Socioeconomic Inequalities and Intergenerational Support in Functional Health in Brazilian Older Adults

Abstract

There is a growing concern as socioeconomic inequalities affect health outcomes in an older population. Aging in Brazil occurs in the context of deep and persistent income, gender and ethnic inequalities, and intensely challenging health, retirement, and social protection systems. Using data from the 2019-PNS Survey, socioeconomic inequalities in functional health and intergenerational support of care for noninstitutionalized older Brazilians stratified by household income deciles and sex were examined. Inequality indexes reveal significant socioeconomic inequalities in functional health among older Brazilian adults. Across inequality indexes, the poorest in both sexes consistently show a higher prevalence rate in mild BADLs limitations than the wealthiest. In severe BADLs limitations, these differences are not clearly stated, and it depends on the sex and type of BADLs involved. Intergenerational care favored the wealthiest deciles across inequality indexes. Consistently and significantly in both sexes, the wealthiest received more family caregiving in both BADLs limitation categories than the poorest; however, in men, their magnitude differences were lesser and statistically significant in the 10/10 and 20/20 indexes. These findings highlight the need for national policies and programs to decrease socioeconomic inequalities during early adulthood and reduce limitations in functional health later in life, particularly in the poorest.

1. Introduction

“But the beauty of deciles and centiles is precisely that they enable us to compare inequalities that would otherwise be incomparable, using a common language that should in principle be acceptable to everyone” [1].

Health equity is a growing priority for most healthcare systems, as it is critical to health system performance. Measuring health inequalities across relevant population subgroups allows for identifying differences in healthcare access, health service utilization, and health outcomes to measure progress toward achieving health equity [2].

Socioeconomic inequalities are one of the most visible manifestations of differences in living standards within countries [3]. During the last two decades, Brazil has experienced sustained economic growth contributing to reducing extreme poverty [4], improving the population’s living conditions, and increasing life expectancy [5]. Nonetheless, the overall benefits of this growth have yet to be shared equally, and income inequality is still high by international standards [6].

Brazil is among the highest levels of socioeconomic inequality in the world. In 2021, with an index of 0.754, it ranked 87th of 191 countries on the Human Development Index (HDI), decreasing from 7.66 (2019) and falling one place respect to in 2020. It is just slightly above the World HDI average of 0.732, and so far compared with the Organization for Economic Cooperation and Development countries (OECD) average, HDI equals 0.899 [7].

Regarding income inequalities, in the OECD countries (2015), the wealthiest 10% of the population earn 9.6 times the incomes of the poorest 10% [8]; meanwhile, in Brazil (2013), it was 43 times [6]. According to the new OECD income definition, in Brazil (2016), the total population inter-decile ratio P90/P10, that is, the ratio of the upper bound value of the ninth decile (i.e., the 10% of people with the highest income) to that of the upper bound value of the first decile was 9.7 compared with average OECD countries of 4.3. Additionally, in Brazil, the Palma ratio, means the share of all income received by the 10% of people with the highest disposable income divided by the share of all income received by the 40% of people with the lowest disposable income, was 2.92 compared with the average OECD countries of 1.25 [9].

On the other hand, Brazil is the fifth most populous country in the world with more than 210 million inhabitants; starting the twenty-first century is experiencing among the world’s fastest demographic aging worldwide [10]. Based on data from the Brazilian Institute of Geography and Statistics (IBGE), the number of older adults–people aged 60 or over–increased from 14 million in 2002 to 30 million in 2020, and it is expected to reach 58 million by 2043, corresponding at 25% of the total population [11]. This demographic transition is also occurring in a context of an epidemiological transition and significant socioeconomic inequalities [12].

It must be noticed that Brazil has the Unified Health System (in Portuguese, Sistema Único de Saúde (SUS)), designed to provide comprehensive and universal care through decentralized management and provision of health services that are free of charge at the point of delivery [13]. Alongside SUS, 26% of Brazilian citizens have private health plans that allow them to solve their health demands in the private health sector [13].

The implications of socioeconomic inequalities include higher morbidity–noncommunicable diseases–dependency or disability, and more premature mortality. It is well established that the likelihood of physical limitations and multimorbidity increase with age. Older adults with lower socioeconomic status experience worse overall health, more difficulty accessing the health care system, weakening social support, and worse quality of life and well-being [14, 15].

In Brazil, the impact of socioeconomic inequalities, exacerbated by gender and racial disparities, is clearly expressed in older adults’ health. Poorer people present a higher prevalence of noncommunicable diseases (NCDs), multimorbidity, functional limitations, and disabilities. Lima-Costa et al. estimated that about 6.5 million Brazilians aged 60 years or older need help to carry out activities of daily living, 360,000 did not get help although they needed it, and at least 5.7 million relatives or friends provide informal (nonpaid) care for older adults [16].

Additionally, based on data from the 2019 National Health Survey (in Portuguese, 2019 Pesquisa Nacional de Saude), the wealthiest 20% of older adults had 11% two or more BADL limitations, receiving 51% of them help to carry out any of these activities, compared to 20% of the poorest who showed 17% of two or more BADL limitations and only 28% of them receive some help [17].

Although the Brazilian legislation guarantees comprehensive health care throughout a lifetime through the SUS, in practice, even though some progress has been made on health care for older persons, it needs to be improved. The State acts as a partner with limited responsibilities and assigns the family the primary responsibilities for the home care of the older person with functional limitations or disabilities [18]. Thus, intergenerational support has been the primary caregiving source for older persons with functional limitations and disabilities in Brazil.

Brazil is racing toward an aging and longevity society, strengthening health system because the rising importance of NCDs and disability is therefore critical. Public health policies must set targets for preventive health policy and healthy life expectancy. Reducing the age gradient for NCDs and comorbidities requires a health system based on preventive health policies through a life course approach rather than just healthcare provision. Healthy life expectancy is driven by various social determinants that go well beyond the health sector. Then, substantial gains in healthy life expectancy can be achieved by tackling health inequalities and substantially reallocating resources for a broader range of policies and prevention strategies [19].

The present study aims to provide empirical evidence about socioeconomic inequalities in the functional health and intergenerational support of care for noninstitutionalized Brazilian older adults. The effect of the household income distribution by deciles stratified by sex and summarized in inequality indexes on Basic Activities Daily Living (BADL) functional limitations prevalence rate and family caregiving rate was investigated. The hypothesis is that socioeconomic inequalities affect functional health limitation prevalence rates, and family caregiving availability is less in Brazil’s poorest older adults.

In the introduction section, it is outlined the importance, scope, and challenges of socioeconomic inequalities on functional health in older persons in Brazil, a country with high and persistent income, gender, and ethnic inequalities. The second section emphasizes the main worldwide initiatives facing aging, healthy aging, health inequalities, and a detailed Brazilian evolution of rights and policies favoring older persons. The remainder of this paper is structured as follows. Section 3 defines the methods; operational definitions of variables, prevalence rates, and inequalities indexes calculations used to link functional health and intergenerational support with socioeconomic inequalities; Section 4 provides the results expressed graphically and detailed inequalities indexes analysis; Section 5 includes discussion proposing some explanation about findings and comparing these with updated national and international evidence; and Section 6 concludes.

