Social inequalities in the use of preventive healthcare among older women (50+): evidence from ELSI-Brazil

Abstract

Considering the scenario of Brazilian population aging, marked by the feminization of old age and persistent social inequality in access to and use of health services, this study aims to investigate the association between socioeconomic variables and preventive healthcare among older women (50+), according to the source of health care. This is a cross-sectional study, based on ELSI-Brazil (2015-2016) baseline data. The outcomes were Pap smear; mammography; measurements of cholesterol, blood glucose, and blood pressure; and the exposures of interest were educational level, self-reported skin color, and per capita household income. Odds ratio (OR) were estimated in Logistic regression models. Self-reported skin color, educational level, and per capita household income were frequently associated with outcomes for women with and without private health plans, with a higher prevalence of exams among those who were white and those who had higher educational and income levels. The implementation of public policies and multisectoral actions that tackle the structural determinants of health and improve people’s living and working conditions is essential to reducing health inequalities and ensuring the universal right to health.

Key words:
Aged; Screening tests; Women’s health; Measuring health inequalities; Cross-sectional studies

Resumo

Considerando o cenário de envelhecimento populacional brasileiro, marcado pela feminização da velhice e pela persistente desigualdade social no acesso e uso dos serviços de saúde, este trabalho tem como objetivo investigar a associação entre variáveis socioeconômicas e realização de exames preventivos de saúde entre mulheres mais velhas (+50), segundo fonte de atenção à saúde. Trata-se de estudo transversal utilizando dados do ELSI-Brasil (2015-2016). Os desfechos foram a realização de exame de Papanicolau, mamografia, dosagem de colesterol e glicemia e aferição da pressão arterial, e as exposições de interesse foram escolaridade, cor autorreferida e renda domiciliar per capita. Foram ajustados modelos logísticos, com estimativa de razões de chance (α = 5%). Cor autorreferida, escolaridade e renda foram frequentemente associadas aos desfechos para mulheres com e sem afiliação aos planos privados de saúde, com maior realização dos exames entre as brancas e de maior escolaridade e renda. Implementação de políticas públicas e ações multisetoriais que atuem nos determinantes estruturais da saúde e melhorem as condições de vida e trabalho são essenciais para reduzir as iniquidades em saúde e garantir o direito universal a saúde.

Palavras-chave:
Idoso; Uso de serviços de saúde; Saúde da mulher; Mensuração das desigualdades em saúde; Estudos transversais

Resumen

Considerando el escenario de envejecimiento poblacional en Brasil, marcado por la feminización de la vejez y la persistente desigualdad social en el acceso y uso de los servicios de salud, este estudio tiene como objetivo investigar la asociación entre las variables socioeconómicas y los exámenes preventivos de salud entre las mujeres mayores (+50), según la fuente de atención de salud. Se trata de un estudio transversal que utiliza datos de ELSI-Brasil (2015-2016). Los resultados fueron pruebas de Papanicolaou, mamografías, niveles de colesterol y glucosa en sangre y medición de la presión arterial, y las exposiciones de interés fueron la escolarización, el color autodeclarado y el ingreso familiar per cápita. Se ajustaron modelos logísticos, con estimación de odds ratios (α=5%). El color autodeclarado, la escolarización y los ingresos se asociaron con frecuencia a los resultados de las mujeres con y sin seguro médico privado, y se realizaron más pruebas entre las mujeres blancas y las que tenían una mayor escolarización e ingresos. La implementación de políticas públicas y acciones multisectoriales que actúen sobre los determinantes estructurales de la salud y mejoren las condiciones de vida y de trabajo es esencial para reducir las desigualdades en salud y garantizar el derecho universal a la salud.

Palabras clave:
Ancianos; Utilización de los servicios de salud; Salud de la mujer; Medición de las desigualdades en salud; Estudios transversales

Introduction

In the aging process of the Brazilian population, the feminization of old age stands out, primarily as a consequence of women’s greater life expectancy¹. However, despite living longer, they are more subject to the process of weakening their health status, resulting from their social history, which involves discrimination in access to education, work, food, and salary².

As a consequence of population aging, we have observed an increase in the incidence and prevalence of Noncommunicable Diseases (NCDs)³. Globally, the four main groups of NCDs (cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases) account for 71% of all deaths, with low- and middle-income countries being the most impacted⁴. In Brazil, these groups of chronic diseases accounted for 54.7% of deaths in 2019⁵.

Addressing NCDs is a challenge for public health and requires the health system to organize itself to offer regular preventive actions, timely diagnoses, and early treatment in order to reduce the incidence of complications and avoid premature deaths. The provision of comprehensive longitudinal care required to address NCDs increases the demand for health services, particularly among older adults, a population group that tends to have a higher number of chronic diseases. Research conducted by Nunes et al. (2018)⁶, using data from the Brazilian Longitudinal Study of Elderly Health (ELSI-Brazil), showed that the prevalence of multimorbidity was higher among women and increased with age.

