ABSTRACT:

Objective:

Estimate the magnitude of the income inequality in the prevalence of functional dependency for basic and instrumental activities of daily life (BADLs, IADLs) and the abandonment of advanced activities (AADLs).

Methods:

This was a cross-sectional, population-based study, developed using sample data of 986 elderly people from a health survey carried out in the municipality of Campinas, São Paulo, in 2014/15. The prevalence of functional dependency in BADLs and IADLs and of abandonment of the AADLs was estimated according to monthly family income per capita. A multiple regression Poisson analysis was developed to estimate the prevalence ratio (PR) adjusted by gender and age.

Results:

There was no significant association between income and functional dependency for BADLs. Of the seven IADLs analyzed, five presented a higher prevalence of dependency in the lower-income stratum, with special highlight to using the phone (PR = 3.50), controlling medication usage (PR = 2.44), and use of transportation (PR = 2.35). The abandonment of AADLs was higher among low-income elderly people in all activities analyzed, with the greatest inequalities observed in making contact by letter, phone and e-mail (PR = 3.76), using the Internet (PR = 3.34), driving vehicles (PR = 2.85) and visiting family (PR = 2.77).

Conclusions:

The broad inequality detected among income stratum regarding the functional capability for the IADLs and abandonment of the AADLs emphasize the importance of fully implementing and maintaining the policies and programs directed toward the social protection of elderly adults. The focus should be on the most socially vulnerable segments, with the aim of achieving a population that is more equal, active, independent, and involved in participatory ageing.

Keywords:
the Elderly; Health surveys; Health status disparities; Activities of daily living

INTRODUCTION

Relevant scientific, technological and social advancements of the 20th century¹1. Kalache A, Veras RP, Ramos LR. O envelhecimento da população mundial: um desafio. Rev Saúde Pública 1987; 21(3): 200-10. https://doi.org/10.1590/S0034-89101987000300005
https://doi.org/https://doi.org/10.1590/... have contributed to the rapid aging of the population, especially in the least developed regions of the world¹1. Kalache A, Veras RP, Ramos LR. O envelhecimento da população mundial: um desafio. Rev Saúde Pública 1987; 21(3): 200-10. https://doi.org/10.1590/S0034-89101987000300005
https://doi.org/https://doi.org/10.1590/... . Demographic projections indicate that, in 2050, two billion (21%) individuals around the world population will reach 60 years old or older, and among them, 425 million will be 80 years old²2. United Nations Department of Economic and Social. Affairs Population Division. World Prospects: The 2012 Revision. Highlights and Advance Tables. Nova York: United Nations; 2013.. In Brazil, it is estimated that, in 2050, almost a third of the population will be elderly (29.3%) and 6.7% will be 80 years old or older³3. Brasil. Câmara dos Deputados. Brasil 2050: desafios de uma nação que envelhece. Centro de Estudos e Debates Estratégicos. Edições Câmara; 2017. Série Estudos Estratégicos (8) ..

Given this scenario, it is essential to achieve better health and quality of life for the elderly, in order to preserve their autonomy as much as possible. This goal represents a serious challenge for health services, governments and social organizations⁴4. World Health Organization. Relatório Mundial sobre Envelhecimento e Saúde. Genebra: WHO; 2015.. Preserving and stimulating functional capacity to perform daily activities is essential for active aging, as advocated by the World Health Organization (WHO) and national policies⁴4. World Health Organization. Relatório Mundial sobre Envelhecimento e Saúde. Genebra: WHO; 2015.^,55. Brasil. Ministério da Saúde. Estatuto do Idoso [Internet]. 3ª ed. Brasília: Ministério da Saúde; 2013 [acessado em 10 ago. 2018]. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/estatuto_idoso_3edicao.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

Functional capacity is an important indicator of health in aging, as it reveals how independent the elderly population is in order to be able to carry out activities of different degrees of complexity, usually classified as basic (BADLs), instrumental (IADLs) and advanced activities of daily living (AADLs)⁶6. Campos ACV, Almeida MHM, Campos GV, Bogutchi TF. Prevalence of functional incapacity by gender in elderly people in Brazil: a systematic review with meta-analysis. Rev Bras Geriatr Gerontol 2016; 19(3): 545-59. https://doi.org/10.1590/1809-98232016019.150086
https://doi.org/https://doi.org/10.1590/... . The inability to perform them, which is associated with the presence of chronic diseases⁷7. Andriolo BNG, Santos NV, Volse AA, Fé LCM, Amaral ARC, Carmo BMSS, et al. Avaliação do grau de funcionalidade em idosos usuários de um centro de saúde. Rev Soc Bras Clin Med 2016; 14(3): 139-44., old age⁸8. Castro DC, Nunes DP, Pagoto V, Pereira LV, Bachion MM, Nakatani AYK. Incapacidade funcional para atividades básicas de vida diária de idosos: estudo populacional. Ciênc Cuid Saúde 2016; 15(1): 109-17. https://doi.org/10.4025/cienccuidsaude.v15i1.27569
https://doi.org/https://doi.org/10.4025/... and cognitive declines⁹9. Bleijenberg N, Zuithoff NPA, Smith AK, Wit NJ, Schuurmans MJ. Disability in the Individual ADL, IADL, and Mobility among Older Adults: a Prospective Cohort Study. J Nutr Health Aging 2017; 21: 897-903. https://doi.org/10.1007/s12603-017-0891-6
https://doi.org/https://doi.org/10.1007/... , indicates dependence on care by third parties¹⁰10. Giacomin KC, Uchôa E, Firmo JOA, Lima-Costa MF. Projeto Bambuí: um estudo de base populacional da prevalência e dos fatores associados à necessidade de cuidador entre idosos. Cad Saúde Pública 2005; 21(1): 80-91. https://doi.org/10.1590/S0102-311X2005000100010
https://doi.org/https://doi.org/10.1590/... and the risk of frequent hospitalizations ⁸8. Castro DC, Nunes DP, Pagoto V, Pereira LV, Bachion MM, Nakatani AYK. Incapacidade funcional para atividades básicas de vida diária de idosos: estudo populacional. Ciênc Cuid Saúde 2016; 15(1): 109-17. https://doi.org/10.4025/cienccuidsaude.v15i1.27569
https://doi.org/https://doi.org/10.4025/... .

