing the evaluated activities, with a prevalence of 15.9% for ADL and 29.7% for IADL. The prevalence of disability (ADL + IADL) was significantly higher among women (37.6%) than in men (26.5%), similarly to the case with the average ALI (µ_women = 0.167, 95%CI 0.161 - 0.173; µ_men = 0.119, 95%CI 0.112 - 0.125). In addition, older women presented disadvantages in terms of disability in the evaluated variables. More details on the characteristics of the survey participants can be found in Table 1.

Gender differences in disability were observed in most of the federative units. Figure 1 shows the extent of gender differences in disability for each one. The differences and severity of the disability among women are greater in the North and Northeast regions. The closer the results are to the diagonal line, which represents gender equality, the fewer the differences in disability between men and women. Despite the fact that Maranhão (MA), Amapá (AP), Pará (PA) and São Paulo (SP) had the smallest differences between men and women, AP and PA had worse results than SP, but better than MA. However, Alagoas (AL) presented the greatest difference in disability between men and women, while maintaining a high level of it among the older adults. In this regard, we can extract two extreme models, AL and SP, each of them representing the negative and positive aspects of disability in Brazil.

GENDER DIFFERENCES IN DISABILITY AND CONTEXTUAL VARIABLES

In the first model, disability was significantly higher among women aged 60 or older (γ_women = 0.050, p < 0.001) when compared to men, as shown in Table 2. In an adjusted multilevel analysis (Model III), more advanced age, activity restrictions in the last two weeks prior to the survey, a health-self-perceived as “fair, poor or very poor” and being illiterate or having primary studies are factors associated with greater disability among older adults. On the other hand, social activity participation was associated with lower disability. Those functional disabilities were shown to be significantly influenced by income inequality in all federative units (γ_gini = 0.022, p < 0.001). Thus, income inequality has a negative impact on disability in older adults. The best model, in the end, was able to explain 61% of the differences between the federative units with the social gender inequalities. The differences in disability between men and women were increased when adjusted for the other variables (γ_mgiiXsex = 0.020, p = 0.004).

DISCUSSION

Results showed that the limitations in IADL were more prevalent than the ADL among older adults. This can be explained because the ability to perform the IADL is primarily affected, especially because it requires greater motor and cognitive skills, which tend to be lost early in the aging process³³33. Bosco R de M, Assis EPS, Pinheiro RR, Queiroz LCV de, Pereira LSM, Antunes CMF. Anemia and functional capacity in elderly Brazilian hospitalized patients. Cad Saúde Pública 2013; 29(7): 1322-32. http://doi.org/10.1590/S0102-311X2013000700007
https://doi.org/http://doi.org/10.1590/S... ^,3434. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde: Ciclos de vida [National Health Survey: Life Cycles], Brazil [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística [Brazilian Institute of Geography and Statistics] ; 2013 [cited on April 15, 2018]. [p. 30-5]. Available from: Available from: http://biblioteca.ibge.gov.br/visualizacao/livros/liv94522.pdf
http://biblioteca.ibge.gov.br/visualizac... ^,3535. Wu C-Y, Hu H-Y, Li C-P, Fang Y-T, Huang N, Chou Y-J. The association between functional disability and acute care utilization among the elderly in Taiwan. Arch Gerontol Geriatr 2013; 57(2): 177-83. http://doi.org/10.1016/j.archger.2013.04.011
https://doi.org/http://doi.org/10.1016/j... .

The participation of older adults in community activities and the restriction in the performance of activities in the last two weeks have a direct relationship with one another, pointing out an evaluation of the quality of social life among older adults towards the disability consequences. The participation in community activities is related to the control of the physical and social environment, reflecting better functioning and cognitive skills of older adults³⁶36. Dias EG, Duarte YAO, Almeida MHM, Lebrão ML. Caracterização das atividades avançadas de vida diária (AAVDS): um estudo de revisão [Characterization of advanced activities of daily living (AADL): a review]. Rev Ter Ocup da Univ São Paulo 2011; 22(1): 45-51. http://doi.org/10.11606/issn.2238-6149.v22i1p45-51
https://doi.org/http://doi.org/10.11606/... .