The expansion of Family Health Strategy (FHS) teams has improved the performance of several health indicators for the population, with a significant reduction in hospitalizations and mortality due to chronic conditions that are sensitive to Primary Health Care (PHC)^7-9. A study conducted in the state of Espírito Santo demonstrated that, after the implementation of the FHS teams, there was a reduction in hospitalizations due to conditions that are sensitive to primary care, especially those related to hypertension among adults and the elderly¹⁰. Another initiative that contributed to the control of NCDs was the implementation of the Hyperdia program, an initiative of the FHS launched in 2001, which enabled more systematic monitoring of people with diabetes and hypertension by health teams¹¹.

The FHS has established itself as an important tool for addressing social inequalities in health, mainly by expanding access to PHC services and preventing complications from chronic conditions^7-9. However, despite these advances, Brazil is still extremely marked by social inequalities in access to and use of health services, and individuals with greater social disadvantages are less likely to seek and use these services. Evidence suggests that, although the FHS teams have contributed to expanding access to and use of health services, barriers still persist that limit universality and equity in care, reflecting the continued inequalities in the country^12,13.

Social inequality in access to health services is also evident in the use of medical examinations among women. The literature indicates that married, white women, women with higher educational levels, and with private health insurance are more likely to have undergone a Pap smear, a preventive exam used to diagnose cervical cancer, the third leading cause of death in women in Brazil^14-18. Similar results were observed for mammography, used to detect breast cancer, the neoplasm that most kills women in Brazil¹⁹. Studies indicate that women with higher educational and income levels, who live with a partner, who live in urban areas, and who have private health insurance are more likely to undergo the exam^14,17,18,20.

For the Pap smear, the Ministry of Health (MoH) protocols recommend performing two exams with a one-year interval between them and, if both are negative, that the frequency be increased to three years, with the target audience being women aged 25 to 64 years²¹. Regarding mammography, the recommendation is that the exam should be performed every two years for women aged 50 to 69 years²¹.

In addition to neoplasms, two other groups of NCDs are responsible for a major part of the morbidity and mortality among women: circulatory system diseases, especially cardiovascular diseases, and diabetes. It is well-known that systemic arterial hypertension (SAH) and dyslipidemia constitute modifiable risk factors for the development of cardiovascular diseases and are considered a major public health problem^22,23. According to the Brazilian Hypertension Guidelines, healthy individuals with adequate blood pressure values ​​measured in the office and pre-hypertensive patients should have their blood pressure measured at least once a year^22,24.

High cholesterol is associated with an increased risk of heart disease and stroke²⁵. There is no consensus regarding the frequency of screening, and it is usually determined according to cardiovascular risk. For individuals with normal results, it is suggested that the measurement be performed every five years. A shorter interval may be recommended for people with values ​​close to the limit²⁶.

As for diabetes mellitus, there is no evidence regarding an ideal frequency for screening; however, the MoH recommends that individuals with risk factors should be tested every three to five years²⁷.

In view of the above, considering the scenario of Brazilian population aging, marked by the feminization of old age and social inequality in access to and use of health services, the present study aimed to investigate the association between socioeconomic variables and preventive healthcare among older women (50 years and older), according to the source of care (exclusive users of SUS or affiliation with a private health plan). Stratification by source of care is necessary due to differences in the organization of the systems, which may be an important confounding factor for the object of study.

This work seeks to fill a gap in the Brazilian context by contributing information that strengthens public health policies in Brazil, helping to ensure comprehensive longitudinal care for women aged 50 and older. Furthermore, the results presented herein can contribute to expanding the availability of preventive services and to the promotion of multisectoral measures that act upon socioeconomic conditions as a strategy to reduce social inequalities in health and guarantee equity.

Methods

Study population

Cross-sectional study conducted with baseline data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), collected between 2015 and 2016. To ensure representativeness of urban and rural areas in municipalities of different sizes (small, medium, and large), the ELSI-Brazil sampling process adopted a design with selection stages, involving stratification, according to population size, primary sampling units (municipalities), census tracts, and households. The planned number of interviews was 10,000 (9,412 participated), residing in 70 municipalities, located in the five Brazilian macro-regions. The ELSI-Brazil sample is representative of the non-institutionalized Brazilian population aged 50 and over.

More details on the methodology were described in another publication²⁸ and on the research website (https://elsi.cpqrr.fiocruz.br/). Females aged 50 years or older were eligible for this study, making up all 5,314 female ELSI participants.

Study variables

Dependent variables (healthcare service use indicators)

The outcomes of interest were indicators of the use of health services by older participants, assessed based on Pap smear and mammogram tests, in accordance with the MoH²¹ guidelines for the age group, blood glucose and cholesterol levels, and blood pressure measurements²², as described below:

• a) Pap smear, for participants aged 50 to 64 years (three years or less; more than three years or never had one)

• b) Mammography, for participants aged 50 to 69 years (two years or less; more than two years or never had one)

• c) Blood glucose level, for participants aged 50 or over (three years or less; more than three years or never had one)

• d) Cholesterol level, for participants aged 50 or over (three years or less; more than three years or never had one)

• e) Blood pressure measurement, for participants aged 50 or over (Up to one year; more than one year or never had one)

The temporality of the outcomes was defined in this way to ensure alignment with current public health policies in Brazil, in addition to reflecting the standard practice of the health system in our context.