Research has shown significant associations between functional capacity and different indicators of socioeconomic status,¹⁰10. Giacomin KC, Uchôa E, Firmo JOA, Lima-Costa MF. Projeto Bambuí: um estudo de base populacional da prevalência e dos fatores associados à necessidade de cuidador entre idosos. Cad Saúde Pública 2005; 21(1): 80-91. https://doi.org/10.1590/S0102-311X2005000100010
https://doi.org/https://doi.org/10.1590/... ^,1111. Nunes DP, Brito TRP, Giacomin KC, Duarte YAO, Lebrão ML. Performance pattern of activities of daily living for older adults in the city of São Paulo in 2000, 2006, and 2010. Rev Bras Epidemiol 2018; 21(Supl. 2). https://doi.org/10.1590/1980-549720180019.supl.2
https://doi.org/https://doi.org/10.1590/... ^,1212. Bierhals IO, Meller FO, Assunção MCF. Dependência para a realização de atividades relacionadas à alimentação em idosos. Ciênc Saúde Coletiva [Internet]. 2016 [acessado em 18 jun. 2020]; 21(4): 1297-308. http://dx.doi.org/10.1590/1413-81232015214.12922015
https://doi.org/http://dx.doi.org/10.159... analyzing BADLs¹³13. Andrade TB, Andrade FB. Unmet need for assistance with activities of daily life among older adults in Brazil. Rev Saúde Pública 2018; 52: 75. https://doi.org/10.11606/s1518-8787.2018052000463
https://doi.org/https://doi.org/10.11606... ^,1414. Andrade FB, Duarte YAO, Souza Júnior PRB, Torres JL, Lima-Costa MF, Andrade FCD. Inequalities in basic activities of daily living among older adults: ELSI-Brazil, 2015. Rev Saúde Pública 2018; 52(Supl. 2): 14s. https://doi.org/10.11606/s1518-8787.2018052000617
https://doi.org/https://doi.org/10.11606... ^,1515. Giacomin KC, Duarte YAO, Camarano AA, Nunes DP, Fernandes D. Cuidado e limitações funcionais em atividades cotidianas - ELSI-Brasil. Rev Saúde Pública 2018; 52(Supl. 2): 9s. https://doi.org/10.11606/s1518-8787.2018052000650
https://doi.org/https://doi.org/10.11606... or IADLs⁷7. Andriolo BNG, Santos NV, Volse AA, Fé LCM, Amaral ARC, Carmo BMSS, et al. Avaliação do grau de funcionalidade em idosos usuários de um centro de saúde. Rev Soc Bras Clin Med 2016; 14(3): 139-44.^,1616. Farías-Antúnez S, Lima NP, Bierhals IO, Gomes AP, Vieira LS, Tomasi E. Incapacidade funcional para atividades básicas e instrumentais da vida diária: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014. Epidemiol Serv Saúde 2018; 27(2): e2017290. https://doi.org/10.5123/s1679-49742018000200005
https://doi.org/https://doi.org/10.5123/... . Family income per capita (FIPC), as an indicator of socioeconomic level, is justified by its importance in social reproduction in Brazil. Given the absence or insufficiency of social support, such as quality education, adequate provision of health services, transportation, leisure and decent housing conditions, income assumes a primary role as an indicator of spending and purchasing power of goods and services that are considered to be important for having a satisfactory life¹⁷17. Parahyba MI, Simões CCS. A prevalência de incapacidade funcional em idosos no Brasil. Ciênc Saúde Coletiva [Internet]. 2006 [acessado em 18 jun. 2020]; 11(4): 967-74. Disponível em: http://dx.doi.org/10.1590/S1413-81232006000400018
https://doi.org/http://dx.doi.org/10.159... .

In countries like Brazil, where profound socioeconomic inequalities prevail, it is essential to know and monitor the role of income in preserving active and healthy aging. It is also important to assess the magnitude of possible disparities considering daily activities of different degrees of complexity, as well as the specific activities most affected by income differences. This analysis is based on the principle that dependence on each activity generates different impacts on the life of the elderly and on the demand for care. Several authors have analyzed specific activities⁸8. Castro DC, Nunes DP, Pagoto V, Pereira LV, Bachion MM, Nakatani AYK. Incapacidade funcional para atividades básicas de vida diária de idosos: estudo populacional. Ciênc Cuid Saúde 2016; 15(1): 109-17. https://doi.org/10.4025/cienccuidsaude.v15i1.27569
https://doi.org/https://doi.org/10.4025/... ^,1212. Bierhals IO, Meller FO, Assunção MCF. Dependência para a realização de atividades relacionadas à alimentação em idosos. Ciênc Saúde Coletiva [Internet]. 2016 [acessado em 18 jun. 2020]; 21(4): 1297-308. http://dx.doi.org/10.1590/1413-81232015214.12922015
https://doi.org/http://dx.doi.org/10.159... ^,1313. Andrade TB, Andrade FB. Unmet need for assistance with activities of daily life among older adults in Brazil. Rev Saúde Pública 2018; 52: 75. https://doi.org/10.11606/s1518-8787.2018052000463
https://doi.org/https://doi.org/10.11606... ^,1818. Tareque MI, Tiedt AD, Islam TM, Begum S, Saito Y. Gender differences in functional disability and self-care among seniors in Bangladesh. BMC Geriatr. 2017;17(1):177. http://dx.doi.org/10.1186/s12877-017-0577-2
https://doi.org/http://dx.doi.org/10.118... , but there is a lack of Brazilian studies on social inequalities and dependency on these activities.