1.1 Population ageing and functional health inequalities

In 2001, the World Health Organization (WHO) proposed the International Classification of Functioning, Disability and Health (ICF) as a biopsychosocial model for functioning and disability. The ICF is a framework for measuring health and disability at individual and population levels. Functional ability consists of the intrinsic capacity of the individual, relevant environmental characteristics, and the interaction between them. Intrinsic capacity comprises all the mental and physical capacities that a person can draw on and includes their ability to walk, think, see, hear, and remember. The level of intrinsic capacity is influenced by several factors, such as diseases, injuries, and age-related changes [20].

Subsequently, at the Second United Nations World Assembly on Aging, Madrid, Spain, in April 2002, to address longevity implications, health and social needs of older adults, and other concerns about population aging, the WHO proposed a multidimensional approach to aging and adopted a policy framework: “Active aging,” that is, a formulation of action plans that promote healthy and active aging [21].

Health inequalities in older adults are a critical public policy and a priority issue. The United Nations General Assembly declared the Decade of Healthy Aging (2021–2030) to reduce health inequities and improve older people’s lives, families, and communities [22]. The inequalities in functional health in older adults measured by the decline in functionality with BADL provide valuable information regarding older people’s functional autonomy and independence, especially in unequal aging societies. When one or several BADLs are compromised due to diseases or physiological changes, they can lead to isolation, dependence, and illness and accelerate the individual’s death [23].

On the other hand, the family cared for older adults for centuries in several societies worldwide. However, this traditional intergenerational care has changed since the second half of the twenty-first century. Demographic, social, and cultural factors, such as reduced family size, increasing numbers of couples without children, increasing atomized family structure, and the increased participation of women in the labor market, are affecting the intergenerational care supply of older persons [24]. Despite the older social protection policies implemented in Brazil in recent decades, the State’s provision of services is restricted to specific and one-off healthcare actions and assigns to the family the commitment to home long-term care. No specific policy determining the roles of the family and the public service network is available, making both older adults and caregivers vulnerable [25].

Since the Federal Constitution promulgation in 1988, consecrating a concept of “citizenship rights”, Brazilian older people acquiring a set of guaranteed rights, dealing with the irreducibility of retirement and pension wages, gratuity in collective transportation and the benefit of a minimum wage for older people without living conditions [10]. In 1994, the Older Persons National Act, Law No. 8842, was enacted. This law defined an older person as anyone over 60, advocating a different approach to their physical, social, economic, and political needs and prioritizing family life over the elders’ home [10].

Subsequently, in 1999 the Ministry of Health created the National Policy on Health for Older Persons (in Portuguese, PNSI Política Nacional de Saúde do Idoso). Several guidelines were defined in the context of PNSI, emphasizing the promotion of healthy aging aimed at maintaining a functional capacity to prevent functional losses, reinforcing actions aimed at the early detection of noncommunicable diseases, improvement of their functional abilities through the early adoption of healthy lifestyles, reducing harmful behaviors to health, as well as guidance for the older persons and their relatives regarding the environmental conditions to avoid falls [10, 26].

In response to Madrid Plan, in October 2003, the Statute of the Older Persons (in Portuguese, Estatuto do Idoso) was approved. With its 118 articles, the Statute consolidates various federal, state, and city rights regarding health, education, culture, sports and leisure, professionalization and work, social security, social assistance, housing, transportation, surveillance of care entities, and classification of crimes against the older persons [18, 27].

In October 2006, the National Policy on the Health of the Older Persons (NPHOP) was created [18, 28]. This new health policy for older persons had the objective of allowing healthy aging, which means preserving its functional capacity, its autonomy and maintaining the level of quality of life, following the principles and guidelines of the Unified Health System (SUS), which direct individual and collective measures at all levels of health care. Also, this policy was concerned with the implementation of the actions and guiding the continuous evaluation process and considering possible adjustments determined by the practice [10].

An inalienable challenge to the policy formulation and implementation process public is the monitoring and evaluation of their goals. In Brazil, the PNSPI, defined the older population as a priority group, implementing a specific policy, and a monitoring indicators system. However, in 2012, in the transition process between the PNSPI and the Organizational Contract of Public Health Action (in Portuguese, Contrato Organizativo de Ação Pública de Saúde), the prioritization of the older persons was lost, losing also specific indicators monitoring of SUS service conditions for this group of the population [29]. So, despite the important evolution of the Brazilian regulatory framework for the health of older persons, and policies implemented have solid foundations; however, monitoring indicators systems are insufficient to express the impact on reality.

These facts must explain the scarce literature that addresses public policies related to the older population in allowing the monitoring of the current policy for older persons in Brazil [29]. A recent qualitative study to evaluate the implementation of the NPHOP in a municipal setting of the Ceará State involving intersectoriality, own budget, and the social participation of the older adults established that this policy is still in the process of being improved at the municipal level, subject to a re-discussion of policy planning, mainly because professionals do not have a clear notion of its existence, as well as its functioning at the municipal environment [30].

2. Methods

A cross-sectional study included noninstitutionalized adult people aged 60 or over (OA60+) residents in Brazil. The data come from the last Brazilian National Health Survey or Pesquisa Nacional de Saude (2019-PNS), conducted by the IBGE in partnership with the Ministry of Health [31].

The 2019-PNS is a household-based survey representative of the Brazilian noninstitutionalized population at the national, regional, state, and major metropolitan area levels. The selected sample originated from a IBGE master sample, stratified into three cluster stages: census tracts selected with proportional probability, households selected by simple random, and individual aged 15 or over randomly selected within each household. The interviews were carried out between August 2019 and March 2020 by trained teams using smartphone devices programmed with the survey questionnaire and the processes of criticizing the variables. A total of 90,846 households and 275,323 individuals were interviewed. The response rate for households was 93.6% [31].

To avoid selection bias, older adults who answered the module about functional health by themselves or another household resident were included in the analysis. Then, the sample for the current analysis includes data from 42,274 surveys corresponding to noninstitutionalized people aged 60 or more.

Basic Activities Daily Living is defined as the primary activities aimed at self-care and mobility of individuals, involving a minimum cognitive effort that offers autonomy and independence to live without needing continuous help from others [32]. The BADLs included in this study were eating, bathing, personal mobility, using the toilet, getting in/out of bed, dressing, and sitting down/getting up off a chair. In the 2019-PNS survey, each BADL variable has four-category impairment levels: cannot do it, has great difficulty, has little difficulty, and has no difficulty. For the analysis, BADL variables were aggregated into two levels: little difficulty and great difficulty/cannot do it. The BADL functional limitations prevalence rates for 1000 surveyed, stratified by sex, were calculated for overall and aggregate levels of the functional limitations.