Exposure variables (socioeconomic indicators)

• a) Self-reported race (white; other (black, brown, yellow, and indigenous))

• b) Educational level (< 4 years; 4-7 years; ≥ 8 years of study)

• c) Per capita household income (in tertiles: up to R$587.00; from R$587.00 to R$1,050.00; above R$1,050.00)

Adjustment variables

• a) Age (50-59; 60-69; 70-79; 80 years and over)

• b) Living arrangement (lives alone; does not live alone)

• c) Number of chronic diseases, considering self-reported medical diagnosis for high blood pressure, diabetes, heart attack, angina, heart failure, stroke, chronic obstructive pulmonary disease, arthritis or rheumatism, depression, cancer and chronic renal failure (absence of disease; one chronic disease; two or more chronic diseases)

Stratification variable

Source of health care (with health insurance; without health insurance).

Data analysis

The sample characteristics were presented using relative frequencies, with their respective 95% confidence intervals (95%CI). In the unadjusted analyses, Pearson’s chi-square test, with Rao-Scott correction, was used to assess the statistical significance of differences between proportions, according to the source of health care.

The magnitudes of the associations between the exposure variables (self-reported race, education, and per capita household income) and the outcomes (Pap smear, mammography, blood glucose and cholesterol levels, and blood pressure measurement) were analyzed using the logistic regression model, with estimated odds ratios and their respective 95%CI. Crude models and models adjusted for potential confounding factors were adjusted in the sample stratified according to the source of health care. The goodness-of-fit of the model adjustment was assessed using the Hosmer-Lemeshow test. All analyses were conducted using Stata software version 14.1, taking into account the complexity of the sample design and the weight of the individuals. The significance level was set at 5%.

Ethical aspects

ELSI-Brazil was approved by the Fundação Oswaldo Cruz (FIOCRUZ) ethics committee, Minas Gerais, Brazil (protocol number 886.754). All participants registered their consent to participate in the study by signing the Free and Informed Consent Form (FICF).

ELSI-Brazil was funded by the MoH: DECIT/SCTIE (Processes: 404965/2012-1 and TED 28/2017); COPID/DECIV/SAPS (Processes: 20836, 22566, 23700, 25560, 25552, and 27510).

Results

The ELSI-Brazil sample included 5,314 women. Those who met the selection criteria regarding the age group and provided valid responses for the outcomes of interest were included in the study, with the largest loss, of 2.13%, being due to invalid responses for the outcome related to cholesterol measurement. The final study sample consisted of 5,225; 5,201; and 5,265 women for, respectively, the outcomes of blood glucose, cholesterol levels, and blood pressure measurements, and 2,942 and 3,727 women for Pap smear (50 to 64 years) and mammogram (50 to 69 years), respectively.

Affiliation to a private health plan was declared by 25.3% of the participants. According to Table 1, 54.2% of the participants were 60 years of age or older and 57.3% self-identified as black, brown, yellow, or indigenous. Approximately one in ten lived alone, and 34.5% had less than four years of education. Approximately 39% of the participants reported no chronic disease and 28% self-reported multimorbidity (diagnosis of at least two chronic diseases). Regarding preventive healthcare, approximately 78% had undergone a Pap smear in the last three years and 74% had a mammogram in the last two years. Approximately 90% of the participants had blood glucose and cholesterol tests performed in the last three years, while 94% had their blood pressure measured in the last year. With the exception of the number of chronic diseases, all other variables included in the study were statistically associated with affiliation to a private health plan, with preventive healthcare being more frequent among participants with a health plan.

Table 1
Characterization of the sample, total and stratified by affiliation to a private health plan (ELSI Brazil, 2015-2016).