As such, this study aimed to estimate the magnitude of income inequalities in the prevalence of functional dependence in BADL and IADL, as well as in the abandonment of AADL, among elderly people living in a municipality in southeastern Brazil.

METHODS

This is a cross-sectional, population-based study, developed with data from the Health Survey in the Municipality of Campinas (ISACamp), conducted in 2014 and 2015. The survey population consisted of individuals aged 10 years or over, living in private households in the urban area of the municipality. The sampling process was stratified by clusters in two stages. In the first stage, 70 census tracts were drawn and in the second stage, households were selected.

The sample size was defined to guarantee estimates of a 0.50 proportion, with a 95% confidence interval (95%CI), and an error of 4 to 5 percentage points, considering the design effect of 2. Of the three age groups (adolescents, adults and the elderly) that comprised the sample domains of the survey, only the elderly were analyzed in this study. A sample size of one thousand elderly people was defined, with 2,853 households being randomly selected to interview. A non-response rate of 20% was considered based on previous surveys. These households were drawn in the 70 census sectors previously sampled, generating a representative sample of the elderly population in the municipality. In each household, all residents of the age group for which the address had been drawn were interviewed. The option of not randomly selecting individuals in each household is due to the fact that this type of design is similar in terms of accuracy and has a lower cost in relation to the drawing of one person per household¹⁹19. Alves MCGP, Escuder MML, Claro RM, Silva NN. Seleção dentro das famílias em pesquisas de saúde. Rev Saúde Pública [Internet]. 2014 [acessado em 18 jun. 2020]; 48(1): 86-93. Disponível em: https://doi.org/10.1590/S0034-8910.2014048004540
https://doi.org/https://doi.org/10.1590/... .

The ISACamp 2014/2015 questionnaire was structured into 13 thematic blocks and applied by trained and supervised interviewers, using tablets given directly to the selected individual. In the case of elderly people with difficulties in answering the questionnaire, the information was provided by a family member or caregiver.

Regarding the study variables, functional dependence referred to the need for partial or total help in performing BADLs and IADLs. The BADLs included: bathing; getting dressed; using the toilet; lying down/getting up, and eating²⁰20. Katz S, Akpom CA. A measure of primary sociobiological functions. Int J Health Serv 1976; 6(3): 493-508. http://doi.org/10.2190/UURL-2RYU-WRYD-EY3K
https://doi.org/http://doi.org/10.2190/U... . The IADLs analyzed were: using the phone; using transportation; shopping; preparing their own meal; performing household chores; controlling their use of medications, and taking care of their finances²¹21. Lino VTS, Pereira SMR, Camacho LAB, Ribeiro Filho ST, Buksman S. Adaptação transcultural da Escala de Independência em Atividades da Vida Diária (Escala de Katz). Cad Saúde Pública 2008; 24(1): 103-12. https://doi.org/10.1590/S0102-311X2008000100010
https://doi.org/https://doi.org/10.1590/... . The prevalence of dependence on IADLs was estimated in relation to those who used to do the activity.

The study also analyzed the abandonment of AADLs, that is, the report of having stopped doing them. The AADLs considered were: performing voluntary work; writing people letters, sending e-mails or calling people on the telephone; receiving and visiting friends and family; participating in cultural or social activities; using the internet; taking short or long trips, and driving a car²²22. Oliveira EM, Silva HS, Lopes A, Cachioni M, Falcão DVS, Batistoni SST, et al. Advanced Activities of Daily Living (AADL) and cognitive performance among older adults. Psico-USF 2015; 20(1): 109-20. http://dx.doi.org/10.1590/1413-82712015200110
https://doi.org/http://dx.doi.org/10.159... ^,2323. Dias EN, Silva JV, Pais-Ribeiro JL, Martins T. Validation of the advanced activities of daily living scale. Geriatr Nurs 2019; 40(1): 7-12. http://doi.org/10.1016/j.gerinurse.2018.05.008
https://doi.org/http://doi.org/10.1016/j... . The prevalences of those who abandoned the AADLs were estimated in relation to those who, previously, had done the activity.

The main independent variable analyzed was monthly family income in minimum wages per capita (which in 2014 corresponded to R$ 724), obtained by adding the income of the family members, divided by the number of residents of the household. For this income, three categories were developed: less than 1 minimum wage, between 1 and 2 minimum wages, more than 2 minimum wages.

The other independent variables used to characterize the study population were:

The prevalence and prevalence ratios (PRs) of dependence on each BADL and each IADL were estimated, as well as abandonment of each AADL, according to income strata. The prevalence of dependency in at least one BADL and in at least one IADL was also estimated, as well as having abandoned at least one AALD. To determine the associations, Pearson’s χ² test was used, with a Rao-Scott adjustment, considering those with p <0.05 to be statistically significant. And to estimate the PRs adjusted for sex and age, Poisson multiple regression was used.