On the other hand, the 2019-PNS survey collected data on monetary and nonmonetary contributions to household incomes. Once the data have been collected, IBGE calculates monthly household income in nominal terms, excluding those whose status was pensioner, in-door domestic worker, or relative of the in-door domestic worker. Household income is the sum of all the payments received by all the household members from work and other income sources, such as pensions, rent, financial investments return, social programs, or any other income [33].

In the present study, the health inequalities in the OA60+ sample were measured by linking the individual BADL’s functional limitations rate stratified by sex with the household income deciles. The first decile (I) represents the poorest 10% of households, and the tenth decile (X), represents the richest 10% of households.

Considering the negative connotation of the health variable and helping to facilitate the interpretation of the differences in functional health inequalities across household income deciles groups, the 10/10, 20/20 and 40/10 inequalities indexes were calculated. Index 10/10 shows the relationship between the BADL’s functional limitations rate exhibited by 10% with the lowest total household income and the corresponding 10% of higher-income households. Index 20/20 shows the relationship between the BADL’s functional limitations rate exhibited by 20% lowest total household income and the corresponding 20% of higher-income households. Finally, an index of 40/10 shows the relationship between the BADL’s functional limitations rate exhibited by 40% with the lowest total household income and the corresponding 10% of higher-income households.

Furthermore, a family caregiving rate was calculated to evaluate the intergenerational support with OA60+. Data from the same survey allow for building a ratio between relatives living in the same house and providing help to older people with BADL limitations with the register of all surveyed aged 15 or over declaring to work in caring for people at home. However, data do not allow discrimination of the caregiver sex for older adults surveyed. Therefore, the total aged 15 or over declaring to work in caring for people at home was used in the rate denominator. The family caregiver rate by deciles across the BADL’s limitations, expressed for 1000 surveyed, was included in the secondary axis in the graphs.

The statistical significance of the difference in the analyzed variables was tested using Wald’s chi-square statistic. We accepted a level of significance of 5% in the test, and Stata SE/14.0 was used for the analyses.

3. Results

The 2019-PNS Survey surveyed 43,554 OA60+, representing 14.8% of the total sample. After excluding individuals whose BADL data were provided by relatives who did not reside with them (n: 1.261) and without household income recorded (n: 19), the analyzed sample was 42,274 individuals, of which 56% were women. In the sample, 70% of the questionnaires were answered by OA60+ themselves. The average age of the women in the sample was 70.1 years (SD: 8.14) and 69.5 years (SD: 7.66) for men. Thirty-five percent of the OA60+ lived in the northeast, 24% in the southeast, 16% in the north, 14% in the south, and 10% in the central west region.

Forty-five percent of the OA60+ surveyed were self-referred as brown-skinned, 43% white, 11% black, and the other 2% were indigenous and oriental ethnicities. Fifty-two percent were married, and 76% lived in urban areas; however, most women (80%) lived in urban areas compared to 72% of men. These differences were statistically significant. Regarding the education level, 21% of the OA60+ were unscholarly, 44% were incomplete elementary school, and 10% graduated. The education level of women was better than men, and the differences were statistically significant. Individuals in the 1st and 10th deciles had an average monthly household income of (December 2019) US $87.5 and $4311.4, respectively. The median household income value in OA60+ in the 10th decile was 43 times higher than those in the 1st decile.

Twenty-five percent of OA60+ have health insurance, and just 8% have dental insurance. Twenty-eight percent of the OA60+ surveyed have two or more chronic diseases; however, most women (31%) were affected by chronic diseases compared to 23% of men. These differences were statistically significant. In addition, 35% state that chronic diseases restrict their usual activities; women (39%) are significantly more affected than men (30%). In general, 44% of the OA60+ surveyed reported a “good/very good”, 43% “fair” and 13% “bad/very bad” self-rated health (SRH) status. The SRH status of women was worse than men, and the differences were statistically significant.

3.1 Prevalence rate of the BADL functional limitations

To make reading easier for the reader, the BADLS functional limitations categories “little difficulty” and “great difficulty/cannot do it “will be summarized as mild and severe limitations, respectively.

In the data, an overall prevalence of functional limitations in at least one BADL was 21%. Disaggregated by sexes; 24% in women and 17% in men. Table 1 shows the prevalence rate of BADL’s functional limitations among both sexes of the OA60+. The differences along all BADL categories between sexes were statistically significant (p < 0.001).

BADLs	men (n: 18,753)	women (n: 23,521)
Eating functional limitation	5.1%	6.1%
great/cannot do it	2.4%	2.7%
little	2.7%	3.4%
Bathing functional limitation	6.7%	9.4%
great/cannot do it	3.6%	4.9%
little	3.1%	4.6%
Personal mobility functional limitation	9.4%	13.5%
great/cannot do it	4.7%	6.0%
little	4.7%	7.5%
Using the toilet functional limitation	8.0%	11.0%
great/cannot do it	4.5%	5.7%
little	3.5%	5.3%
Getting in/out bed functional limitation	10.5%	14.7%
great/cannot do it	4.6%	6.0%
little	5.9%	8.7%
Dressing functional limitation	10.2%	13.9%
great/cannot do it	4.3%	5.6%
little	5.9%	8.3%
Sitting down/getting up off chair functional limitation	9.9%	14.3%
great/cannot do it	4.4%	5.6%
little	5.5%	8.7%

Table 1.

The prevalence rate of BADL functional limitation.OA60+ Brazil 2019.

Getting in/out of bed was the basic daily activity that showed the most significant functional limitations in both sexes, followed by dressing, sitting down/getting up a chair, and personal mobility. Women presented more severe functional limitations in all BADLs than men.

An analysis by five-year age groups shows that the prevalence rates in all analyzed BADL’s functional limitations and their severity increase with age in both sexes. In general, women have higher rates of limitations in BADL than men in all age groups. Differences between sex were statistically significant (p < 0.0001) for mild BADL functional limitation and just in the 60–64 and 80+ year groups in those with severe BADL functional limitation. Concerning the number of compromised BADLs, the prevalence also increases with age and is higher in women. Regarding potential caregivers of the OA60+, on average, there are 2.6 residents over 15 years of age in the home of people with functional limitations in one or more BADLs. Women, on average, represent 64% of the total family caregiver, and this role decreases across de poorest (70%) to the wealthiest (59%) deciles. On the other hand, 38% of the OA60+ with functional limitations in one or more BADLs need help, and 93% receive it.

Seventy-five percent of men in 1st and 2nd deciles received help mainly from family caregivers and 15% from relatives living outside the home. On the other hand, men in 9th and 10th deciles received help provided for family caregivers (80%), relatives living outside the home (2%), and formal (paid) caregivers (12%).

Help for women in 1st and 2nd deciles was provided by family caregivers (60%) and relatives living outside the home (29%). For women in 9th and 10th deciles, help was provided by family caregivers (74%), by formal caregivers (14%), and marginally by relatives living outside the home (4%). The differences between the sexes were only statistically significant concerning relatives outside the home. Nurses or technicians hired and paid to provide care represented 4.6%. However, there are statistically significant differences in using these services between the first two (3%) and the last two (12%) income deciles in both sexes.