Variable	Total sample1 % (IC95%)	With health plan % (IC95%)	Without health plan % (IC95%)	p2 value
Sociodemographic characterization
Age range				< 0.001
50-59 years	45.8 (42.6-49.0)	39.6 (35.4-44.0)	47.9 (44.6-51.4)
60-69 years	29.6 (27.9-31.4)	29.2 (26.0-32.5)	29.8 (27.9-31.8)
70-79 years	16.4 (14.8-18.1)	19.4 (17.0-22.0)	15.4 (13.7-17.2)
80 years and over	8.2 (6.8-9.6)	11.8 (9.6-14.6)	6.8 (5.6-8.3)
Self-reported skin color				< 0.001
White	42.7 (36.6-48.9)	54.7 (49.2-60.1)	38.5 (31.9-45.4)
Non-white	57.3 (51.1-63.3)	45.3 (39.9-50.8)	61.5 (54.6-68.0)
Lives alone				< 0.001
Yes	10.7 (9.6-12.0)	12.9 (10.9-15.3)	9.9 (8.9-11.1)
No	89.3 (88.0-90.4)	87.1 (84.7-89.1)	90.0 (88.7-91.0)
Educational level				< 0.001
< 4 years of study	34.5 (31.1-38.0)	17.6 (14.4-21.2)	40.2 (36.4-44.3)
4-7 years of study	31.2 (28.6-34.0)	25.8 (23.0-28.9)	33.1 (29.8-36.6)
8 years or more	34.3 (31.4-37.3)	56.6 (51.8-61.2)	26.6 (23.8-29.6)
Household per capita income				< 0.001
Tertile 1	35.5 (31.6-39.7)	21.3 (18.2-24.7)	40.4 (35.8-45.2)
Tertile 2	33.5 (31.6-35.4)	24.2 (21.3-27.4)	36.7 (34.3-39.1)
Tertile 3	31.0 (27.8-34.4)	54.5 (50.1-58.9)	22.9 (19.9-26.2)
Health condition
Number of chronic diseases				0.354
No chronic disease	39.1 (36.6-41.6)	36.8 (33.4-40.3)	39.8(36.9-42.8)
1 chronic disease	33.1 (31.9-34.4)	34.8(31.7-38.1)	32.6(31.1-34.1)
2 or more chronic diseases	27.8 (25.6-30.1)	28.4(25.2-31.9)	27.6(24.9-30.5)
Use of health services
Pap smear (last 3 years)3	77.7 (75.6-79.6)	86.3 (82.9-89.1)	75.1 (72.5-77.5)	< 0.001
Mammography (last 2 years)4	74.2 (71.7-76.4)	80.9 (77.4-83.9)	71.7 (68.6-74.7)	< 0.001
Blood glucose (last 3 years)	88.7 (87.0-90.2)	94.4 (92.4-95.9)	86.8 (84.7-88.6)	< 0.001
Cholesterol (last 3 years)	89.7 (87.9-91.3)	95.4 (93.6-96.8)	87.8 (85.5-89.7)	< 0.001
Blood pressure (up to 1 year)	94.0 (93.0- 94.8)	95.8 (94.4-96.9)	93.4 (92.1-94.5)	0.012

• ¹
  n = 5,314; ² p-value of the chi-square test with Rao-Scott correction; ³ includes only women between 50-64 years old, considering the specific recommendations for this exam; ⁴ includes only women between 50-69 years old, considering the specific recommendations for this exam.
• Source: Authors.

The associations between sociodemographic variables and the performance of preventive healthcare are presented in Tables 2 and 3 for participants with and without health insurance, respectively. For both groups, self-reported race, educational level, and per capita income were associated with most of the analyzed outcomes, with a higher prevalence of exams among white participants, with higher educational levels, and living in households with higher per capita income. Among participants with health insurance, age group and living arrangements were not statistically associated with any of the analyzed outcomes (Table 2). By contrast, for exclusive users of SUS, age group was strongly associated with the use of health services. For Pap smear and mammography exams, a higher frequency was observed among younger participants, whereas for the other exams, there was a higher frequency among older participants (Table 3). It is also important to note that there was a higher frequency of mammography and blood glucose testing among those who did not live alone (Table 3).

Table 2
Prevalence (% (95%CI)) of preventive healthcare among older women who have private health insurance, according to sociodemographic variables (ELSI Brazil, 2015-2016).

