andrade and ortega presentation - assessment of the impact of socioeconomic disparities in health...

ASSESSMENT OF THE IMPACT OF SOCIOECONOMIC DISPARITIES IN HEALTH AMONG RETIREMENT AGE ADULTS IN BRAZIL AND MEXICO

Flavia C. D. AndradeUniversity of Illinois at Urbana-Champaign, USA

Mariana López-OrtegaInstituto Nacional de Geriatría, Mexico

Background•Brazil and Mexico have the largest populations of older adults in Latin America. •2015: 16.5 million(8%) in Brazil and 8.2 million people (6.5%) in Mexico [1].

•Both countries also have experienced large gains in life expectancy in recent decades.

•Life expectancy at birth in 2010-2015: 74 in Brazil and 77.5 in Mexico.

Background•The increase in the proportion of older adults living longer has affected both public health care costs and pension systems in both countries.

•As a result, the issue of extending working life became an important policy issue given the population aging.

RetirementBRAZIL • Retirement age remains relatively low and no universal minimum age is

imposed [2]. • Average age at retirement on time at contribution was 54.4 for men and

51.3 for women – as a result, a man who retires receives his pension for an average 23.0 years and a woman for 29.2 years [3].

• About 7.2% of the Brazilian gross domestic product (GDP) is used to pay for retirement benefits.

MEXICO• In 2013, only 26.1% adults 60 years and over—35 per cent for men and

18.5 per cent for women [9]—had a retirement pension. • The public and private expenditure on pension benefits is approximately

1.8 percent of GDP [8].

Brazil

Mexico

Objective• Compare educational and sex differences in the health (i.e.

diabetes and hypertension) among adults 50-74. • We use estimates from nationally representative samples in Brazil

and Mexico to evaluate how the adoption of homogenous policies may differently influence social groups.

Data•Brazil

•Brazilian National Household Survey (PNAD) 2003 •National Health Survey (PNS) 2013.

•Mexico •Mexican National Health Survey (ENSA) 2000 •National Health and Nutrition Survey (ENSANUT) 2012

Methods•Descriptive statistics are provided by age, sex and period. •Logistic regressions•Locally-weighted scatterplot smoother (LOWESS)•Main variables: age, sex, educational levels, self-reported diabetes and hypertension

Education No education - no education or less than one year of formal schooling; Primary- one to six years of completed formal education More than primary - seven or more years of schooling

Brazil Mexico  2003 2013 2000 2012Health conditionsDiabetes 10.0 14.5 16.8 22.0Hypertension 40.8 42.0 30.8 31.1

EducationNo education 26.5 21.4 5.4 13.9Primary 48.0 45.8 69.3 49.3More than primary 25.5 32.8 25.3 36.8

SexMale 46.0 46.1 50.0 47.6Female 54.0 53.9 50.0 52.4

Age groups 50-54 30.2 28.6 32.5 31.2 55-59 23.6 26.0 24.0 26.2 60-64 19.2 19.4 19.8 18.0 65-69 15.1 14.9 13.8 13.4 70-74 12.0 11.1 9.9 11.1Sample size 57300 17320 8888 13020

Table 1. Descriptive statistics by year, Brazil and Mexico (weighted estimates)

Table 3. Estimates of logistic regressions on the association between self-reported diabetes, hypertension and socioeconomic status. Brazil and Mexico

Brazil MexicoVARIABLES OR ORDiabetes  Education (ref=no education)Primary 1.07** 1.16***More than primary 0.86*** 1.04

Age 1.04*** 1.03***Female (ref=Male) 1.38*** 1.33***Most recent (ref=least recent) 1.50*** 1.37***Constant 0.01*** 0.03***Observations 73,443 21,778HypertensionEducation (ref=no education)Primary 1.03* 1.39***More than primary 0.79*** 1.40***

Age 1.04*** 1.04***Female (ref=Male) 1.76*** 2.02***Most recent (ref=least recent) 1.00 1.05Constant 0.04*** 0.02***Observations 74,378 20,995

Graph 1. Diabetes among Adult Women in Brazil (2013) and Mexico (2012)

Brazil

0.1

.2.3

.4D

iabe

tes

50 55 60 65 70 75Age in years

No education PrimaryMore than primary

Mexico

0.1

.2.3

.4

50 55 60 65 70 75age in years

No education PrimaryMore than primary

Graph 2. Diabetes among Adult Men in Brazil (2013) and Mexico (2012)

Brazil0

.1.2

.3.4

Dia

bete

s

50 55 60 65 70 75Age in years

No education PrimaryMore than primary

Mexico

0.1

.2.3

.4

50 55 60 65 70 75age in years

No education PrimaryMore than primary

Graph 3. Hypertension among Adult Women in Brazil (2013) and Mexico (2012)

Brazil

.1.2

.3.4

.5.6

Hyp

erte

nsio

n

50 55 60 65 70 75Age in years

No education PrimaryMore than primary

Mexico

.1.2

.3.4

.5.6

50 55 60 65 70 75age in years

No education PrimaryMore than primary

Graph 4. Hypertension among Adult Men in Brazil (2013) and Mexico (2012)