3.2 Socioeconomic inequalities in the BADL functional limitations

The relationship between BADL’s prevalence rates and income deciles varies according to the type of BADL, sex, age, severity, and the number of activities involved. In both sexes, the number of BADLs committed increases with age. On the other hand, in both sexes and through the deciles, the prevalence rate decreases as the number of involved BADLS grows to five, then increases when the affected activities are six or seven.

The following graphs show the gradient of both categories of the BADL functional limitation rates, moving from the poorest to the wealthiest deciles in both sexes. Additionally, to compare the intergenerational support in BADLs functional limitations functional of the older adults, the secondary axis in the graphs includes the family caregiving rate across household incomes deciles. Subsequently, the relative differences in BADL limitations and family caregiving rates between household income deciles were compared using the inequality indexes.

In all graphs, the trend of prevalence rates of the mild limitation shows a consistently linear decreasing gradient from the poorest to the wealthiest deciles in both sexes. For dressing and sitting down/getting up off a chair functional limitations, the gradient was more pronounced in men. On the other hand, in both sexes, trends of the prevalence rate for severe limitations in all BADLs, resemble an inverted convex parabolic curve, in most increasing up to the 5th to decreasing to the 10th decile. For bathing and dressing functional limitations, the trend curves increase up to the 7th to decrease to the 10th decile in both sexes and for eating limitations in women.

Figure 1 shows the trends of eating limitations and family caregiver rates in both BADL categories and sexes. On both categories of eating functional limitation rates, the sex differences were consistent and statistically significant in the two wealthiest deciles (p < 0.001).

Figure 1.

Eating functional limitation in OA60+. Prevalence & Family caregiver rates by 1000 surveyed. Brazil 2019.

Concerning the family caregiving rate, the poorest three deciles show lower caregiving support in both sexes; however, excepting care in severe limitations in the two poorest deciles, women have better caregiving rate than men in both eating BADL limitation categories. In the mild category, the sex differences in the family caregiving rate were only statistically significant (p < 0.01) in the 5th, 9th, and 10th deciles. The sex differences in the family caregiving rate in the severe category were statistically significant in the four wealthiest deciles (p < 0.01).

According to the inequality indexes, the men’s poorest 10%, 20%, and 40% show 1.6, 2.3, and 2.5 times more mild eating limitations than the 10%, 20%, and 10% of the wealthiest men, respectively. These differences were only statistically significant (p < 0.0001) for the 20/20 and 40/10 indexes. On the other hand, men’s poorest 10%, 20%, and 40% show 1.3, 2.7, and 1.7 times more severe eating limitations than the wealthiest 10%, 20%, and 10% of men, respectively. The difference was only statistically significant (p < 0.005) for the 20/20 and 40/10 indexes.

Regarding family caregiving, the men’s wealthiest 10% and 20% received 3.2 and 1.6 times more care by family caregivers when they had mild eating limitations than the poorest 10% and 20% of men, respectively. The difference was only statistically significant (p < 0.05) for the 10/10 index. Conversely, men’s poorest 40% received 1.6 times more care from family caregivers when they had mild eating limitations than the wealthiest 10% of men. This difference was not statistically significant. On the other hand, the men’s wealthiest 10% and 20% received 3.9 and 1.4 times more care by family caregivers when they have severe eating limitations than the poorest 10% and 20% of men, respectively. The differences were only statistically significant (p < 0.005) for the 10/10 index. The 40/10 index shows that the poorest 40% received 1.14 times more care from family caregivers when they have severe eating limitations than the wealthiest 10% of men. This difference was not statistically significant.

The poorest women, 10%, 20%, and 40%, show 1.4, 1.2, and 1.3 times more mild eating limitations than the 10%, 20%, and 10% wealthiest women, respectively. The difference was only statistically significant (p < 0.05) for the 40/10 index. On the other hand, women’s wealthiest 10%, 20%, and 10% show 2.0, 1.6, and 1.3 times more severe eating limitations than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.05).

Concerning family caregiving, women’s wealthiest 10%, 20%, and 10% receive 7.7, 2.9, and 1.5 times more care from family caregivers when they have mild eating limitations than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.005). Concerning severe eating limitations, women’s wealthiest 10%, 20%, and 10% receive 11.3, 3.8, and 1.6 times more care by family caregivers than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.01).

Figure 2 shows the trends of bathing limitations and family caregiver rates in both BADL categories and sexes. In mild bathing limitation prevalence rates, excepting the 2nd decile, the sex differences were statistically significant (p < 0.05). In severe bathing limitations, the differences between both sexes were only statistically significant in the higher three deciles (p < 0.01).

Figure 2.

Bathing functional limitation in OA60+. Prevalence & Family caregiver rates by 1000 surveyed. Brazil 2019.

Regarding the family caregiving rate, the poorest three deciles show lower caregiving support in both sexes. Higher caregiving rates were observed in women across all deciles and both bathing limitation categories. In the mild category, the sex differences in the family caregiving rate excepting 1st, 2nd, and 6th deciles were statistically significant (p < 0.05) in the rest of the deciles. The sex differences in the family caregiving rate in the severe category were firmly statistically significant in the four wealthiest deciles (p < 0.001) and less significant in the 2nd, 4th, and 5th deciles (p < 0.05).

According to the inequality indexes, the men’s poorest 10%, 20%, and 40% show 1.3, 1.9, and 1.7 times more mild bathing limitations than the 10%, 20%, and 10% wealthiest men, respectively. These differences were only statistically significant (p < 0.001) for the 20/20 and 40/10 indexes. On the other hand, men’s poorest 10%, 20%, and 40% show 1.2, 1.4, and 1.8 times more severe bathing limitations than the wealthiest 10%, 20%, and 10% of men, respectively. The difference was only statistically significant (p < 0.05) for the 20/20 and 40/10 indexes.

Regarding family caregiving, the men’s wealthiest 10%, 20%, and 10% received 12.2, 2.2, and 1.5 times more care by family caregivers when they have mild bathing limitations than the poorest 10%, 20%, and 40% of men, respectively. The difference was only statistically significant (p < 0.005) for the 10/10 and 20/20 indexes. On the other hand, the men’s wealthiest 10% and 20% received 4.1 and 1.8 times more care from family caregivers when they have severe bathing limitations than the poorest 10% and 20% of men, respectively. The differences were statistically significant (p < 0.005). The 40/10 index shows that men’s poorest 40% received 1.14 times more care from family caregivers when they have severe bathing limitations than the wealthiest 10% of men. This difference was not statistically significant.

The poorest women, 10%, 20%, and 40%, show 1.7, 1.4, and 1.6 times more mild bathing limitations than the 10%, 20%, and 10% wealthiest women, respectively. These differences were statistically significant (p < 0.01). On the other hand, women’s wealthiest 10%, 20%, and 10% show 1.7, 1.5, and 1.3 times more severe bathing limitations than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.05).