Sociodemographic Variables	Pap smear1 (last 3 years) % (IC95%)	Mammography2 (last 2 years) % (IC95%)	Blood glucose (last 3 years) % (IC95%)	Cholesterol (last 3 years) % (IC95%)	Blood pressure (last year) % (IC95%)
Age Range
50-59 years	86.4 (82.0-89.9)	81.5 (76.9-85.4)	94.7 (91.3-96.8)	95.1 (92.1-97.0)	94.9 (92.4-96.6)
60-69 years	86.0 (80.5-90.1)	79.9 (75.4-83.9)	96.2 (93.5-97.8)	96.8 (94.1-98.3)	96.3 (93.5-97.9)
70-79 years	-	-	92.6 (86.1-96.2)	94.8 (89.8-97.4)	97.2(92.5-99.0)
80 years and over	-	-	92.0 (83.1-96.5)	94.1 (84.9-97.9)	95.4 (90.2-97.9)
p3-value	0.894	0.565	0.371	0.672	0.594
Self-reported skin color
White	85.9 (80.7-89.9)	82.4 (77.9-86.2)	96.0 (93.6-97.6)	96.9 (94.8-98.2)	96.4 (94.5-97.6)
Non-white	87.1 (82.9-90.4)	79.5 (73.7-84.4)	92.3 (88.6-94.8)	93.7 (90.9-95.7)	95.0 (92.1-96.8)
p3-value	0.678	0.383	0.034*	0.012*	0.313
Lives alone
Yes	84.6 (73.1-91.7)	82.9 (74.4-89.1)	94.6 (90.7-96.9)	95.3 (90.7-97.7)	97.9 (93.5-99.3)
No	86.4 (82.8-89.4)	80.7 (76.9-83.9)	94.4 (92.2-95.9)	95.5 (93.5-96.8)	95.5 (93.9-96.7)
p3-value	0.718	0.587	0.894	0.941	0.216
Educational level
< 4 years of study	70.1 (55.6-81.5)	73.5 (62.7-82.0)	91.2 (87.0-94.6)	92.2 (88.3-94.9)	96.7 (91.6-98.7)
4-7 years of study	87.9 (81.9-92.1)	80.0 (71.9-86.2)	92.1(86.9-95.4)	93.3 (88.2-96.2)	94.8 (91.1-97.0)
8 years or more	87.8 (84.0-90.8)	82.5 (78.5-85.8)	96.3 (94.4-97.5)	97.4 (95.9-98.4)	96.0 (94.2-97.3)
p3-value	0.001*	0.187	0.009*	0.002*	0.634
Household per capita income
Tertile 1	83.1 (73.4-89.8)	75.7 (65.4-83.7)	91.0 (85.7-94.5)	92.3 (87.6-95.3)	94.9 (90.6-97.3)
Tertile 2	85.3 (77.9-90.5)	76.3 (68.2-82.9)	92.8 (87.4-95.9)	94.2 (90.5-96.6)	95.2 (91.6-97.2)
Tertile 3	87.9 (83.8-91.2)	84.7 (81.0-87.7)	96.5 (94.3-97.8)	97.2 (95.1-98.4)	96.5 (94.5-97.7)
p3-value	0.428	0.041*	0.026*	0.009*	0.550

• 95%CI: 95% confidence interval. 1 Includes only women aged 50-64 years, considering the specific recommendations for this exam; 2 includes only women aged 50-69 years, considering the specific recommendations for this exam; 3 p-value of the chi-square test with Rao-Scott correction. * p < 0.05.
• Source: Authors.

Table 3
Prevalence (% (95%CI)) of preventive healthcare among older women who do not have private health insurance, according to sociodemographic variables (ELSI Brazil, 2015-2016).

Sociodemographic Variables	Pap smear1 (last 3 years) % (IC95%)	Mammography2 (last 2 years) % (IC95%)	Blood glucose (last 3 years) % (IC95%)	Cholesterol (last 3 years) % (IC95%)	Blood pressure (last year) % (IC95%)
Age Range
50-59 years	77.2 (74.3-79.8)	72.8 (69.4-75.9)	84.8 (82.1-87.1)	85.8 (82.8-88.4)	91.3 (89.3-93.0)
60-69 years	68.8 (63.7-73.4)	69.9 (65.9-73.7)	87.7 (84.6-90.1)	88.4 (85.5-90.8)	94.0 (92.4-95.2)
70-79 years	-	-	89.4 (86.1-92.0)	90.6 (88.4-92.5)	97.4 (95.6-98.5)
80 years and over	-	-	91.3 (85.9-94.8)	92.5 (88.3-95.3)	96.0 (92.5-97.9)
p3-value	0.001*	0.137	0.012*	0.001*	< 0.001**
Self-reported skin color
White	75.2 (71.4-78.7)	70.3 (66.1-74.3)	89.6 (87.4-91.4)	90.2 (88.1-91.9)	93.9 (92.1-95.3)
Non-white	75.4 (71.9-78.5)	73.0 (68.8-76.9)	85.5 (82.8-87.8)	86.5 (83.5-89.0)	92.9 (91.3-94.3)
p3-value	0.955	0.326	0.003*	0.007*	0.319
Lives alone
Yes	73.5 (66.6-79.4)	65.8 (59.0-72.0)	83.0 (78.9-86.5)	85.5 (81.5-88.7)	91.2 (87.0-94.1)
No	75.2 (72.5-77.7)	72.2 (69.2-75.1)	87.2 (85.1-89.0)	88.0 (85.8-89.9)	93.6 (92.2-94.8)
p3-value	0.605	0.019*	0.020*	0.083	0.160
Educational level
< 4 years of study	71.3 (66.2-75.9)	67.6 (63.2-71.7)	83.5 (80.4-86.2)	83.8 (80.5-86.6)	94.1 (92.4-95.4)
4-7 years of study	75.7 (71.9-79.1)	73.7 (70.2-77.0)	88.0 (85.3-90.3)	89.9 (87.4-91.9)	93.1 (90.9-94.7)
8 years or more	77.8 (73.5-81.5)	73.0 (68.3-77.3)	90.1 (87.7-92.1)	90.9 (88.6-92.9)	92.8 (89.8-94.9)
p3-value	0.093	0.034*	< 0.001**	< 0.001**	0.583
Household per capita income
Tertile 1	70.5 (66.3-74.3)	70.3 (65.5-74.6)	83.4 (79.9-86.3)	84.4 (81.1-87.2)	92.6 (90.9-94.0)
Tertile 2	78.5 (74.1-82.3)	72.8 (68.5-76.7)	88.1 (85.7-90.2)	88.8 (86.1-91.0)	93.3 (91.3-94.9)
Tertile 3	79.0 (72.7-84.1)	72.4 (67.2-77.0)	90.6 (87.9-92.7)	92.0 (89.5-93.9)	94.8 (92.7-96.3)
p3-value	0.018*	0.624	< 0.001**	< 0.001**	0.158