The disabilities associated with self-perceived health status among older adults were consistent with other findings in previous research¹²12. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: A multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78. http://doi.org/10.1590/S0034-89102010005000009
https://doi.org/http://doi.org/10.1590/S... ^,1616. Lima ALB, Lima KC. Activity limitation in the elderly people and inequalities in Brazil. Open Access Library Journal 2014; 1: e739. http://doi.org/10.4236/oalib.1100739
https://doi.org/http://doi.org/10.4236/o... . Hence, it has been suggested that ‘poor’ self-perceived health among women is a reflection of the higher burden of diseases they suffer. However, when this burden of diseases was compensated, the gender gap disappeared³⁷37. Malmusi D, Artazcoz L, Benach J, Borrell C. Perception or real illness? How chronic conditions contribute to gender inequalities in self-rated health. Eur J Public Health 2012; 22(6): 781-6. http://doi.org/10.1093/eurpub/ckr184
https://doi.org/http://doi.org/10.1093/e... .

Another finding was that the subscription to a health insurance was not associated with disability. It is likely that, in line with the theory of lack of information asymmetry, there is little significance in health condition variables that explain the private ownership status among older adults³⁸38. Hernandes ESC, Lebrão ML, Duarte YAO, Santos JLF. Idosos com e sem plano de saúde e características socioepidemiológicas associadas [Health insurance coverage of the elderly and socioepidemiological characteristics associated]. Rev Saúde Pública 2012; 46(6): 1030-8. http://doi.org/10.1590/S0034-89102012000600013
https://doi.org/http://doi.org/10.1590/S... ^,3939. Bós AMG, Bós ÂJG. Determinantes na escolha entre atendimento de saúde privada e pública por idosos [Determinants of elders’ choice between private and public health care providers]. Rev Saúde Pública. 2004; 38(1): 113-20. http://doi.org/10.1590/S0034-89102004000100016
https://doi.org/http://doi.org/10.1590/S... ^,4040. Lima e Costa MF, Uchoa E, Guerra HL, Firmo JO, Vidigal PG, Barreto SM. The Bambuí health and ageing study (BHAS): methodological approach and preliminary results of a population-based cohort study of the elderly in Brazil. Rev Saúde Pública. 2000; 34(2): 97-103. http://doi.org/10.1590/S0034-89102000000200005
https://doi.org/http://doi.org/10.1590/S... . However, a Brazilian study showed that older adults who were enrolled in a health insurance had lower probability of high level of difficulty in accomplishing the ADL compared to those who did not have a health insurance¹²12. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: A multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78. http://doi.org/10.1590/S0034-89102010005000009
https://doi.org/http://doi.org/10.1590/S... .

Regarding education and income, as the levels increase, the probability of the older adults to be able to perform ADL increase¹²12. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: A multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78. http://doi.org/10.1590/S0034-89102010005000009
https://doi.org/http://doi.org/10.1590/S... . Low educational level has a direct association with greater disabilities among the older adults, compromising access to health education, which is a strategy that allows the adoption of healthy behaviors and social mobilization to improve living conditions⁴¹41. Geib LTC. Social determinants of health in the elderly. Ciênc Saúde Coletiva [Science & Collective Health] 2012; 17(1): 123-33. http://doi.org/10.1590/S1413-81232012000100015
https://doi.org/http://doi.org/10.1590/S... . Among older women, education seems to be associated with better functional capacity⁴²42. Park SM, Jang SN, Kim DH. Gender differences as factors in successful ageing: A focus on socioeconomic status. J Biosoc Sci 2010; 42(1): 99-111. http://doi.org/10.1017/S0021932009990204
https://doi.org/http://doi.org/10.1017/S... .