Concerning family caregiving, women’s wealthiest 10%, 20%, and 10% receive 9.1, 3.4, and 1.7 times more care from family caregivers when they have mild bathing limitations than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.005). Concerning severe bathing limitations, women’s wealthiest 10%, 20%, and 10% receive 8.3, 2.7, and 1.5 times more care by family caregivers than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.0005).

Figure 3 shows the trends of personal mobility limitations and family caregiver rates in both BADL categories and sexes. In mild personal mobility limitation prevalence rates, the sex differences were statistically significant (p < 0.05) across all deciles. In severe personal mobility limitations, the differences between both sexes were only statistically significant in the higher three deciles (p < 0.01).

Figure 3.

Personal mobility functional limitation in OA60+. Prevalence & Family caregiver rates by 1000 surveyed. Brazil 2019.

Regarding the family caregiving rate, the poorest three deciles show lower caregiving support in both sexes. Higher caregiving rates were observed in women across all deciles and both personal mobility limitation categories. In the mild category, the sex differences in the family caregiving rate, excepting 1st, 6th, and 10th deciles, were statistically significant (p < 0.05) in the 2nd, 4th, 7th, and 9th deciles. Marginal statistical differences (p < 0.06) were observed in the 3rd, 5th, and 8th deciles. The sex differences in the family caregiving rate in the severe category were firmly statistically significant in the three wealthiest deciles (p < 0.001) and less significant in the 2nd, 5th, 6th, and 7th deciles (p < 0.05).

According to the inequality indexes, the men’s poorest 10%, 20%, and 40% show 1.6, 2.0, and 2.2 times more mild personal mobility limitations than the 10%, 20%, and 10% wealthiest men, respectively. These differences were statistically significant (p < 0.05). On the other hand, men’s poorest 10%, 20%, and 40% show 1.1, 1.4, and 1.6 times more severe personal mobility limitations than the wealthiest 10%, 20%, and 10% of men, respectively. The difference was only statistically significant (p < 0.01) for the 20/20 and 40/10 indexes.

Regarding family caregiving, the men’s wealthiest 10%, 20%, and 10% received 13.3, 2.7, and 1.5 times more care by family caregivers when they have mild personal mobility limitations than the poorest 10%, 20%, and 40% of men, respectively. The difference was only statistically significant (p < 0.001) for the 10/10 and 20/20 indexes. On the other hand, the men’s wealthiest 10% and 20% received 3.1 and 1.5 times more care from family caregivers when they have severe personal mobility limitations than the poorest 10% and 20% of men, respectively. The differences were statistically significant (p < 0.05). The 40/10 index shows that men’s poorest 40% received 1.4 times more care from family caregivers when they have severe personal mobility limitations than the wealthiest 10% of men. This difference was not statistically significant.

The poorest women, 10%, 20%, and 40%, show 1.6, 1.6, and 1.8 times more mild personal mobility limitations than the 10%, 20%, and 10% wealthiest women, respectively. These differences were statistically significant (p < 0.01). On the other hand, women’s wealthiest 10%, 20%, and 10% show 1.4, 1.3, and 1.2 times more severe personal mobility limitations than the poorest 10%, 20%, and 40% of women, respectively. However, the difference was statistically significant (p < 0.05) only for the 20/20 index.

Concerning family caregiving, women’s wealthiest 10%, 20%, and 10% receive 6.0, 2.5, and 1.2 times more care from family caregivers when they have mild personal mobility limitations than the poorest 10%, 20%, and 40% of women, respectively. These differences were only statistically significant (p < 0.0001) for the 10/10 and 20/20 indexes. Concerning severe personal mobility limitations, women’s wealthiest 10%, 20%, and 10% receive 6.7, 2.4, and 1.4 times more care by family caregivers than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.01).

Figure 4 shows the trends of using the toilet limitations and family caregiver rates in both BADL categories and sexes. In mild using the toilet limitation prevalence rates, excepting 1st, 2nd, and 10th deciles, the sex differences were statistically significant (p < 0.05) across the rest of the deciles. In severe using the toilet limitations, the differences between both sexes were only statistically significant (p < 0.05) in the 3rd and 8th deciles and strongly statistically significant in the wealthiest two deciles (p < 0.001).

Figure 4.

Using the toilet functional limitation in OA60+. Prevalence & Family caregiver rates by 1000 surveyed. Brazil 2019.

Regarding the family caregiving rate, the poorest three deciles show lower caregiving support in both sexes. Higher caregiving rates were observed in women across all deciles and using the toilet limitation categories. In the mild category, the sex differences in the family caregiving rate were statistically significant (p < 0.05) in the middle 4th to 7th deciles and 9th decile. The sex differences in the family caregiving rate in the severe category were firmly statistically significant in the three wealthiest deciles (p < 0.001) and less significant in the 2nd, 3rd, 5th, 6th, and 7th deciles (p < 0.05).

According to the inequality indexes, the men’s poorest 10%, 20%, and 40% show 1.8, 2.3, and 2.0 times more mild using toilet limitations than the 10%, 20%, and 10% wealthiest men, respectively. These differences were statistically significant (p < 0.05). On the other hand, men’s poorest 10%, 20%, and 40% show 1.2, 1.2, and 1.5 times more severe using toilet limitations than the wealthiest 10%, 20%, and 10% of men, respectively. The difference was only statistically significant (p < 0.05) for the 40/10 index.

Regarding family caregiving, the men’s wealthiest 10%, 20%, and 10% received 8.1, 2.1, and 1.3 times more care by family caregivers when they have mild using the toilet limitations than the poorest 10%, 20%, and 40% of men, respectively. The difference was only statistically significant (p < 0.05) for the 10/10 and 20/20 indexes. On the other hand, the men’s wealthiest 10% and 20% received 3.6 and 1.6 times more care from family caregivers when they have severe using toilet limitations than the poorest 10% and 20% of men, respectively. The differences were statistically significant (p < 0.05). The 40/10 index shows that men’s poorest 40% received 1.3 times more care from family caregivers when they have severe using toilet limitations than the wealthiest 10% of men. This difference was not statistically significant.

The poorest women, 10%, 20%, and 40%, show 1.9, 1.7, and 2.0 times more mild using toilet limitations than the 10%, 20%, and 10% wealthiest women, respectively. These differences were statistically significant (p < 0.01). On the other hand, women’s wealthiest 10%, 20%, and 10% show 1.3, 1.3, and 1.2 times more severe using toilet limitations than the poorest 10%, 20%, and 40% of women, respectively. However, the difference was statistically significant (p < 0.05) only for the 20/20 index.

Concerning family caregiving, women’s wealthiest 10%, 20%, and 10% receive 19.7, 3.2, and 1.4 times more care from family caregivers when they have mild using toilet limitations than the poorest 10%, 20%, and 40% of women, respectively. These differences were only statistically significant (p < 0.0001) for the 10/10 and 20/20 indexes. Concerning severe using toilet limitations, women’s wealthiest 10%, 20%, and 10% receive 8.6, 2.7, and 1.6 times more care by family caregivers than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.05).