Because it is a complex sample, the data were analyzed using the command svy from the statistical software Stata, version 14.0 (Stata Corp., College Station, United States), which allows for the consideration of the sample weights, post-stratification weights and design by clusters.

ISACamp was approved by the Research Ethics Committee of the School of Medical Sciences of the Universidade Estadual de Campinas under opinion nº 3,734,746, of November 29, 2019 (Plataforma Brasil, Presentation Certificate for Ethical Appreciation - Certificado de Apresentação para Apreciação Ética - CAAE no. 24785519.0. 0000.5404).

RESULTS

In the 2,853 households chosen to interview the elderly, there was 6.8% refusals and other losses. Among the 1,168 elderly people located in the selected households, there were 15.5% losses, subdivided into 14% refusals and 1.5% for other reasons. The final sample consisted of 986 elderly people and 57 (5.7%) of them completed the questionnaire with the help of a family member or caregiver. The study population consisted of 57.7% women and 56.8% individuals aged 60 to 69 years.

Significant sociodemographic inequalities differentiated the elderly from the three income strata analyzed. While 51% of the elderly in the FIPC segment below a minimum wage had less than four years of schooling, this percentage declined to 11.3% in the upper income stratum. In this stratum, 49.2% of the elderly had nine or more years of study, while only 10.2% of the lower income segment reached this level of education. In the upper income stratum, 80% of the elderly were white, 76.1% had 11 or more pieces of equipment at home, 61.5% had access to a computer and 75.7% had a private health plan, lowering these percentages, respectively, to 62.8, 32.4, 40, and 23% in the lower income stratum (Table 1).

The percentage of elderly people with self-rated health as fair to very poor increased with decreasing income, reaching 43.8% of the elderly in the poorest segment. The prevalence of dependence on some IADL and abandonment of some AADL also increased significantly with declining income (Table 1).

Regarding functional dependence for BADL (Table 2), there were no significant differences for the performance of any of the activities in the comparisons between the income categories. In relation to functional dependence in IADLs, the prevalence of dependent elderly people was higher among those belonging to the lower income segment, compared to those with higher income, in five activities. The greatest inequalities detected were in: using the telephone (PR = 3.50), using transportation (PR = 2.35) and controlling their use of medications (PR = 2.40). A gradient was observed with an increase in the percentages of dependence accompanying the reduction in income.

In Table 3, it is observed that the prevalence of abandonment of all analyzed AADLs was significantly higher in the elderly with lower income. The biggest differences found between the extreme strata of income were in making contact through letters, email or over the telephone (PR = 3.76), using the internet (PR = 3.34), driving vehicles (PR = 2.85) and visiting family and friends (PR = 2.77). There was an increase in the percentage of those who abandoned the AADLs following the reduction in income from the strata.

DISCUSSION

Important demographic, socioeconomic and access to private health care inequalities were observed among the income strata of the elderly population studied. This research revealed the existence of significant income inequalities in the prevalence of dependence for five IADLs and in the prevalence of abandonment for all studied AADLs. It became evident that the level of inequality differs between activities and that disparities tend to be more present and of greater magnitude in AADLs compared to IADLs. In this study, no statistically significant differences were detected between the prevalence of dependence on BADLs according to income level.

