Gender inequalities in health among older Brazilian adults.

OBJECTIVE: To investigate gender differences among older Brazilians in their health status and their use of health services. METHODS: Participants were individuals aged 60 years and older included in a national household survey conducted in Brazil in 1998. Data were analyzed by multiple logistic regression, taking into account the design effect due to multistage sampling. RESULTS: There were differences in the health and living conditions of older men and older women that were not explained by age or place of residence. Older women had worse indicators of schooling and personal income but better indicators of housing standards and per capita household income. The older women also reported more chronic diseases, had poorer indicators of independence and physical mobility, sought health services more often, and reported more medical visits in the previous year. Despite their apparent worse health conditions, elderly women in urban areas had lower hospitalization rates in the previous year (odds ratio = 0.89; 95% confidence interval, 0.82-0.96) than did elderly men in urban areas. CONCLUSIONS: Our results indicate that among older Brazilians there are gender inequalities in health that cannot be explained by age and place of residence. The findings raise questions on how health, socioeconomic, and cultural factors influence gender patterns of seeking and using health care in later life in the country. As pressures on health care and health funding increase in Brazil as a result of the aging of the population, there is a need to take a gender perspective into account.     

Health,work, and aging in Brazil

The rapid aging process of the Brazilian population is accompanied by a similar change in the composition of the country's work force. The objective of this study is to determine health differentials in the elderly according to their insertion in the work market, after considering the influence of socio-demographic factors. This study included 2,886 males > or = 65 years residing in ten Brazilian metropolitan areas and included in the National Household Survey conducted by the National Institute of Geography and Statistics, or National Census Bureau (IBGE) in 1998. The analysis included the chi-square and odds ratios estimated by multiple logistic regression. More than a fourth of the elderly worked. Among the formally retired elderly, those who still worked were younger seniors, those with more schooling, and those with higher per capita family income; they reported fewer chronic diseases and presented less difficulty in performing their activities of daily living, but did not show any differences in relation to health services utilization. According to our results, health and especially indicators of autonomy and physical mobility are independent predictive factors for the elderly to remain active.     

Health status,physical functioning,health services utilization,and expenditures on medicines among Brazilian elderly: a descriptive study using data from the National Household Survey

The objective of this research was to describe health conditions and health services utilization among Brazilian seniors. The study was based on 28,943 adults > 60 years (99.9%) from an overall National Household Survey (PNAD 1998). The results show that prevalence rates for at least one chronic disease (69.0%), hypertension (43.9%), arthritis (37.5%), and inability to feed oneself/bathe/use the toilet (2.0%) are very similar to those observed in other populations. Physician visits and hospitalization patterns are within the variation reported by different countries. The low prevalence rates of older adults who had interrupted activities because of a health problem (13.9%) or had been bedridden (9.5%) in the previous 2 weeks or hospitalized in the previous year (13.6%) show that the vast majority are not subject to these events. Considering that 50% of this population live on less than or equal to one Brazilian monthly minimum wage, expenditures on medications consume approximately one-fourth (23%) of total income for half of the elderly population.     

Trends in health conditions and use of health services by the Brazilian elderly: a study based on the National Household Sample Survey (1998, 2003)

This study examined trends in health conditions and use of health services by the Brazilian elderly, based on health data from the National Household Sample Surveys (PNAD) conducted in 1998 and 2003. 28,943 and 35,042 individuals aged > 60 years were included in the study, respectively. The results showed an improvement in health conditions in the study population during this period, as measured by self-rated health, having remained bedridden in the previous two weeks, ability to perform selected activities of daily living, number of chronic conditions, and self-reported arthritis. There was also an increase in the number of doctor and dentist visits from 1998 to 2003. The trends were consistent for both men and women. The results emphasize the importance of the PNAD health supplement as a source of information for the surveillance or monitoring of health and health-related conditions in the Brazilian elderly population.     

Health inequalities based on ethnicity in individuals aged 15 to 64, Brazil, 1998

This study aimed to analyze inequalities in health status and utilization of medical consultations and hospital services by Brazilian young and adult populations according to ethnicity. The survey analyzes a representative sample of the Brazilian population aged 15 to 64 years, except those living in the rural area of the Amazon. The prevalence of fair or poor health status was substantially higher among black men, white women, and black women. The influence of gender and ethnicity remains significant after adjusting for age and socioeconomic conditions (OR = 1.11; 1.49 and 1.86 respectively). Differences between blacks and whites decrease with age, but increase with socioeconomic status. There were 10% more medical consultations among white individuals. The differences were more striking among young people who reported good health status. For individuals with fair or poor health, no differences were observed in frequency of medical consultations between blacks and whites. There were no significant differences in hospitalization rates. With regard to health status, differences between blacks and whites were striking. However, the same was not true for utilization of health services.     