Figure 5 shows the trends of getting in/out of bed limitations and family caregiver rates in both BADL categories and sexes. In mild getting in/out of bed limitation prevalence rates, excepting the 1st decile, the sex differences were statistically significant (p < 0.05) across the rest of the deciles. In severe getting in/out of bed limitations, the differences between both sexes were only statistically significant (p < 0.05) in the 9th decile and strongly statistically significant in the 10th decile (p < 0.0001).

Figure 5.

Getting in/out of bed functional limitation in OA60+. Prevalence & Family caregiver rates by 1000 surveyed. Brazil 2019.

Regarding the family caregiving rate, the poorest three deciles show lower caregiving support in both sexes. Higher caregiving rates were observed in women across all deciles and getting in/out of bed limitation categories. In the mild category, the sex differences in the family caregiving rate were statistically significant (p < 0.05) after the 4th deciles. The sex differences in the family caregiving rate in the severe category were statistically significant in the five wealthiest deciles (p < 0.01) and also significant in the 2nd decile (p < 0.05).

According to the inequality indexes, the men’s poorest 10%, 20%, and 40% show 2.3, 2.7, and 2.5 times more mild getting in/out of bed limitations than the 10%, 20%, and 10% wealthiest men, respectively. These differences were firmly statistically significant (p < 0.0001). On the other hand, men’s poorest 10%, 20%, and 40% show 1.4, 1.5, and 1.7 times more severe getting in/out of bed limitations than the wealthiest 10%, 20%, and 10% of men, respectively. The difference was only statistically significant (p < 0.001) for the 20/20 and 40/10 indexes.

Regarding family caregiving, men’s wealthiest 10% and 20% received 4.9 and 1.5 times more care by family caregivers when they have mild getting in/out of bed limitations than the poorest 10% and 20% of men, respectively. The difference was only statistically significant (p < 0.05) for the 10/10 index. The 40/10 index shows that men’s poorest 40% received 1.1 times more care from family caregivers when they have mild getting in/out of bed limitations than the wealthiest 10% of men. This difference was not statistically significant. On the other hand, the men’s wealthiest 10% and 20% received 3.3 and 1.4 times more care from family caregivers when they have severe getting in/out of bed limitations than the poorest 10% and 20% of men, respectively. The difference was only statistically significant (p < 0.05) for the 10/10 index. The 40/10 index shows that men’s poorest 40% received 1.5 times more care from family caregivers when they have severe getting in/out of bed limitations than the wealthiest 10% of men. This difference was not statistically significant.

The poorest women, 10%, 20%, and 40%, show 1.9, 1.9, and 1.9 times, more mild getting in/out of bed limitations than the 10%, 20%, and 10% wealthiest women, respectively. These differences were strongly statistically significant (p < 0.001). On the other hand, women’s poorest 10% and 40% show 1.09 and 1.02 times more severe getting in/out of bed limitations than the wealthiest 10% of women, respectively. These differences were not statistically significant. The 20/20 index shows that 20% of wealthiest women have 1.09 times more severe getting in/out of bed limitations than the poorest 20% of women. This difference was not statistically significant.

Concerning family caregiving, women’s wealthiest 10%, 20%, and 10% receive 9.7, 3.0, and 1.5 times more care from family caregivers when they have mild getting in/out of bed limitations than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.005). Concerning severe getting in/out of bed limitations, women’s wealthiest 10%, 20%, and 10% receive 7.4, 2.2, and 1.2 times more care by family caregivers than the poorest 10%, 20%, and 40% of women, respectively. These differences were only statistically significant (p < 0.001) for the 10/10 and 20/20 indexes.

Figure 6 shows the trends of dressing limitations and family caregiver rates in both BADL categories and sexes. In mild dressing limitation prevalence rates, excepting the three poorest deciles, the sex differences were statistically significant (p < 0.05) across the rest of the deciles. In severe dressing limitations, the differences between both sexes were only statistically significant (p < 0.001) in the wealthiest three deciles.

Figure 6.

Dressing functional limitation in OA60+. Prevalence & Family caregiver rates by 1000 surveyed. Brazil 2019.

Regarding the family caregiving rate, the poorest three deciles show lower caregiving support in both sexes. Higher caregiving rates were observed in women across all deciles and dressing limitation categories. In the mild category, the sex differences in the family caregiving rate were statistically significant (p < 0.05) after the 4th decile. The sex differences in the family caregiving rate in the severe category, excepting the 1st decile, were statistically significant (p < 0.05) in the remaining deciles and firmly significant (p < 0.001) in the three wealthiest deciles.

According to the inequality indexes, the men’s poorest 10%, 20%, and 40% show 1.9, 1.9, and 1.9 times more mild dressing limitations than the 10%, 20%, and 10% wealthiest men, respectively. These differences were statistically significant (p < 0.001). On the other hand, men’s poorest 10%, 20%, and 40% show 1.5, 1.6, and 2.1 times more severe dressing limitations than the wealthiest 10%, 20%, and 10% of men, respectively. The difference was only statistically significant (p < 0.001) for the 20/20 and 40/10 indexes.

Regarding family caregiving, men’s wealthiest 10% and 20% and 10% received 9.7, 1.9, and 1.5 times more care by family caregivers when they have mild dressing limitations than the poorest 10%, 20%, and 40% of men, respectively. The difference was only statistically significant (p < 0.05) for the 10/10 and 20/20 indexes. On the other hand, the men’s wealthiest 10% and 20% received 3.8 and 1.7 times more care from family caregivers when they have severe dressing limitations than the poorest 10% and 20% of men, respectively. The differences were statistically significant (p < 0.005). The 40/10 index shows that men’s poorest 40% received 1.2 times more care from family caregivers when they have severe dressing limitations than the wealthiest 10% of men. This difference was not statistically significant. Including care by other relatives, nurses, or technicians paid for in both groups of the 40/10 index still shows that the poorest 40% of men received 1.1 times more care than the wealthiest 10%. This difference was not statistically significant.

The poorest women, 10%, 20%, and 40%, show 1.6, 1.4, and 1.5 times more mild dressing limitations than the 10%, 20%, and 10% wealthiest women, respectively. These differences were statistically significant (p < 0.005). On the other hand, women’s wealthiest 10% and 20% show 1.05 and 1.2 times more severe dressing limitations than the poorest 10% and 20% of women, respectively. These differences were not statistically significant. The 40/10 index shows that 40% of the poorest women have 1.01 times more severe dressing limitations than the wealthiest 10% of women. This difference was not statistically significant.

Concerning family caregiving, women’s wealthiest 10%, 20%, and 10% receive 8.9, 3.0, and 1.5 times more care from family caregivers when they have mild dressing limitations than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.01). Concerning severe dressing limitations, women’s wealthiest 10%, 20%, and 10% receive 7.3, 2.5, and 1.3 times more care by family caregivers than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.005).