The prevalence of dependence in at least one of the five basic activities analyzed in this study was 8.4% in the elderly aged 60 years old or older. This prevalence is higher than that observed in a study carried out in Singapore (6.6%)²⁴24. Ng TP, Niti M, Chiam PC, Kua EH. Prevalence and correlates of functional disability in multiethnic elderly singaporeans. J Am Geriatr Soc 2006; 54(1): 21-9. https://doi.org/10.1111/j.1532-5415.2005.00533.x
https://doi.org/https://doi.org/10.1111/... and similar to that found in research carried out in Ireland (8%)²⁵25. Millán-Calenti JC, Tubío J, Pita-Fernández S, Abraldes IG, Lorenzo T, Fernández-Arruty T, et al. Prevalence of functional disability in activities of daily living (ADL), instrumental activities of daily living (IADL) and associated factors, as predictors of morbidity and mortality. Arq Gerontol Geriatr 2010; 50(3): 306-10. https://doi.org/10.1016/j.archger.2009.04.017
https://doi.org/https://doi.org/10.1016/... . But a study carried out in New York, with individuals aged 65 and over, found that 28% of them had lacked an ability in at least one BADL²³23. Dias EN, Silva JV, Pais-Ribeiro JL, Martins T. Validation of the advanced activities of daily living scale. Geriatr Nurs 2019; 40(1): 7-12. http://doi.org/10.1016/j.gerinurse.2018.05.008
https://doi.org/http://doi.org/10.1016/j... . In Brazil, data from the National Health Survey (Pesquisa Nacional de Saúde - PNS) indicated the presence of these disabilities in 16% of the elderly population aged 60 years old or older¹³13. Andrade TB, Andrade FB. Unmet need for assistance with activities of daily life among older adults in Brazil. Rev Saúde Pública 2018; 52: 75. https://doi.org/10.11606/s1518-8787.2018052000463
https://doi.org/https://doi.org/10.11606... . Even higher prevalence rates were observed in other Brazilian studies: 36.1% in the research by Farías-Antúnez et al.¹⁶16. Farías-Antúnez S, Lima NP, Bierhals IO, Gomes AP, Vieira LS, Tomasi E. Incapacidade funcional para atividades básicas e instrumentais da vida diária: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014. Epidemiol Serv Saúde 2018; 27(2): e2017290. https://doi.org/10.5123/s1679-49742018000200005
https://doi.org/https://doi.org/10.5123/... and 26.8% in the study by Del Duca et al.²⁶26. Del Duca GF, Silva MC, Hallal PC. Disability relating to basic and instrumental activities of daily living among elderly subjects. Rev Saúde Pública [Internet]. 2009 [acessado em 18 jun. 2019]; 43(5): 796-805. https://doi.org/10.1590/S0034-89102009005000057
https://doi.org/https://doi.org/10.1590/... . Some studies include the presence of urinary or fecal incontinence among the studied BADLs, regardless of whether the condition caused functional dependence or not⁸8. Castro DC, Nunes DP, Pagoto V, Pereira LV, Bachion MM, Nakatani AYK. Incapacidade funcional para atividades básicas de vida diária de idosos: estudo populacional. Ciênc Cuid Saúde 2016; 15(1): 109-17. https://doi.org/10.4025/cienccuidsaude.v15i1.27569
https://doi.org/https://doi.org/10.4025/... ^,1616. Farías-Antúnez S, Lima NP, Bierhals IO, Gomes AP, Vieira LS, Tomasi E. Incapacidade funcional para atividades básicas e instrumentais da vida diária: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014. Epidemiol Serv Saúde 2018; 27(2): e2017290. https://doi.org/10.5123/s1679-49742018000200005
https://doi.org/https://doi.org/10.5123/... ^,2626. Del Duca GF, Silva MC, Hallal PC. Disability relating to basic and instrumental activities of daily living among elderly subjects. Rev Saúde Pública [Internet]. 2009 [acessado em 18 jun. 2019]; 43(5): 796-805. https://doi.org/10.1590/S0034-89102009005000057
https://doi.org/https://doi.org/10.1590/... . Other studies have included the prevalence of elderly people who have some difficulty in carrying out the activity, even if they do not need the help of others¹³13. Andrade TB, Andrade FB. Unmet need for assistance with activities of daily life among older adults in Brazil. Rev Saúde Pública 2018; 52: 75. https://doi.org/10.11606/s1518-8787.2018052000463
https://doi.org/https://doi.org/10.11606... ^,1414. Andrade FB, Duarte YAO, Souza Júnior PRB, Torres JL, Lima-Costa MF, Andrade FCD. Inequalities in basic activities of daily living among older adults: ELSI-Brazil, 2015. Rev Saúde Pública 2018; 52(Supl. 2): 14s. https://doi.org/10.11606/s1518-8787.2018052000617
https://doi.org/https://doi.org/10.11606... . These two conditions tend to raise the prevalence values. In the present study, urinary/fecal incontinence was not included and only elderly people who needed some help, whether partial or complete help, were considered dependent for BADLs. Thus, the differences in prevalence between studies depend on the list of investigated activities, the age group analyzed and differences in other methodological aspects, in addition to differences in the health conditions of the target populations.

In this study, no association was found between dependence for BADLs and family income. A similar result was observed in a study carried out in the Netherlands, using different levels of education⁸8. Castro DC, Nunes DP, Pagoto V, Pereira LV, Bachion MM, Nakatani AYK. Incapacidade funcional para atividades básicas de vida diária de idosos: estudo populacional. Ciênc Cuid Saúde 2016; 15(1): 109-17. https://doi.org/10.4025/cienccuidsaude.v15i1.27569
https://doi.org/https://doi.org/10.4025/... , and in a study carried out in Pelotas, which found no inequality in the prevalence of BADL dependency between income or schooling levels²⁶26. Del Duca GF, Silva MC, Hallal PC. Disability relating to basic and instrumental activities of daily living among elderly subjects. Rev Saúde Pública [Internet]. 2009 [acessado em 18 jun. 2019]; 43(5): 796-805. https://doi.org/10.1590/S0034-89102009005000057
https://doi.org/https://doi.org/10.1590/... . However, many studies have detected socioeconomic inequalities in the prevalence of dependence for BADLs¹³13. Andrade TB, Andrade FB. Unmet need for assistance with activities of daily life among older adults in Brazil. Rev Saúde Pública 2018; 52: 75. https://doi.org/10.11606/s1518-8787.2018052000463
https://doi.org/https://doi.org/10.11606... ^,1616. Farías-Antúnez S, Lima NP, Bierhals IO, Gomes AP, Vieira LS, Tomasi E. Incapacidade funcional para atividades básicas e instrumentais da vida diária: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014. Epidemiol Serv Saúde 2018; 27(2): e2017290. https://doi.org/10.5123/s1679-49742018000200005
https://doi.org/https://doi.org/10.5123/... . Differences in the instruments used for the evaluation of BADLs, with regard to the statistical power of the studies and the socioeconomic indicators employed, may account, in part, for the detection or not of socioeconomic inequalities. Because the prevalence for BADL dependece is low, the detection of significant differences requires larger sample sizes. The survival bias cannot be ruled out either, considering that individuals of lower socioeconomic levels tend to have higher premature mortality.