GENDER DIFFERENCES IN DISABILITY

Similar to other studies¹⁰10. Melzer D, Parahyba MI. Socio-demographic correlates of mobility disability in older Brazilians: Results of the first national survey. Age Ageing 2004; 33(3): 253-9. http://doi.org/10.1093/ageing/afh075
https://doi.org/http://doi.org/10.1093/a... ^,1212. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: A multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78. http://doi.org/10.1590/S0034-89102010005000009
https://doi.org/http://doi.org/10.1590/S... ^,1616. Lima ALB, Lima KC. Activity limitation in the elderly people and inequalities in Brazil. Open Access Library Journal 2014; 1: e739. http://doi.org/10.4236/oalib.1100739
https://doi.org/http://doi.org/10.4236/o... , disability was found to be worse among women in all the federative units. The high prevalence of disability in women is due to a combination of high incidence and long duration of disability, resulting from lower rates of rehabilitation and mortality among women with functional disability⁴³43. Hardy SE, Allore HG, Guo Z, Gill TM. Explaining the effect of gender on functional transitions in older persons. Gerontology 2008; 54(2): 79-86. http://doi.org/10.1159/000115004
https://doi.org/http://doi.org/10.1159/0... . Gender may be a risk factor for explaining a worse physical function among women, but moving to equity could attenuate gender gaps in the physical function with advanced age¹³13. Zunzunegui MV, Alvarado BE, Guerra R, Gómez JF, Ylli A, Guralnik JM, et al. The mobility gap between older men and women: The embodiment of gender. Arch Gerontol Geriatr 2015; 61(2): 140-8. http://doi.org/10.1016/j.archger.2015.06.005
https://doi.org/http://doi.org/10.1016/j... ^,4444. Leveille SG, Penninx BW, Melzer D, Izmirlian G, Guralnik JM. Sex differences in the prevalence of mobility disability in old age: the dynamics of incidence, recovery, and mortality. J Gerontol B Psychol Sci Soc Sci 2000; 55(1): 41-50. http://doi.org/10.1093/geronb/55.1.S41
https://doi.org/http://doi.org/10.1093/g... . According to BNHS data, all Brazilian regions showed similar levels of disability to the national average, with no differences between men and women³⁴34. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde: Ciclos de vida [National Health Survey: Life Cycles], Brazil [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística [Brazilian Institute of Geography and Statistics] ; 2013 [cited on April 15, 2018]. [p. 30-5]. Available from: Available from: http://biblioteca.ibge.gov.br/visualizacao/livros/liv94522.pdf
http://biblioteca.ibge.gov.br/visualizac... .

Two models of gender differences in disability can be highlighted: AL, with a high level of disability among older adults and a large disadvantage of women versus men, which is above the national average in both cases; and SP, with a low level of disability among older adults and a few differences between men and women, which is below the national average for both. Alagoas and São Paulo represent the socioeconomic extremes among the Brazilian federative units. In addition to the low level of human development, AL cannot meet the needs of the current generations without compromising the capacity of reaching the needs of future generations, due to the low sustainability. Therefore, urgent state interventions are demanded⁴⁵45. Alves DB, Barbosa MTS. Desigualdades na mortalidade por doenças crônicas entre idosos e sua associação com indicadores socioeconômicos no Brasil [Inequalities in mortality due to chronic diseases among the older adults and their association with socioeconomic indicators in Brazil]. Rev Bras Ciênc Envelhec Hum 2011; 7(1): 22-33. https://doi.org/10.5335/rbceh.2012.263
https://doi.org/https://doi.org/10.5335/... ^,4646. Macedo MAS, Ferreira AFR, Cípola FC. Análise do nível de sustentabilidade das Unidades Federativas do Brasil e de suas capitais: um estudo sob as perspectivas econômica, social e ambiental [Analysis of the sustainability level of the Brazilian Federative Units and its capitals: a study under the economic, social and environmental perspectives]. Rev Gestão Soc e Ambient 2011; 5(3): 73-89. http://doi.org/10.24857/rgsa.v5i3.341
https://doi.org/http://doi.org/10.24857/... . It is noteworthy that SP, besides the socioeconomic advantages that it presents ahead of many other federative units, is considered an “older adults friendly state”. In practical terms, SP adapts its structures and services to be accessible and inclusive to the older adults with varying needs and capacities⁴⁷47. Gragnolati M, Jorgensen OH, Rocha R, Fruttero A. Growing Old in an Older Brazil: Implications of Population Aging on Growth, Poverty, Public Finance and Service Delivery. Washington, D.C.: The World Bank; 2011. 299 p. http://doi.org/10.1596/978-0-8213-8803-7
https://doi.org/http://doi.org/10.1596/9... .