Figure 7 shows the trends of sitting down/getting up off a chair limitations and family caregiver rates in both BADL categories and sexes. In mild sitting down/getting up off a chair limitation prevalence rates, excepting the 1st, 2nd, 4th, 7th, and 8th deciles, the sex differences were statistically significant (p < 0.05) across the remaining deciles. In severe sitting down/getting up off a chair limitation, the differences between both sexes were statistically significant (p < 0.01) in the wealthiest three deciles.

Figure 7.

Sitting down/getting up off a chair functional limitation in OA60+. Prevalence & Family caregiver rates by 1000 surveyed. Brazil 2019.

Regarding the family caregiving rate, the poorest three deciles show lower caregiving support in both sexes. Higher caregiving rates were observed in women across all deciles and sitting down/getting up off a chair limitations categories. In the mild category, the sex differences in the family caregiving rate, except for the two poorest deciles, the remaining were statistically significant (p < 0.05). The sex differences in the family caregiving rate in the severe category, excepting the six poorest deciles, were statistically significant (p < 0.005).

According to the inequality indexes, the men’s poorest 10%, 20%, and 40% show 2.2, 2.5, and 2.3 times more mild sitting down/getting up off a chair limitation than the 10%, 20%, and 10% wealthiest men, respectively. These differences were statistically significant (p < 0.001). On the other hand, men’s poorest 20% and 40% show 1.2 and 1.5 times more severe sitting down/getting up off a chair limitation than the wealthiest 20% and 10% of men, respectively. The difference was only statistically significant (p < 0.005) for the 40/10 index. Conversely, men’s wealthiest 10% show 1.08 times more severe sitting down/getting up off a chair limitation than the poorest 10% of men which was not statistically significant.

Regarding family caregiving, men’s wealthiest 10% and 20% and 10% received 3.8, 1.5, and 1.1 times more care by family caregivers when they have mild limitations sitting down/getting up off a chair than the poorest 10%, 20%, and 40% of men, respectively. The difference was only statistically significant (p < 0.05) for the 10/10 index. On the other hand, the men’s wealthiest 10% and 20% received 3.6 and 1.5 times more care from family caregivers when they have severe limitations sitting down/getting up off a chair than the poorest 10% and 20% of men, respectively. The differences were statistically significant (p < 0.05). The 40/10 index shows that men’s poorest 40% received 1.3 times more care from family caregivers when they have severe limitations sitting down/getting up off a chair than the wealthiest 10% of men. This difference was not statistically significant.

The poorest women, 10%, 20%, and 40%, show 2.1, 1.8, and 1.9 times more mild limitations sitting down/getting up off a chair than the 10%, 20%, and 10% wealthiest women, respectively. These differences were statistically significant (p < 0.001). On the other hand, women’s wealthiest 10%, 20%, and 10% show 1.2, 1.2, and 1.1 times more severe limitations sitting down/getting up off a chair than the poorest 10%, 20%, and 40% of women, respectively. The difference was only statistically significant (p < 0.05) for the 20/20 index.

Concerning family caregiving, women’s wealthiest 10%, 20% and 10% receive 1.5, 2.9, and 1.5 times more care from family caregivers when they have mild limitations sitting down/getting up off a chair than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.005). Concerning severe limitations sitting down/getting up off a chair, women’s wealthiest 10%, 20%, and 10% receive 7.2, 2.6, and 1.4 times more care by family caregivers than the poorest 10%, 20%, and 40% of women, respectively. These differences were statistically significant (p < 0.05).

4. Discussion

Aging in Brazil occurs in the context of deep and persistent income, gender and ethnic inequalities, intensely challenging the health, retirement, and social protection systems. Significant socioeconomic disparities were evident in the sample. In the OP60+ with one or more BADLs, the illiteracy rate in the poorest two deciles were 15 and 5 time more than the two wealthiest deciles in men and women, respectively. Additionally, the average household income in the two wealthiest deciles was over 16 times more than the two poorest deciles. Also, ethnic differences between deciles are relevant; OP60+ men declared black, skin-browned, or indigenous in the two poorest deciles show two times more BADLs prevalence rate than white in the two wealthiest deciles. In women, this difference was 1.5 times. These differences were strongly statistically significant (p < 0.0001).

The results show an overall prevalence rate of functional limitations in at least one BADL of the 21% and disaggregated by sexes was 24% for women and 17% for men. This prevalence is increased regarding the previous 16% from 2013-PNS; however, it must be noted that this study considered just six BADLs [34] and higher than that observed in a previous study carried out in Brazil by Veloso et al. considering five BADLs in a sample data of 986 people aged 60 years or over from municipality of Campinas, São Paulo in 2014/15, shows a prevalence of 8.4% [35]. Thus, the differences in prevalence between studies depend on the functional health limitations of the target populations and methodological aspects such as type of instruments for assessing functional health or the number of BADLs analyzed; thus, comparability of the findings of this study with others is limited.

Getting in/out of bed was the most relevant functional limitation involved, followed by sitting down/getting up off a chair and dressing in both sexes, suggesting permanent caregiver help and care. Women presented more severe functional limitations in all BADLs than men, and the differences were statistically significant.

The results support the importance of distinguishing the degrees of severity of BADLs because, as a continuum of severity, it allows quantifying a vulnerable group that could benefit from implementing interventions that maintain or improve their physical and functional abilities. Except for bathing BADL, the mild category prevalence rates were more remarkable than the severe category in all the other BADLs. The prevalence rates of the mild limitation in all BADLs show a linear decreasing trend across deciles in both sexes. This trend suggests that mild BADL limitations are related more to household income gradient than other factors. Furthermore, the relatively high prevalence rates of mild limitation in getting in/out of bed, sitting down/getting up chair, dressing, and personal mobility in women could be an opportunity window from a dependency prevention perspective.

However, trends of the prevalence rate for severe limitation in all BADLs resemble better invert convex parabolic curves, increasing up to the 7th and then decreasing to the 10th decile. Factors beyond the economic gradient may contribute to explaining this trend. In both sexes, the OP60+ in the two poorest deciles are younger than those in the middle and two wealthiest deciles. Also, they have a household head role which implies active provider participation, then more likely to maintain them physically active. Also, the survival bias cannot be ruled out either, considering that individuals of lower socioeconomic levels tend to have higher premature mortality. Other factors to consider could be less likely to receive care or that the poorest have a higher level of resilience, underestimating the severity of the functional limitation.

In both sexes OP60+ with severe BADLs limitation, the two poorest deciles are 6 and 7 years for men and women, respectively, younger than those in the middle and two wealthiest deciles. Furthermore, the household head rate in the poorest two deciles was 2.5% for men and 3.2% for women, compared with 1.7% and 3.0% in the wealthiest two deciles in men and women, respectively. The difference was only statistically significant for men (p < 0.02). Regarding care availability, women in the poorest two deciles show a 4.1% caregiver rate compared with 6.1% of the women in the wealthy two deciles. The difference was statistically significant (p < 0.0001). Men show lower availability of caregivers than women, and the difference between the poorest two and wealthiest two deciles was insignificant.