Regarding IADLs, this study found that 42.9% of the elderly were dependent for at least one of the activities analyzed. This prevalence is similar to that found in Lafaiete Coutinho, Bahia (41%)²⁷27. Freitas RS, Fernandes MH, Coqueiro RS, Reis Júnior WM, Rocha SV, Brito TA. Functional capacity and associated factors in the elderly: a population study. Acta Paul Enferm 2012; 25(6): 933-9. https://doi.org/10.1590/S0103-21002012000600017
https://doi.org/https://doi.org/10.1590/... , and in research with elderly people in rural areas of Pelotas (45.4%)²⁸28. Pinto AH, Lange C, Pastore CA, Llano PMP, Castro DP, Santos F. Capacidade funcional para realizar atividades de vida diária entre idosos residentes em áreas rurais cadastradas na Estratégia de Saúde da Família. Ciênc Saúde Coletiva 2016; 21(11): 3545-55. https://doi.org/10.1590/1413-812320152111.22182015
https://doi.org/https://doi.org/10.1590/... , but it is lower than that found in Spain in people aged 65 or over (53.5%)²⁵25. Millán-Calenti JC, Tubío J, Pita-Fernández S, Abraldes IG, Lorenzo T, Fernández-Arruty T, et al. Prevalence of functional disability in activities of daily living (ADL), instrumental activities of daily living (IADL) and associated factors, as predictors of morbidity and mortality. Arq Gerontol Geriatr 2010; 50(3): 306-10. https://doi.org/10.1016/j.archger.2009.04.017
https://doi.org/https://doi.org/10.1016/... Nevertheless, this prevalence is higher than that found in other studies¹⁶16. Farías-Antúnez S, Lima NP, Bierhals IO, Gomes AP, Vieira LS, Tomasi E. Incapacidade funcional para atividades básicas e instrumentais da vida diária: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014. Epidemiol Serv Saúde 2018; 27(2): e2017290. https://doi.org/10.5123/s1679-49742018000200005
https://doi.org/https://doi.org/10.5123/... ^,2929. Torres JL, Lima-Costa MF, Marmot M, Oliveira C. Riqueza e incapacidade em vida posterior: O Estudo Longitudinal Inglês do Envelhecimento (ELSA). PloS One 2016; 11(11): e0166825. https://doi.org/10.1371/journal.pone.0166825
https://doi.org/https://doi.org/10.1371/... .

In this study, inequalities were detected between income strata regarding dependence for five IADLs. The inequalities varied, with the stratum of the worst income having a prevalence of dependence between 1.56 and 3.5 times higher than that of the highest income, depending on the IADL considered. Similar to the present study, some studies also detected social inequalities in the prevalence of being dependent for at least one IADL, however, this was found when using educational level¹⁵15. Giacomin KC, Duarte YAO, Camarano AA, Nunes DP, Fernandes D. Cuidado e limitações funcionais em atividades cotidianas - ELSI-Brasil. Rev Saúde Pública 2018; 52(Supl. 2): 9s. https://doi.org/10.11606/s1518-8787.2018052000650
https://doi.org/https://doi.org/10.11606... ^,3030. Nunes JD, Saes MO, Nunes BP, Siqueira FCV, Soares DCS, Fassa MEG, et al. Functional disability indicators and associated factors in the elderly: a Population-based study in Bagé, Rio Grande do Sul, Brazil. Epidemiol Serv Saúde 2017; 26(2): 295-304. https://doi.org/10.5123/S1679-49742017000200007
https://doi.org/https://doi.org/10.5123/... as an indicator of social inequality. But other studies have found no association between socioeconomic status indicators and disability for IADL²⁶26. Del Duca GF, Silva MC, Hallal PC. Disability relating to basic and instrumental activities of daily living among elderly subjects. Rev Saúde Pública [Internet]. 2009 [acessado em 18 jun. 2019]; 43(5): 796-805. https://doi.org/10.1590/S0034-89102009005000057
https://doi.org/https://doi.org/10.1590/... ^,3131. Virtuoso Júnior JS, Tribess S, Menezes AS, Meneguci J, Sasaki JE. Factors associated with functional disability in Brazilian older adults. Rev Andal Med Deporte 2016. http://doi.org/10.1016/j.ramd.2016.05.003
https://doi.org/http://doi.org/10.1016/j... .

Some studies have analyzed the prevalence of dependence for specific tasks of IADLs. In a study carried out in Goiânia, disability varied from 12.4% for taking medications to 30.5% for using the telephone³⁰30. Nunes JD, Saes MO, Nunes BP, Siqueira FCV, Soares DCS, Fassa MEG, et al. Functional disability indicators and associated factors in the elderly: a Population-based study in Bagé, Rio Grande do Sul, Brazil. Epidemiol Serv Saúde 2017; 26(2): 295-304. https://doi.org/10.5123/S1679-49742017000200007
https://doi.org/https://doi.org/10.5123/... . Research carried out in Pelotas demonstrated that 11.8% of the elderly were incapable of handling money and 17.6% were incapable of using transport²⁶26. Del Duca GF, Silva MC, Hallal PC. Disability relating to basic and instrumental activities of daily living among elderly subjects. Rev Saúde Pública [Internet]. 2009 [acessado em 18 jun. 2019]; 43(5): 796-805. https://doi.org/10.1590/S0034-89102009005000057
https://doi.org/https://doi.org/10.1590/... .

However, no studies have been found that have assessed socioeconomic inequality in the prevalence of dependence for specific IADLs. The results of this research revealed that no significant inequalities were found between income strata, only for domestic tasks and the preparation of meals. The greatest inequalities were detected in activities that reduce social participation or that have more direct health implications. For example, inequalities when using the telephone imply limitations to social connection and additionally with regard to health care, in the event of a need to call for help in an emergency situation. Dependence for the use of public transport can reduce mobility and increase demand for family members or caregivers. The inability to control medication usage and, especially, the need for more complex medical home care, become important problems for public health due to the costs and risks they represent.

The marked inequalities detected in dependence for IADLs and the fact that they differ according to the activity considered, point to the need for further studies to assess and monitor social disparities in specific IADLs, so that they can be considered in policies and programs to promote elderly health.