Therefore, SP is an example in which intersectoriality happens in policies directed towards older adults. The other federative units should see SP as a positive model, although not ideal, and replicate intersectoral policies with the aim of improving the older adult population’s life⁴⁸48. Oliveira AD, Ramos OA, Panhoca I, Alves VLS. A intersetorialidade nas políticas públicas para o envelhecimento no Brasil [The intersectoriality in public policies for aging in Brazil]. Rev Kairós Gerontol [Internet] 2014 [cited on July 5, 2018]; 17(2): 91-103. Available from: Available from: https://revistas.pucsp.br/index.php/kairos/article/view/21278/15556
https://revistas.pucsp.br/index.php/kair... . Thus, it is necessary to provide active and healthy aging, applying and implementing health information and education strategies, focusing on the prevention of disabilities and their determinants, going beyond prescriptive methodologies and placing older adults as transforming subjects of their reality.

GENDER DIFFERENCES IN DISABILITY AND CONTEXTUAL FACTORS

Social gender inequalities

In Brazil, the highest rates of social gender inequality were associated with higher gender differences in disability, with women at a greater disadvantage¹⁶16. Lima ALB, Lima KC. Activity limitation in the elderly people and inequalities in Brazil. Open Access Library Journal 2014; 1: e739. http://doi.org/10.4236/oalib.1100739
https://doi.org/http://doi.org/10.4236/o... . A previous study found that the greatest social gender inequalities in federative units seem to be associated with high incidence of long-term disability among older women⁴³43. Hardy SE, Allore HG, Guo Z, Gill TM. Explaining the effect of gender on functional transitions in older persons. Gerontology 2008; 54(2): 79-86. http://doi.org/10.1159/000115004
https://doi.org/http://doi.org/10.1159/0... . In fact, gender differences in disability may be related to broader social gender inequalities, raising questions on how health, socioeconomic, and cultural factors influence gender patterns of seeking and using health care in later life in the country⁴⁹49. Espelt A, Font-Ribera L, Rodriguez-Sanz M, Artazcoz L, Ferrando J, Plaza A, et al. Disability among older people in a southern European city in 2006: Trends in gender and socioeconomic inequalities. J Womens Health 2010; 19(5): 927-33. http://doi.org/10.1089/jwh.2009.1608
https://doi.org/http://doi.org/10.1089/j... ^,5050. Barreto SM, Giatti L, Kalache A. Gender inequalities in health among older Brazilian adults. Rev Panam Salud Publica 2004; 16(2): 110-17. http://doi.org/10.1590/S1020-49892004000800006
https://doi.org/http://doi.org/10.1590/S... .

Socioeconomic contextual factors

Income inequality is a main contextual factor in the social environment, and it affects directly health, increasing the probability of older adults presenting functional disability¹²12. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: A multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78. http://doi.org/10.1590/S0034-89102010005000009
https://doi.org/http://doi.org/10.1590/S... . Therefore, income inequality deepens gender inequality and disadvantages for older women that have a history of low participation in the labor market, have minimal retirement benefits and depend on the public health system⁴¹41. Geib LTC. Social determinants of health in the elderly. Ciênc Saúde Coletiva [Science & Collective Health] 2012; 17(1): 123-33. http://doi.org/10.1590/S1413-81232012000100015
https://doi.org/http://doi.org/10.1590/S... . With lower incomes than men, women have less access to health and education that can ensure an improvement in their health quality, since highly educated women were more than 10 times as likely to age successfully as were women with low levels of education¹⁰10. Melzer D, Parahyba MI. Socio-demographic correlates of mobility disability in older Brazilians: Results of the first national survey. Age Ageing 2004; 33(3): 253-9. http://doi.org/10.1093/ageing/afh075
https://doi.org/http://doi.org/10.1093/a... ^,4242. Park SM, Jang SN, Kim DH. Gender differences as factors in successful ageing: A focus on socioeconomic status. J Biosoc Sci 2010; 42(1): 99-111. http://doi.org/10.1017/S0021932009990204
https://doi.org/http://doi.org/10.1017/S... .