• 95%CI: 95% confidence interval. 1 Includes only women aged 50-64 years, considering the specific recommendations for this exam; 2 includes only women aged 50-69 years, considering the specific recommendations for this exam; 3 p-value of the chi-square test with Rao-Scott correction. * p < 0.05.
• Source: Authors.

Tables 4 and 5 show the association between socioeconomic variables and preventive healthcare for participants with and without health insurance, respectively, adjusted for age groups, living arrangements, and number of chronic diseases. Among participants who reported having health insurance, compared to black, brown, yellow, or indigenous individuals, there was a greater chance of having cholesterol levels measured within the last three years among white individuals (OR = 2.00; 95%CI 1.13-3.56). Educational level was significantly associated with having a Pap smear and having cholesterol levels measured. Compared to participants with less than four years of education, having between four and seven years of education and eight years or more was associated with a greater chance of having a Pap smear (OR = 3.88; 95%CI 1.85-8.13 and OR = 3.04; 95%CI 1.62-5.67, respectively). Participants with 8 or more years of education were also more likely to have their cholesterol levels measured (OR = 2.73; 95%CI 1.19-6.27). Finally, participants in the highest tertile of household per capita income were more likely to have their blood glucose levels (OR = 2.51; 95% CI 1.47-4.30) and cholesterol levels (OR = 2.65; 95%CI 1.24-5.64) measured, as compared to those in the lowest tertile. Having had a mammogram in the last two years and having had one’s blood pressure measured in the last year were not statistically associated with the analyzed socioeconomic factors. Detailed results can be seen in Table 4.

Table 4
Association (OR (95%CI)) between sociodemographic characteristics and the performance of preventive healthcare among older women who have private health insurance (ELSI Brazil, 2015-2016).

Sociodemographic Variables	Pap smear1,2 (last 3 years) OR (IC95%)	Mammography1,3 (last 2 years) OR (IC95%)	Blood glucose1 (last 3 years) OR (IC95%)	Cholesterol1 (last 3 years) OR (IC95%)	Blood pressure1 (last year) OR (IC95%)
Self-reported skin color
White	1.00	1.00	1.00	1.00	1.00
Non-white	0.83 (0.49-1.43)	1.14 (0.73-1.80)	1.70 (0.94-3.08)	2.00 (1.13-3.56)	1.32 (0.67-2.61)
Educational level
< 4 years of study	1.00	1.00	1.00	1.00	1.00
4-7 years of study	3.88 (1.85-8.13)	1.40 (0.77-2.57)	1.06 (0.49-2.24)	1.05 (0.47-2.35)	0.44 (0.09-1.96)
8 years or more	3.04 (1.62-5.67)	1.35 (0.73-2.47)	1.85 (0.74-4.64)	2.73 (1.19-6.27)	0.64 (0.14-2.99)
Household per capita income
Tertile 1	1.00	1.00	1.00	1.00	1.00
Tertile 2	1.13 (0.57-2.21)	1.02 (0.56-1.86)	1.73 (0.81-3.74)	1.75 (0.75-4.08)	1.31 (0.49-3.51)
Tertile 3	1.40 (0.64-3.06)	1.67 (0.85-3.25)	2.51 (1.47-4.30)	2.65 (1.24-5.64)	1.39 (0.60-3.23)

• OR: odds ratio; 95%CI: 95% confidence interval. 1 Estimates adjusted for age group, living arrangement and number of chronic diseases; 2 includes only women between 50-64 years old, considering the specific recommendations for this exam; 3 includes only women between 50-69 years old, considering the specific recommendations for this exam.
• Source: Authors.

Table 5
Association (OR (95%CI)) between sociodemographic characteristics and the performance of preventive healthcare among older women who do not have private health insurance (ELSI Brazil, 2015-2016).

