Socioeconomic Inequalities in Health in Older Adults in Brazil and England

Objectives. We examined socioeconomic inequalities in health among older adults in England and Brazil.Methods. We analyzed nationally representative samples of residents aged 50 years and older in 2008 data from the Brazilian National Household Survey (n = 75 527) and the English Longitudinal Study of Ageing (n = 9589). We estimated prevalence ratios for self-rated health, functional limitations, and reported chronic diseases, by education level and household income tertiles.Results. Brazilians reported worse health than did English respondents. Country-specific differences were higher among the poorest, but also affected the wealthiest persons. We observed a strong inverse gradient of similar magnitude across education and household income levels for most health indicators in each country. Prevalence ratios (lowest vs highest education level) of poor self-rated health were 3.24 in Brazil and 3.50 in England; having 2 or more functional limitations, 1.81 in Brazil and 1.96 in England; and having 1 or more diseases, 1.14 in Brazil and 1.36 in England.Conclusions. Socioeconomic inequalities in health affect both populations, despite a less pronounced absolute difference in household income and education in Brazil than in England.Inequalities in socioeconomic status (SES) are important determinants of health disparities in high-, middle-, and low-income cou ntries.1 Comparisons among countries can help to identify both commonalities among pathways linking socioeconomic and health inequalities and opportunities for their reduction. However, few international studies have compared the relationship between indicators of SES and health outcomes in older adults, and they were conducted in higher-income member countries of the Organisation for Economic Co-operation and Development.2,3 These studies showed that older adults in England are healthier than their US counterparts despite a larger gross national product and per capita health care expenditures that are 2 to 3 times as high in the United States as in England. Both countries have a socioeconomic gradient in health, with the worst health among those at the bottom of the socioeconomic hierarchy.2,3Socioeconomic inequalities are more prominent in most middle- and low-income countries,4 and life expectancy has increased much faster in these countries than in richer ones.5 Life expectancy between 1960 and 1999 increased 24% in Latin America and the Caribbean and 12% in high-income Organisation for Economic Co-operation and Development countries.5 This demographic transition is generating populations with unprecedented numbers of older adults exposed to significant social inequalities. Assessing the relationship between SES and health inequalities in these societies therefore provides an opportunity to broaden our understanding of SES and health gradients.Brazil is the world’s fifth most populous nation, with more than 190 million inhabitants6 and one of the world’s highest levels of income inequality (2009 Gini coefficient = 0.54).4 Although poverty rates fell from 42% to 21% between 1990 and 2009, 40 million Brazilians are still considered to be poor and 13 million, extremely poor.7 Life expectancy is 72.9 years (79.8 years in England), and Brazil ranks 73rd in the world on the Human Development Index (England is 26th).8 Health inequalities among elderly Brazilians (aged ≥ 65 years) are remarkable. Individuals in the lowest household income quintile report worse health, more functional limitations, fewer doctor and dentist visits, and higher hospitalization rates than do wealthier respondents.9 Even small differences in household income are correlated with inequalities in reported illnesses and biological markers of disease among older people.10We used data from nationally representative surveys in Brazil and in England to examine health variations in older adults by income and education. To our knowledge, this was the first study to compare these 2 populations and to assess the relative magnitude of SES-based inequalities among older adults in 2 countries with very different social, political, demographic, and economic contexts.