In addition, it is noteworthy that disability is strongly associated with chronic disease, and functional disability relates to the performance of physical activities and social participation⁵¹51. Loke SC, Lim WS, Someya Y, Hamid TA, Nudin SS. Examining the disability model from the international classification of functioning, disability, and health using a large data set of community-dwelling Malaysian older adults. J Aging Health 2016; 28(4): 704-25. http://doi.org/10.1177/0898264315609907
https://doi.org/http://doi.org/10.1177/0... . Therefore, prevention policies (for example, those that combat chronic disease) can help to delay the processes that lead to disability in older adults⁵²52. McGough EL, Zumsteg JM. Lifestyle changes in the prevention of mobility disability. Healthy Aging Clin Care Elder 2014; 6: 33-41. http://doi.org/10.4137/HACCE.S12502
https://doi.org/http://doi.org/10.4137/H... . As in this study, other manuscripts did not find the GDP effect of disability on older adults in Brazil¹²12. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: A multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78. http://doi.org/10.1590/S0034-89102010005000009
https://doi.org/http://doi.org/10.1590/S... ^,1616. Lima ALB, Lima KC. Activity limitation in the elderly people and inequalities in Brazil. Open Access Library Journal 2014; 1: e739. http://doi.org/10.4236/oalib.1100739
https://doi.org/http://doi.org/10.4236/o... . As for life expectancy, there was no effect either, even though it is an important indicator of the population’s quality of life. It has also demonstrated the negative impact of disability on the health of older adults and its differential effects on women, considering their higher disabled life expectancy¹⁸18. Andrade FCD, Guevara PE, Lebrão ML, Duarte YAO, Santos JLF. Gender differences in life expectancy and disability-free life expectancy among older adults in Sao Paulo, Brazil. Womens Health Issues 2011; 21(1): 64-70. http://doi.org/10.1016/j.whi.2010.08.007
https://doi.org/http://doi.org/10.1016/j... . Other studies could be conducted by adding new individual and contextual variables, including the disability-free life expectancy, and making a comparison with other countries.

STRENGTHS AND LIMITATIONS

This study provides a representative approach to self-reported functional performance of older Brazilians and contributes to the analysis of the health situation in Brazil, allowing researchers to trace the disability profile in Brazil. It also reinforces the importance of policies that reduce social inequalities in disability. Despite this, this study has some limitations. The response rates were lower in some federative units compared to others, although sample weights have been used to correct this. Another limitation is derived from the nature of the sample: information was only collected from older adults living in the community and excluded other living situations, such as nursing homes, convents, and hospitals³⁴34. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde: Ciclos de vida [National Health Survey: Life Cycles], Brazil [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística [Brazilian Institute of Geography and Statistics] ; 2013 [cited on April 15, 2018]. [p. 30-5]. Available from: Available from: http://biblioteca.ibge.gov.br/visualizacao/livros/liv94522.pdf
http://biblioteca.ibge.gov.br/visualizac... . Moreover, the database that represents the general population, has limitations, particularly because it addressed self-reported diagnosis data⁵³53. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51(Suppl. 1): 1-10. http://doi.org/10.1590/s1518-8787.2017051000090
https://doi.org/http://doi.org/10.1590/s... . Older adults, at a disadvantaged socioeconomic level, might not have understood the questions asked during the BNHS or might be unaware of certain problems assessed in their locality, underestimating the prevalence. Furthermore, the study consisted of 27 samples in the second level of analysis, which could limit the ability to detect statistically significant differences between groups.

CONCLUSIONS

Women had higher disability disadvantages compared to men, and those differences were associated with social gender inequalities among the Brazilian federative units influenced by income inequality. However, it is important to consider that more studies are needed to elucidate other dimensions of functionality within and between the federative units, considering other social determinants of health.

ACKNOWLEDGMENTS

This article is part of the doctoral thesis of André Luiz Barbosa Lima, of the Federal University of Rio Grande do Norte, Brazil, with support from the Public Health Agency of Barcelona, Spain.

REFERENCES

Publication Dates

History