Sociodemographic Variables	Pap smear1,2 (last 3 years) OR (IC95%)	Mammography1,3 (last 2 years) OR (IC95%)	Blood glucose1 (last 3 years) OR (IC95%)	Cholesterol1 (last 3 years) OR (IC95%)	Blood pressure1 (last year) OR (IC95%)
Self-reported skin color
White	1.00	1.00	1.00	1.00	1.00
Non-white	0.88 (0.68-1.15)	0.81 (0.62-1.05)	1.30 (1.01-1.68)	1.19 (0.89-1.59)	1.10 (0.80-1.51)
Educational level
< 4 years of study	1.00	1.00	1.00	1.00	1.00
4-7 years of study	1.22 (0.88-1.68)	1.35 (1.08-1.69)	1.56 (1.16-2.09)	2.04 (1.52-2.74)	0.97 (0.62-1.52)
8 years or more	1.20 (0.84-1.70)	1.26 (0.94-1.69)	1.67 (1.27-2.20)	2.10 (1.62-2.72)	0.97 (0.62-1.51)
Household per capita income
Tertile 1	1.00	1.00	1.00	1.00	1.00
Tertile 2	1.50 (1.06-2.10)	1.16 (0.89-1.51)	1.28 (0.98-1.66)	1.27 (0.97-1.66)	0.95 (0.68-1.34)
Tertile 3	1.47 (1.02-2.12)	1.10 (0.79-1.54)	1.55 (1.14-2.10)	1.68 (1.23-2.30)	1.36 (0.88-2.11)

• OR: odds ratio; 95%CI: 95% confidence interval. 1 Estimates adjusted for age group, living arrangement and number of chronic diseases; 2 includes only women aged 50-64 years, considering the specific recommendations for this exam; 3 includes only women aged 50-69 years, considering the specific recommendations for this exam.
• Source: Authors.

For exclusive SUS users, positive and statistically significant associations were identified among self-reported race, educational level, per capita household income, and the use of health services (Table 5). White participants were more likely to have had their blood glucose levels measured within the last three years (OR = 1.30; 95%CI 1.01-1.68). Compared to participants with less than four years of education, those with 4-7 years of education were more likely to have had a mammogram in the last two years (OR = 1.35; 95%CI 1.08-1.69), as well as blood glucose and cholesterol levels measured in the last three years (respectively, OR = 1.56; 95%CI 1.16-2.09 and OR = 2.04; 95%CI 1.52-2.74). Having eight or more years of education was also associated with a higher chance of undergoing blood glucose (OR = 1.67; 95%CI 1.27-2.20) and cholesterol (OR = 2.10; 95%CI 1.62-2.72) exams. Regarding income, participants in the second tertile of per capita household income were more likely to undergo a Pap smear (OR = 1.50; 95%CI 1.06-2.10). Participants in the third tertile of income were more likely have a Pap smear (OR = 1.47; 95%CI 1.02-2.12) and blood glucose (OR = 1.55; 95%CI 1.14-2.10) and cholesterol (OR = 1.68; 95%CI 1.23-2.30) exams. The socioeconomic factors analyzed in this study were not associated with blood pressure measurements in the last year. Additional details are presented in Table 5.

Discussion

The results of this study highlighted the presence of inequalities in preventive healthcare among Brazilian women aged 50 and over, in the investigated outcomes. The main results include (a) the greater frequency of cholesterol (private health plan members) and blood glucose (exclusive SUS users) exams among white women; (b) education as an important determinant for the performance of exams among older Brazilian women with private health insurance (Pap smear and cholesterol) and without private health insurance (mammography, blood glucose, and cholesterol); (c) income as an important determinant for the performance of exams among older Brazilian women with private health insurance (blood glucose and cholesterol) and without private health insurance (Pap smear, blood glucose, and cholesterol).

Socioeconomic markers are determinants of the performance of preventive exams among Brazilian women aged 50 and over. In this age group, NCDs are the most prevalent conditions, and since 2014, neoplasms have been the leading cause of death from NCDs among women in Brazil, overloading the health system and generating high economic costs^29-31.

In this context, Brazil implemented the Strategic Action Plan to Combat NCDs (2011-2022), focusing on the prevention and control of such diseases as diabetes, high blood pressure, breast cancer, and cervical cancer. The 2021-2030 plan was recently launched, prioritizing disease prevention and health promotion, with a view to eliminating health inequalities^32,33. It is important to emphasize that government actions should prioritize the prevention and reduction of risk factors, poverty, and social inequality, with action on the structural and intermediate determinants of health.

Although strategic action plans exist, evidence suggests that socioeconomic disparities persist in indicators of health service use, particularly those related to race/color, education, and income, regardless of the source of health care.

The Brazilian health system is comprised of SUS, which offers universal and free care, and the private system, based on one’s ability to pay of individuals, families, and employers³⁴. Due to differences in the organization of the systems, the present study opted to use stratification by source of care. Despite the constitutional principles of universality, equity, and comprehensiveness of SUS, the population finds it difficult to schedule appointments and surgeries, and undergo examinations. Important differences can also be observed between exclusive SUS users and individuals with private health insurance^34,35. It is important to note that although SUS offers all the exams studied in our work, affiliation with a private insurance plan continues to be a determining factor in performing them^14,20,36-38.