Social inequality and homicide rates in Sao Paulo City, Brazil

OBJECTIVE: The relation between income and mortality due to violence has been studied in recent years. The Synthesis of Social Indicators of 2002 [Sintese de Indicadores Sociais, 2002], published by The Brazilian Institute of Geography and Statistics (IBGE), states that one of the most outstanding characteristic of Brazilian society is inequality. The proposal of this ecological study was to test the association between homicide rates, and some health and socioeconomic indicators. METHODS: This is an ecological cross-sectional study. Data regarding Sao Paulo City, Brazil in the year 2000 was analyzed. The association between homicide coefficients and the following five indicators were tested: infant mortality rates, monthly average income of household heads, percentage of adolescents aged 15 to 17 years not attending school, proportion of pregnant adolescent women aged 14 to 17 years and demographic density. Pearson's correlation coefficient and a multiple linear regression model were utilized to test these associations. RESULTS: The municipal homicide rate was 57.3/100,000. The correlation between homicide rates and average monthly income was strong and negative (r=-0.65). Higher homicide rates were found in the districts whose inhabitants had lower incomes and lower rates were found in those districts whose inhabitants had higher incomes. The correlation between homicide rates and proportion of adolescents not attending school was positive and strong (r=0.68). The correlation between homicide rates and the proportion of pregnant adolescent women was positive and strong (r=0.67). The correlation between homicides and the rate of infant mortality was r=0.24 (for all: p<0.05). The correlation between demographic density and homicides was not significant. Although the univariate regression was positive for four indicators, the multivariate regression test was only significant for average monthly income (negative) and proportion of adolescents not attending school (positive) (for both indicators: p<0.01). CONCLUSIONS: The findings highlight the problem of homicides and socioeconomic disparities in S. Paulo City. Economic development and reducing socioeconomic inequality may have an impact on the rates of mortality due to violence.     

The structure of self-rated health among older adults: the Bambuí health and ageing study (BHAS)

OBJECTIVE: To determine factors associated with self-rated health among older adults, considering five dimensions: sociodemographic variables, social support, lifestyle risk factors, health status, and access to/use of healthcare services. METHODS: Of the 1,742 older adults (> or =60 years) living in the town of Bambuí (southeastern Brazil), 1,516 (87.0%) participated in the study. Information was obtained by means of standardized interviews and physical and laboratory exams. RESULTS: Self-rated health as good/very good, reasonable, and poor/very poor was reported by 24.7%, 49.2%, and 26.1% of subjects, respectively. The following characteristics showed independent positive associations with worse self-rated health: social ties (dissatisfaction with social network, attendance to clubs and associations), health status (symptoms of depression/anxiety in the last two weeks, sleeplessness in the last 30 days, greater number of prescribed medications used in the last 30 days), and access to/use of healthcare services (complaints when seeking medical care, greater number of medical appointments in the last 12 months, greater number of hospital admissions in the last 12 months). An independent negative association was found with monthly family income (<2.0 vs. > or =4 minimum wages). CONCLUSIONS: Our results show that self-rated health among older adults is multidimensional in structure, being influenced by socioeconomic conditions, social support, health status (with emphasis on mental health), and access to/use of healthcare services. This structure resembles the definition of health adopted by the World Health Organization (an individual's "physical, mental and social well-being").     

Race and inequality among women: an example in southern Brazil

This study uses epidemiological data to investigate socioeconomic proportions of distinctions raised by "racism" in Brazilian society. A population-based cross-sectional study was conducted with a sample of 2,779 women ages 14 through 49, living in a southern Brazilian city. Black and mixed-race women had less schooling, lower family income, and worse housing conditions than white women. They also used contraceptive methods less frequently, had more children, and had higher spontaneous abortion and stillbirth rates than white women. Virtually all of the results show a linear relationship between such categories, i.e., the "darker" the woman's skin color, the worse her socioeconomic and reproductive conditions. We also observed that black women were either separated, divorced, or widowed, another apparent factor for black women's impoverishment, related mainly to their limited employment opportunities. The results of the current study indicate that racial relations among women are an issue that should foster a discussion concerning citizenship in Brazil.     

Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors

This study investigated the hypothesis that socioeconomic differences in health status change can largely be explained by the higher prevalence of individual health-risk behaviors among those of lower socioeconomic position. Data were from the Americans' Changing Lives study, a longitudinal survey of 3,617 adults representative of the US non-institutionalized population in 1986. The authors examined associations between income and education in 1986, and physical functioning and self-rated health in 1994, adjusted for baseline health status, using a multinomial logistic regression framework that considered mortality and survey nonresponse as competing risks. Covariates included age, sex, race, cigarette smoking, alcohol consumption, physical activity, and Body Mass Index. Both income and education were strong predictors of poor health outcomes. The four health-risk behaviors under study statistically explained only a modest portion of the socioeconomic differences in health at follow-up. For example, after adjustment for baseline health status, those in the lowest income group at baseline had odds of moderate/severe functional impairment in 1994 of 2.11 (95% C.I.: 1.40, 3.20) in an unadjusted model and 1.89 (95% C.I.: 1.23, 2.89) in a model adjusted for health-risk behaviors. The results suggest that the higher prevalence of major health-risk behaviors among those in lower socioeconomic strata is not the dominant mediating mechanism that can explain socioeconomic disparities in health status among US adults.     

Socio-demographic factors associated with dental services among Brazilian older adults: a study based on the National Household Sample Survey

The objective of this study was to determine the prevalence of (and social-demographic factors associated with) the use of dental services. It was based on a sample of 28,943 adults > 60 years of age from the Brazilian National Household Sample Survey. Socio-demographic characteristics of seniors who had visited a dentist in the last year were compared with those of seniors who had visited a dentist more than one year previously and those who had never been to the dentist. The study showed independent associations between intervals > 1 year in visits to the dentist and such variables as age, residence, years of schooling, and per capita household income. All these variables, in addition to male gender and residence in the rural area, showed independent associations with absence of dental visits during the individual's lifetime. The results indicate a low rate of use of dental services among elderly Brazilians and that regional and socioeconomic differences are important determinants of dental services' use by Brazilian seniors.     

Inequities in Ambulatory Care and the Relationship Between Socioeconomic Status and Respiratory Hospitalizations: A Population-Based Study of a Canadian City

PURPOSE

Individuals of lower socioeconomic status have higher rates of hospitalization due to ambulatory care–sensitive conditions, particularly chronic obstructive pulmonary disease and asthma. We examined whether differences in patient demographics, ambulatory care use, or physician characteristics could explain this disparity in avoidable hospitalizations.

METHODS

Using administrative data from the city of Winnipeg, Manitoba, Canada, we identified all adults aged 18 to 70 years with chronic obstructive pulmonary disease or asthma, grouped together as obstructive airway disease. We divided patients into census-derived income quintiles using average household income. We performed a series of multivariate logistic regression analyses to determine how the association of socioeconomic status with the risk of obstructive airway disease–related hospitalizations changed after controlling for blocks of covariates related to patient demographics (socioeconomic status, age, sex, and comorbidity), ambulatory care use (continuity influenza vaccination and specialist referral), and characteristics of the patient’s usual physician (eg, payment mechanism, sex, years in practice).

RESULTS

We included 34,741 patients with obstructive airway disease, 729 (2.1%) of whom were hospitalized with a related diagnosis during a 2-year period. Patients having a lower income were more likely to be hospitalized than peers having the highest income, and this effect of socioeconomic status remained virtually unchanged after controlling for every other variable studied. In a fully adjusted model, patients in the lowest income quintile had approximately 3 times the odds of hospitalization relative to counterparts in the highest income quintile (odds ratio = 2.93; 95% confidence limits: 2.19, 3.93).

CONCLUSIONS

In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care–sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor.     

Examining the relationships between job control and health status: a path analysis approach

OBJECTIVE: To examine the pathways through which job control affects health status; to examine if the effects of job control on health status are attenuated by including other measures associated with lower socioeconomic status, and to examine if the relationship between job control and health status is consistent across socioeconomic status groups. DESIGN: A prospective observational cohort study over eight years (1994-2002). PARTICIPANTS: 4886 Respondents aged 25-60 years, who were non-self-employed labour force participants, working more than 20 hours per week, without physical or mental limitations restricting the type or amount of work they could do at baseline. After longitudinal attrition, the remaining study sample was 3411 (87% of the original study sample who did not die or become pregnant during the survey period). MAIN RESULTS: Low job control in 1994 was associated with worse than expected self-rated health in 2002, both directly and indirectly via a lower physical activity level in 1996. Adjustment for other factors associated with low socioeconomic status did not attenuate these relationships to a large extent. No differences were found in the effects of job control on physical activity or health status between socioeconomic groups (high and low education and high and low household income). CONCLUSIONS: The inclusion of other factors associated with lower socioeconomic status did not attenuate the direct and indirect effects of job control on health status. The finding that low job control is associated with lower physical activity levels deserves further investigation, given the increasing concern about rising levels of obesity in the developed world.     

Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS).

OBJECTIVE: Despite the vast scientific literature on the social determinants of health, there is still a debate on the extent to which this relationship remains in old age. The objective of this study was to examine the association between socioeconomic circumstances and health among older adults in a small town in Brazil. METHODS: The study was carried out in Bambuí, a town of around 15 000 inhabitants that is located in the state of Minas Gerais, which is in southeastern Brazil. From 1 177 residents aged 65 years or older, 1 074 of them (91.2%) were interviewed and 997 (84.7%) were examined (physical measurements and blood tests). Those in the lowest third of the distribution of total household monthly income, with an income of less than US$ 240 per month, were compared with those who had an income above that level. RESULTS: Lower family income was independently associated with: (1) some lifestyle risk factors (less consumption of fresh fruits or vegetables and less frequent exercise during leisure time in the preceding 30 days), (2) several indicators of worse health status (General Health Questionnaire score, self-rated health, self-rated visual acuity, level of difficulty in walking 300 meters, inability to perform routine activities because of a health problem in the preceding 2 weeks, and seropositivity for Trypanosoma cruzi), (3) a higher number of nonprescribed medications used in the preceding 3 months, and (4) a higher number of hospitalizations in the preceding 12 months. Obesity was more frequent in the higher-income group. CONCLUSIONS: The results of this study do not confirm observations in some developed countries of a lack of association between socioeconomic status and health among the aged. Our results showed that a small difference in monthly family income was sufficiently sensitive to identify elderly persons in worse health, even within a community that appears to be uniformly poor.     

Influence of socioeconomic status, wealth and financial empowerment on gender differences in health and healthcare utilization in later life: evidence from India

Empirical studies from developed countries observe that women report worse health and higher healthcare utilization than men, but the health disadvantage diminishes with age; gender differences in self-rated health often vanish or are reversed in older ages. Comparable assessments of health during later life from developing countries are limited because of the lack of large-scale surveys that include older women. Our study attempts to address the shortage of developing country studies by examining gender differences in health and healthcare utilization among older adults in India. Both ordered and binary logit specifications were used to assess significant gender differences in subjective and objective health, and healthcare utilization after controlling for demographics, medical conditions, traditional indicators of socioeconomic status like education and income, and additional wealth indicators. The wealth indicators, measured by property ownership and economic independence, are regarded as financially empowering older adults to exercise greater control over their health and well-being. Data are drawn from a nationally representative decennial socioeconomic and health survey of 120,942 Indian households conducted during 1995-1996. The study sample comprises 34,086 older men and women aged >or= 60 years. Our results indicate that older women report worse self-rated health, higher prevalence of disabilities, marginally lower chronic conditions, and lower healthcare utilization than men. The health disadvantage and lower utilization among women cannot be explained by demographics and the differential distribution of medical conditions. While successive controls for education, income, and property ownership narrows the gender gap in both health and healthcare utilization, significant differentials still persist. Upon controlling for economic independence, gender differentials disappear or are reversed, with older women having equal or better health than otherwise similar men. Financial empowerment might confer older women the health advantage reflected in developed societies by enhancing a woman's ability to undertake primary and secondary prevention during the life course.     

Gender and health inequalities among adolescents and adults in Brazil, 1998.

OBJECTIVES: To assess the extent of gender inequalities in health status and health services utilization among adolescents and adults in Brazil. METHODS: A representative sample of 217,248 individuals from 15 to 64 years of age was obtained from the National Household Sample Survey (Pesquisa Nacional de Amostras por Domicílios, PNAD) conducted in 1998 by the Brazilian Institute of Geography and Statistics and funded by the Ministry of Health. The study focused on three outcome variables (self-assessed health status, medical visits, and hospitalizations (except childbirth)) and five exposure variables (age, gender, ethnicity, income, and education). Unconditional logistic regression and Mantel-Haenszel stratified analysis was employed. Prevalence rate ratios were calculated for each stratum. Confidence intervals were calculated using the Taylor series, with a 95% confidence interval (95% CI). RESULTS: Women were more likely to report fair or poor health than men (odds ratio (OR) = 1.33; 95% CI: 1.31-1.35). Gender disparities were significant for all ages, household income brackets, and education levels, and were always unfavorable to women (1.17 < or = OR < or = 1.44). Gender disparities for medical visits were higher for those in good health; tended to fall as age, income, and education increased; and were always favorable for women (1.12 < or = OR < or = 2.06). Gender disparities in hospitalization rates decreased with age, varied according to income and education level in each age group, and were always favorable for women (1.16 < or = OR < or = 1.66). CONCLUSIONS: The difference in self-reported health status for men and women became even greater after adjusting for socioeconomic variables, suggesting that poorer women have more pronounced, relative differences than men do. The impact of structural determinants, such as education and income, is considerably smaller than the social construct of gender, although the former are more important predictors. Women use health services more often than men do, which is consistent with their health needs. However, medical visit rates show an inverse relationship to health care needs, suggesting an inequitable access to outpatient care, mainly preventive care.     