Brazil

.1.2

.3.4

.5.6

Hyp

erte

nsio

n

50 55 60 65 70 75Age in years

No education PrimaryMore than primary

Mexico

.1.2

.3.4

.5.6

50 55 60 65 70 75age in years

No education PrimaryMore than primary

Diabetes

0.2

.4.6

50 55 60 65 70 75Age in years

Hypertension

0.2

.4.6

50 55 60 65 70 75Age in years

No education Primary

More than primary

Poor health

0.2

.4.6

50 55 60 65 70 75Age in years

Graph 5. Health conditions among Adult Women in Brazil (2013)

Diabetes

0.1

.2.3

.4.5

50 55 60 65 70 75Age in years

Hypertension

0.1

.2.3

.4.5

50 55 60 65 70 75Age in years

Poor health

0.1

.2.3

.4.5

50 55 60 65 70 75Age in years

No education PrimaryMore than primary

Graph 6. Health conditions among Adult Men in Brazil (2013)

0.2

.4.6

.8 Diabetes

50 55 60 65 70 75

0.2

.4.6

.8

Hypertension

50 55 60 65 70 75

0.2

.4.6

.8

Poor health

50 55 60 65 70 75

No educPrimaryMore than primary

0.2

.4.6

.8

ADL

50 55 60 65 70 75

Graph 8. Health conditions among Adult Women in Mexico, MHAS (2015)

0.1

.2.3

.4.5

Diabetes

50 55 60 65 70 75

0.1

.2.3

.4.5 Hypertension

50 55 60 65 70 75

0.1

.2.3

.4.5

Poor health

50 55 60 65 70 75

No educPrimary

More than primary

0.1

.2.3

.4.5

ADL

50 55 60 65 70 75

Graph 8. Health conditions among Adult Men in Mexico, MHAS (2015)

Discussion• For Mexico the possible mediating effect of SES on access to health services and

detection of chronic diseases should be explored in the future as there are important differences in prevalence by self-report vs. measurements, for example in hypertension self-report vs. blood pressure measured at the time of the survey.

Percentage of adults with hypertension, by sex and age group. ENSANUT 2012

Source: Gutierrez et al., 2013

50-59 60-69 70-79 80+

22.333.5 31

39.3

21.8

25.8 28.821.2

MenSelf-reported % Detected %

50-59 60-69 70-79 80+

29.4

47.1 43.135.8

18

14.8 22.7

15.8

WomenSelf-reported % Detected %

Graph 9. Self-reported and Measured Hypertension among Adult Women in Mexico, ENSANUT (2012)

Self-reported

.2.3

.4.5

.6

50 55 60 65 70 75age in years

No education PrimaryMore than primary

Measured

.2.3

.4.5

.6

50 55 60 65 70 75age in number of years

Graph 10. Self-reported and Measured Hypertension among Adult Men in Mexico, ENSANUT (2012)

Self-reported

.1.2

.3.4

.5

50 55 60 65 70 75

No education PrimaryMore than primary

Measured

.1.2

.3.4

.5

50 55 60 65 70 75

Discussion•Important social gradients •Women with more education were less likely to report having diabetes in Brazil and Mexico

•However, among men self-reported diabetes was more reported among those with more education (even though for more recent cohorts, the situation seems to be changing)

Discussion• In Brazil, women with more education reported lower prevalence of

hypertension than those with less education, but the reverse was found in Mexico based on self-reported data. When analyzing blood pressure measurements, similar levels were found among women with no education and more than primary.

• Among men, those with less education reported lower prevalence of hypertension. In contrast, less educated men have higher prevalence of hypertension when using measured blood pressure.

Limitations• Self-reported data that implies individuals have had access to

health care services, while such access can also have important SES gradients.

• Focus only on diabetes and hypertension• Need to incorporate other health conditions (e.g. disability, mobility,

SHR)• Urban/rural differences• Occupational differences

Thanks

WordingBrazil• 2003“...have [health

condition]?”• “Has a doctor has given you a

diagnosis of [health condition]?

Mexico•2000 and 2012: “Has a physician told you have (health condition)”?

(Rocha and Caetano 2008)

(Rofman, Lucchetti et al.)

(Rofman, Lucchetti et al.)

(Rofman, Lucchetti et al.)

Beltran-Sanchez & Andrade (forthcoming)

Beltran-Sanchez & Andrade (forthcoming)

Brazil Mexico Mexico MHASVARIABLES OR se OR se OR seDiabetes    Education (ref=no education) .Primary 1.07** 0.03 1.16*** 0.06 1.10 0.07More than primary 0.86*** 0.03 1.04 0.06 0.88 0.06

Age 1.04*** 0.00 1.03*** 0.00 1.02*** 0.00Female (ref=Male) 1.38*** 0.03 1.33*** 0.05 1.37*** 0.06Year 2013 (ref=2003) 1.50*** 0.04 1.37*** 0.05Constant 0.01*** 0.00 0.03*** 0.01 0.06*** 0.02Observations 73,443   21,778   10491 HypertensionEducation (ref=no education)Primary 1.03* 0.02 1.39*** 0.07 1.14** 0.07More than primary 0.79*** 0.02 1.40*** 0.08 1.01 0.07

Age 1.04*** 0.00 1.04*** 0.00 1.05*** 0.00Female (ref=Male) 1.76*** 0.03 2.02*** 0.06 1.79*** 0.07Most recent year (ref=least recent) 1.00 0.02 1.05 0.03Constant 0.04*** 0.00 0.02*** 0.00 0.02*** 0.01Observations 74,378   20,995   10493