During the aging process, people gradually lose functional capacity, generating cognitive, functional and sensory impairments. To start, the AADLs become compromised and, then the IADLs and BADLs, making a portion of the elderly dependent on continuous assistance³²32. Dias EG, Duarte YAO, Almeida MHM, Lebrão ML. Characterization of advanced activities of daily living (AADL): a review. Rev Ter Ocup Univ 2011; 22(1): 45-51. http://doi.org/10.11606/issn.2238-6149.v22i1p45-51
https://doi.org/http://doi.org/10.11606/... . In a systematic review developed with 31 articles, most studies agree that the inability to perform AADLs implies increased risks of worsening cognitive status, depression and mortality³³33. Barbosa BR, Almeida JM, Barbosa MR, Rossi-Barbosa LAR. Evaluation of the functional capacity of the elderly and factors associated with disability. Ciên Saúde Coletiva 2014; 19(8): 3317-25. https://doi.org/10.1590/1413-81232014198.06322013
https://doi.org/https://doi.org/10.1590/... . The inability to perform advanced activities is associated with demographic, behavioral and health conditions³⁴34. Nogueira SL, Ribeiro RCL, Rosado LEFPL, Franceschini SCC, Ribeiro AQ, Pereira ET. Determinant factors of functional status among the oldest old. Rev Bras Fisioter 2010; 14(4): 322-9. https://doi.org/10.1590/S1413-35552010005000019
https://doi.org/https://doi.org/10.1590/... .

It was found that the inability to perform seven of the analyzed AAVDs had significantly higher prevalences in the lower income stratum. Abandoning contact with friends and family by letter, e-mail or telephone was 2.8 and 3.8 times, respectively, more prevalent in the poorest strata. Abandoning internet usage was 3.3 times higher in the elderly from the poorest strata, a result that differs from that observed in a study carried out in Florianópolis, Santa Catarina, in which no difference was detected in the abandoning of internet use between schooling levels or income³⁵35. Krug RR, Xavier AJ, d’Orsi E. Fatores associados à manutenção do uso da internet, estudo longitudinal EpiFloripa Idoso. Rev Saúde Pública 2018; 52: 37. https://doi.org/10.11606/s1518-8787.2018052000216
https://doi.org/https://doi.org/10.11606... . Research carried out in four Brazilian locations evaluated the abandonment of thirteen AADLs and identified that the highest percentages were in paid work, long trips and participation in social events³⁶36. Neri AL, Vieira LAM. Social involvement and perceived social support in old age. 2013; 16(3): 419-32. https://doi.org/10.1590/S1809-98232013000300002
https://doi.org/https://doi.org/10.1590/... . However, abandonment was not assessed according to socioeconomic level. A study that analyzed the frequency and diversity of contact (with family and friends) in the elderly in the city of São Paulo found that, in men, the poorest quartile had higher chances of low frequency (OR = 2.54; 95%CI % 1.36 - 4.73) and a low diversity of contacts (OR = 4.97; 95%CI 2.54 - 9.69) compared to the richest (3^rd and 4^th income quartiles), but in women, this association was not observed³⁷37. Rosa TEC, Benício MHD, Alves MCGP, Lebrão ML. Structural and functional aspects of social support for the elderly in the city of São Paulo, Brazil. Cad Saúde Pública 2007; 23(12): 2982-92. https://doi.org/10.1590/S0102-311X2007001200019
https://doi.org/https://doi.org/10.1590/... .

The significant income inequalities detected, both in the functional dependence of the elderly for IADLs and in the abandonment of AADLs, underscore the importance of guaranteeing that Brazilian elderly people, especially to the most vulnerable social segments, have access to existing social protection programs and benefits. It also stresses the need to maintain these programs³⁸38. Brasil. Senado Federal. Constituição da República Federativa do Brasil: texto constitucional promulgado em 5 de outubro de 1988. Brasília: Senado Federal; 1988.. The Organic Law on Social Assistance³⁹39. Brasil. Lei nº 8.742, de 7 de dezembro 1993. Dispõe sobre a organização da Assistência Social e dá outras providências [Internet]. Brasília: Presidência da República, 1993 [acessado em 10 ago. 2018]. Disponível em: Disponível em: http://www.planalto.gov.br/ccivil_03/LEIS/L8742.htm
http://www.planalto.gov.br/ccivil_03/LEI... , in turn, guarantees the minimum income necessary for the survival of the elderly and their families, an aid that provides better living conditions. Furthermore, it can repair part of the social losses experienced in earlier stages of life. These factors are relevant to prevent and reduce disability and functional dependence⁴⁰40. Amorim JSC, Salla S, Trelha CS. Factors associated with work ability in the elderly: systematic review. Rev Bras Epidemiol 2014; 17(4): 830-41. https://doi.org/10.1590/1809-4503201400040003
https://doi.org/https://doi.org/10.1590/... .