A noteworthy finding complementing the inverted convex parabolic curves explanation is the high prevalence rates of severe limitations in BADLs across the middle deciles (4th to 7th), particularly in men. One possible explanation is that the so-called “middle class” manifests in this way the long-term adverse effects of a consumer society that conditions unhealthy lifestyles, such as unhealthy eating, lower physical activity, or sedentarism, factors associated with functional health limitations. Analysis with the same data show that OP60+ belonging to middle deciles with severe BADLs limitation in both sexes had significantly (p < 0.05) lower physical activity (<150 min/week) rates than the first three poorest and the last three wealthiest deciles.

These results are consistent with other studies documenting social inequalities on the physical functioning of Brazilian older adults. Lima-Costa et al. showed a strong gradient across education level and household assets [16, 36, 37]. Bof de Andrade et al. (2018) with a nationally representative sample of adults aged 50 years or older indicated that inequalities in BADLs limitation are primarily explained by socioeconomic status (wealth and own education), not by demographic or health factors [38]. On the other hand, Veloso et al. does not found a significant association between dependence on 5-BADLs and family income [35].

Association of socioeconomic inequalities and functional health in older adults, also have been documented in other countries. Lai et al. using data from longitudinal older adults aged 70+ followed them for 10 years in Hong Kong, found that older adults with lower socioeconomic status (SES) were more prone to ADL disability; and such inequalities accentuated with time [39]. Olivares-Tirado and Zanga using data from the Chilean 2017 National Socioeconomic Characterization Survey, indicated a descending gradient of both severity levels on six BADL functional limitation rates, moving from the poorest to the wealthiest deciles in both sexes, suggesting significant socioeconomic inequalities in functional health among older adults in Chile [40]. Stefler et al. indicated a consistently higher risk of low physical and cognitive functioning in participants with lower education or income but the magnitude of these inequalities varies across different social contexts [41]. Acciai using growth curve models show that for self-rated health and physical functioning in individual aged 50 or over, the choice of the indicator of (SES)—wealth, income, or education—is very consequential, as the age trend of social inequalities in health is substantially different for different measures of SES [42].

Concerning intergenerational support, family caregiving was a relevant factor. Overall, on average, women represent 64% of family caregivers. The family caregiver rate was higher for OP60+ with severe BADL limitations across all deciles in both sexes, compared with those with mild BADL limitations. Furthermore, 10% of the OA60+ with at least one BADL limitation provide personal care for household residents, including older adults; 74% were women. In both sexes and both categories of BADLs limitations, the wealthiest two deciles received more family caregivers than the two poorest deciles. The differences were statistically significant (p < 0.001). It must notice that OP60+ in both sexes and both categories of BADLs limitations across middle deciles (4th to 7th) received more family care than the two poorest and two wealthiest deciles. This result confirms those reported by Lima-Costa et al. (2016), suggesting that the wealthiest OP60+ are more likely to receive help for performing ADL tasks and that the receipt of formal care is correlated with better socioeconomic conditions. However, the results differ with these authors regarding informal care being only significantly associated with the poorest and not significantly associated with the wealthiest.

An interesting finding is that across inequality indexes, consistently and significantly poorest OP60+ in both sexes shows around two times higher prevalence rate in mild BADLs limitations than the wealthiest. However, in severe BADLs limitations, these differences are not clearly stated, and it depends on the sex and type of BADLs involved. Except for the 10/10 index for sitting down/getting up off a chair, the poorest men show slightly higher differences across the three indexes in all BADLs; however, the differences were mainly statistically significant in the 20/20 and 40/10 indexes. Paradoxically, in women, excepting 40/10 index in dressing BADL and 10/10 and 40/10 indexes in getting in/out of bed, the wealthiest women show a slightly higher prevalence rate in severe BADL limitations than the poorest women. The differences were statistically significant in the three indexes for eating and bathing BADL and the 20/20 index for personal mobility and sitting down/getting up off a chair.

In this analysis, intergenerational care mostly favored the wealthiest deciles across inequality indexes. Consistently and significantly wealthiest women received more family caregiving in both BADLs limitation categories than the poorest women. In the 10/10 inequality index, women with mild limitations received 6 to 20 times—depending on BADL limitation—more family care than the poorest women. In women with severe BADL limitations, the 10/10 inequality index significantly favored 7 to 11 times the wealthiest. Concerning the other indexes, even advantageous for the wealthiest women, the magnitudes are lower. For the men, the wealthiest received more family caregiving in both BADLs categories than the poorest men. However, their magnitude differences were lesser and statistically significant only in the 10/10 and 20/20 indexes. The 40/10 inequality index favored the poorest men with severe BADL limitations, but the differences were not statistically significant.

The study had some limitations that should be considered when interpreting the results. No causal inference can be drawn when interpreting these results since the study relies on cross-sectional data. Second, the interest variables assessed were obtained through interviews based on self-reports or provided by another resident, increasing the risk of information bias. Another limitation is the descriptive design of the study, which would prevent adjusting for relevant variables the magnitude of the differences in functional health by household income level of the older adults. The effect of age, education level, ethnicity, region of residence, etc., could affect the results presented.

Also, this study had some strengths. It includes a nationally representative sample of the older adults Brazilian population. This allowed quantifying the magnitude and association between household incomes, functional health, and intergenerational support among older Brazilians. Another advantage of the study is its internal validity, given that the PNS produced high-quality data, with careful preparation of instruments and quality control of data collection and processing [31].

5. Conclusion

In conclusion, the study’s results provide elements to understand how the gradient in household income and the availability of family caregiving for older adults with BADL limitations help explain the effects of the vicious circle of health inequality in Brazil. Inequality indexes reveal significant socioeconomic inequalities in functional health prevalence among the older adult population, and their magnitude varies by sex and BADL limitation severity, affecting women more than men. Additionally, there is clear evidence that family support is fundamental to maintaining older adults’ health, quality of life, and well-being. Nevertheless, as current social changes affect the family structure and dynamics, it is crucial to examine community and health system interventions targeting older adults to prevent declining functioning health.

Considering that functional limitations as an indicator for healthy aging were associated with a higher likelihood of retirement and a higher level of health expenditures [43], these findings highlight the need for public policies in the health sector focused on the morbidity compression of the NCDs—main cause of functional limitations—and setting targets for healthy life expectancy during early adulthood, emphasizing healthy aging activities mainly in the vulnerable groups. Achieving that requires reducing inequalities and a health system based on prevention rather than interventions. As successful preventive health policy goes well beyond the health sector, a life course approach and social determinants of health approach must be considered.

Acknowledgments

The author thanks the data access to the Brazilian Institute of Geography and Statistics (IBGE).

Availability of data: https://www.ibge.gov.br/estatisticas/downloads-estatisticas.html?caminho=PNS/2019/Microdados/Dados.

Conflict of interest

The author declares no conflict of interest.