Characteristics associated with use of dental services by dentate and edentulous elders: the SB Brazil Project

This study focused on the characteristics associated with use of dental services during the previous year by Brazilian elderly (with and without teeth) participating in the Brazilian oral health survey (Ministry of Health, 2002/2003). 345 were dentate and 669 edentulous. Prevalence of use was 32% and 11%, respectively. Multivariate logistic regression showed that for dentate elders, use of dental services was more frequent among those who perceived their voices as influenced by oral health. Less frequent use was associated with: residence in rural areas; low income; current oral problems; fewer than two teeth in at least one sextant of the arch; need for dentures; and worse self-perceived appearance. Among edentulous elders, more frequent use was associated with: 5 to 8 years of schooling; pain; and poor self-perceived appearance. Use was less frequent among elders with current oral problems and those who perceived that their personal relations were influenced by oral health. The analysis reviewed the differences between dentate and edentulous individuals. Use of dental services was less common among individuals who needed them the most, suggesting inequality in access to such services among the Brazilian elderly.     

Socioeconomic inequalities in the use of outpatient services in Brazil according to health care need: evidence from the World Health Survey

Background  

The Brazilian health system is founded on the principle of equity, meaning provision of equal care for equal needs. However, little is known about the impact of health policies in narrowing socioeconomic health inequalities. Using data from the Brazilian World Health Survey, this paper addresses socioeconomic inequalities in the use of outpatient services according to intensity of need.     

Effects of socioeconomic status on patients' outcome after total knee arthroplasty.

OBJECTIVE: To identify whether patients in lower socioeconomic groups had worse pain and functional levels prior to total knee arthroplasty and then establish whether these patients had poorer post-operative outcomes following total knee arthroplasty. METHOD: Data was obtained from a prospective observational study of 974 patients undergoing primary total knee arthroplasty for osteoarthritis. The study was undertaken in 13 centers in 4 countries. Pre-operative data was collected and patients were followed for 2 years post-operatively. Pre-operative details of the patients' demographics; socioeconomic status (SES) (education and income); height; weight and co-morbid conditions were obtained. The WOMAC scores were obtained preoperatively and during follow-up. RESULTS: Using multivariate linear regression analysis, patients with a lower income had a significantly worse pre-operative WOMAC Pain (P = 0.021) and function score (P = 0.039) than those with higher incomes. However, income did not have a significant impact on outcome at final follow-up after adjusting for other significant covariates. Level of education did not correlate with pre-operative scores or with outcome at any time during follow-up. CONCLUSION: Across all four countries, patients with lower incomes appeared to have a greater need for total knee arthroplasty. However, level of income and educational status did not appear to affect the final outcome following total knee arthroplasty. Patients with lower incomes appeared able to compensate for their worse pre-operative score and obtain similar outcomes post-operatively. These findings are in contrast to studies on other medical conditions and surgical interventions, in which a lower SES has been found to have a negative impact on patient outcomes.     

Do lower socioeconomic groups use more health services, because they suffer from more illnesses?

BACKGROUND: The more diseases one suffers from, the higher the number of health care services attended. This study aims to examine the role this association plays in socio-economic differences in multiple health care utilization. METHODS: The study population derived from the Netherlands Health Interview Surveys (1990-1998) and was 25 years or older (N=53,339). Socio-economic position was indicated by educational level. Comorbidity was defined as the concurrence of multiple health conditions in the same person. Multiple health care utilization was measured by the number of different health care services contacted in the preceding year. Logistic multiple regression was used, adjusted for age, gender and year of interview. RESULTS: The lower the socioeconomic status, the more often people used multiple health care services (OR 1.46) and the higher the prevalence of comorbidity (OR 2.47). CONCLUSIONS: Lower socioeconomic groups use more health care services, partly because they suffer from more illnesses.