In addition, health promotion, disease prevention and quality care coverage policies are essential to reduce the effect of socioeconomic inequality on the functional capacity of the rapidly aging population⁴⁰40. Amorim JSC, Salla S, Trelha CS. Factors associated with work ability in the elderly: systematic review. Rev Bras Epidemiol 2014; 17(4): 830-41. https://doi.org/10.1590/1809-4503201400040003
https://doi.org/https://doi.org/10.1590/... . However, studies point to setbacks in the coverage and universalization of health services, in addition to the lack of coordination and financing of specific actions that should be available to the elderly⁴¹41. Oxfam Brasil. A distância que nos une: um retrato das desigualdades brasileiras [Internet]. São Paulo: Oxfam; 2017 [acessado em 18 ago. 2019]. Disponível em: Disponível em: https://www.oxfam.org.br/um-retrato-das-desigualdades-brasileiras/a-distancia-que-nos-une/
https://www.oxfam.org.br/um-retrato-das-... ^,4242. Stuckler D, Reeves A, Loopstra R, Karanikolos M, McKee M. Austerity and health: the impact in the UK and Europe. European J Public Health 2017; 27(Supl. 4): 18-21. http://doi.org/10.1093/eurpub/ckx167
https://doi.org/http://doi.org/10.1093/e... . The implementation of actions and policies to protect the health of the elderly is especially important in periods of increased income concentration⁴³43. Pickety T. O capital do século XXI. Rio de Janeiro: Intrínseca; 2014.^,4444. FGV Social. A escalada da desigualdade: qual o impacto da crise sobre a distribuição de renda e a pobreza [Internet]. Rio de Janeiro: FGV Social; 2019 [acessado em 15 abr. 2019]. Disponível em: Disponível em: https://www.cps.fgv.br/cps/bd/docs/A-Escalada-da-Desigualdade-Marcelo-Neri-FGV-Social.pdf
https://www.cps.fgv.br/cps/bd/docs/A-Esc... and economic and political crises that tend to increase social and health inequalities⁴²42. Stuckler D, Reeves A, Loopstra R, Karanikolos M, McKee M. Austerity and health: the impact in the UK and Europe. European J Public Health 2017; 27(Supl. 4): 18-21. http://doi.org/10.1093/eurpub/ckx167
https://doi.org/http://doi.org/10.1093/e... .

One of the limitations of this study, due to its cross-sectional design, is the impossibility of establishing cause and effect relationships. Thus, it was not possible to exclude the occurrence of reduced income caused by the appearance of functional disabilities¹³13. Andrade TB, Andrade FB. Unmet need for assistance with activities of daily life among older adults in Brazil. Rev Saúde Pública 2018; 52: 75. https://doi.org/10.11606/s1518-8787.2018052000463
https://doi.org/https://doi.org/10.11606... . But this effect would be more present in the lack of ability regarding BADLs in which, in this study, there were no differences according to the income category. Comparisons with results from other studies are hampered by the use of different indicators and analysis strategies. It is also necessary to consider the sample losses that occurred. The percentage of losses was lower than expected in the sample planning (20%), and a bias that could result from differential loss would have been, to a large extent, controlled by the post- stratification used in the analyzes of this study. The sample size also limited the statistical power of the study in identifying PRs <1.7 as statistically significant when the prevalence of disabilities was less than 20%.

The study showed that the income level of the elderly is associated with ethnic, educational, living conditions and functional dependence for IADLs and abandonment of AADLs. It also made it possible to assess social inequality in a more comprehensive profile of functional capacity by analyzing three levels of activities (BADL, IADL and AADL), which has not been done by many studies⁸8. Castro DC, Nunes DP, Pagoto V, Pereira LV, Bachion MM, Nakatani AYK. Incapacidade funcional para atividades básicas de vida diária de idosos: estudo populacional. Ciênc Cuid Saúde 2016; 15(1): 109-17. https://doi.org/10.4025/cienccuidsaude.v15i1.27569
https://doi.org/https://doi.org/10.4025/... ^,2626. Del Duca GF, Silva MC, Hallal PC. Disability relating to basic and instrumental activities of daily living among elderly subjects. Rev Saúde Pública [Internet]. 2009 [acessado em 18 jun. 2019]; 43(5): 796-805. https://doi.org/10.1590/S0034-89102009005000057
https://doi.org/https://doi.org/10.1590/... ^,3737. Rosa TEC, Benício MHD, Alves MCGP, Lebrão ML. Structural and functional aspects of social support for the elderly in the city of São Paulo, Brazil. Cad Saúde Pública 2007; 23(12): 2982-92. https://doi.org/10.1590/S0102-311X2007001200019
https://doi.org/https://doi.org/10.1590/... . Furthermore, it allowed for the measurement of socioeconomic inequalities in specific activities of daily living, which has not yet been done. Considering the contemporary increase in income concentration indices⁴¹41. Oxfam Brasil. A distância que nos une: um retrato das desigualdades brasileiras [Internet]. São Paulo: Oxfam; 2017 [acessado em 18 ago. 2019]. Disponível em: Disponível em: https://www.oxfam.org.br/um-retrato-das-desigualdades-brasileiras/a-distancia-que-nos-une/
https://www.oxfam.org.br/um-retrato-das-... , socioeconomic inequalities, and poverty, the already observed harmful effects of economic austerity policies,⁴⁵45. Stuckler D, Bau S. A economia desumana: porque mata a austeridade. Lisboa: Bizâncio; 2014. and the losses produced by social pension reform modalities⁴⁶46. Oliveira SC, Machado CV, Hein AA. Reformas da Previdência Social no Chile: lições para o Brasil. Cad Saúde Pública 2019; 35(5): e00045219. http://doi.org/10.1590/0102-311x00045219
https://doi.org/http://doi.org/10.1590/0... , there is a need to monitor the magnitude of social inequalities in health and the functional capacity of the elderly.

ACKNOWLEDGMENTS

We would like to thank the National Council for Scientific and Technological Development (CNPq) for M.B.A. Barros’ productivity scholarship; the Research Support Foundation of the State of São Paulo (FAPESP), process no. 2012/23324-3, and the research funding from the Ministry of Health via the Campinas Municipal Health Department; and the Piauí State Health Department, for having allowed the first author to participate in the doctoral program.

References

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