Several studies indicate that education is one of the main socioeconomic markers associated with health outcomes^39-41. In this study, education also proved to be an important determinant of preventive exams among older Brazilian women, with or without a health insurance plan. The literature shows that, in Brazil, women with higher education and who are affiliated with a health insurance plan are more likely to undergo medical exams, such as Pap smears and mammograms^14,20,41,42. Regarding blood glucose levels, evidence also reports a lower prevalence among Brazilians with lower education⁴³. In the USA, the proportion of women who underwent mammograms was 15% lower among those with lower education³⁷. The literature also indicates a positive association between education and cholesterol levels. A study conducted in Poland showed that the chance of undergoing a cholesterol exam is 1.5-fold greater for people with secondary or higher education when compared to people with lower education⁴⁴. Likewise, the proportion of individuals with lower levels of education who undergo this exam is 15% lower in the USA.³⁷ Similar findings were identified in India, where education played a relevant role in the socioeconomic inequality related to the performance of blood pressure and blood glucose exams among individuals over 30 years of age in the four evaluated districts⁴⁵. These findings reinforce how important the contribution of education is in the performance of preventive healthcare and point to the need to adopt strategies focused on reducing the inequalities found, such as the promotion of actions aimed at the less educated population.

In the literature, there is no consensus on the relationship between screening test uptake and race/color. In agreement with data from this study, Boccolini and Souza Junior (2016)⁴³, when conducting a study to investigate the factors associated with inequities in the use of health services in Brazil, showed that non-white people were less likely to undergo exams, such as blood glucose levels exams. However, a study conducted in the USA with women aged 50 to 64 years found no significant differences in relation to race/color for undergoing mammograms and Pap smears³⁷. A study that evaluated inequalities in relation to cholesterol testing in the USA showed that 6% of women aged 45 or over had never undergone a cholesterol exam. However, although the proportion of non-screening was higher among non-whites, the disparities between whites and non-whites were eliminated after adjustments for confounding variables⁴⁶. Despite the lack of consensus, disparities by race/color remain an important determinant in the use of health services among older Brazilian women.

Similar to the findings of this study, data from the literature suggest that income is also considered an important determinant of the use of health services and the performance of tests^40,44. Higher income was positively associated with the performance of the Pap smear among Swiss women, aged 20 to 70 years⁴⁷, and among Brazilian women over 60 years of age living in the city of Juiz de Fora, in the state of Minas Gerais⁴¹. In Peru, a study conducted to assess inequalities in the performance of the Pap smear in the last three years among women, aged 30 to 59 years, revealed that the performance of the exam was concentrated among women with a higher wealth index⁴⁸. In the USA, the proportion of women who performed the Pap smear was 27% lower among those with lower incomes³⁷, and similar results were observed in relation to blood glucose and cholesterol exams. In India, a relevant role of income was observed in the inequality in the performance of blood pressure and blood glucose exams in the population over 30 years of age⁴⁵. In the population over 50 years of age in Italy, Poland, Spain, France, Switzerland, and Austria, these exams are more frequent in high-income groups⁴⁹ and in the USA, cholesterol testing was approximately 15% lower among those with lower incomes³⁷.

In general, the findings of this study show that older Brazilian women (50+), black, brown, Asian, or indigenous, with lower income and education, and who use SUS exclusively are those who least undergo preventive exams.

This study has a limitation of information bias, since the outcomes were self-reported and people who are affected by a problem or disease may tend to remember more about undergoing these exams than would those who are not affected. In addition, people who have health problems tend to seek out services more often. However, the number of chronic diseases was included as an adjustment, which minimized a possible effect of this factor. However, this study also brings significant contributions, as it was conducted with a representative sample of the Brazilian population, aged 50 years and over, who are not institutionalized, living in urban and rural areas in municipalities of different sizes (small, medium, and large). Data collection was carried out by interviewers who were duly trained and certified by the project’s research team in order to guarantee the quality of the collected information. Data analysis was conducted using appropriate statistical methodology, incorporating the effect of complex sampling design and sampling weight.

In short, the results obtained in this study showed that the socioeconomic factors evaluated were significantly associated with the performance of preventive healthcare by older Brazilian women. It is possible that individuals with higher educational levels and income recognize their health needs more and seek out health services and medical care more often, and/or have a greater ease of access. In any case, when factors such as education, self-reported race/color, and income are associated with the use of health care, evidence of inequities appears. In this context, in addition to the provision of health services, public measures and policies aimed at older women with lower income and education and who self-identify as black, brown, yellow, or indigenous, are necessary as a strategy to reduce the inequities present in the use of preventive health services.

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Funding

This study received funding from the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), through a Master’s scholarship. ELSI-Brasil is funded by the Ministério da Saúde: DECIT/SCTIE (Processes: 404965/2012-1 and TED 28/2017); COPID/DECIV/SAPS (Processes: 20836, 22566, 23700, 25560, 25552 and 27510).

Data availability statement

The data sources adopted in the research are indicated in the article’s body.

Chief editors:

Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Publication Dates

• Publication in this collection
  17 Aug 2026
• Date of issue
  Aug 2026

History

• Received
  07 Oct 2024
• Accepted
  30 Apr 2025
• Published
  02 May 2025