Financial and care support and their associated factors in elderly adults: data from a population-based cohort

Abstract

The aim is to examine the receipt of financial and care-related social support, according to sociodemographic characteristics, health status and primary care model in a cohort of elderly people. This is a cross-sectional analysis of the SIGa-Bagé cohort with a sample of 1,593 elderly individuals (≥ 60 years) from the urban area. Poisson regression with robust variance adjustment was used. In 2008, 20.2% received financial support and 54.9% care; in 2016, 16.9% and 37.0%, respectively. In 2008, after adjusting for sociodemographic characteristics and health status, the probability of receiving financial support was 62%, 99% and 48% higher among non-retired people, those unable to perform activities of daily living and those who had not gone out in the last month, respectively. In 2016, women were 83% more likely to receive financial assistance. In 2008, the likelihood of receiving care was 53% higher among elderly people unable to perform instrumental activities and, in 2016, it was 84% ​​higher among those living in Family Health Strategy areas. Considering the associations found, it is necessary to strengthen financial and care support among older adults.

Key words:
Aged; Social support; Financial support; Health of the elderly; Aging

Resumo

O objetivo é examinar o recebimento de apoio social do tipo financeiro e de cuidado, conforme características sociodemográficas, de situação de saúde e modelo de atenção básica em uma coorte de idosos. Trata-se de uma análise transversal da coorte SIGa-Bagé com amostra de 1.593 idosos (≥ 60 anos) da zona urbana. Utilizou-se regressão de Poisson com ajuste robusto da variância. Em 2008, 20,2% recebiam apoio financeiro e 54,9% cuidado; em 2016, 16,9% e 37,0%, respectivamente. Em 2008, após ajuste para as características sociodemográficas e de situação de saúde, a probabilidade de recebimento de apoio financeiro foi 62%, 99% e 48% maior entre os não aposentados, com incapacidade de realizar atividades de vida diária e que não saíram no último mês, respectivamente. Em 2016, receber ajuda financeira foi 83% maior em mulheres. A probabilidade de receber cuidado, em 2008, foi 53% maior entre idosos com incapacidade de realizar atividades instrumentais e, em 2016, foi 84% maior entre os residentes em área de Estratégia Saúde da Família. Considerando as associações encontradas, é necessário fortalecer o apoio financeiro e de cuidado entre os idosos.

Palavras-chave:
Idosos; Apoio social; Apoio financeiro; Saúde do idoso; Envelhecimento

Resumen

El objetivo es examinar la recepción de apoyo social financiero y asistencial, según características sociodemográficas, estado de salud y modelo de atención primaria en una cohorte de personas mayores. Se trata de un análisis transversal de la cohorte SIGa-Bagé con una muestra de 1.593 personas mayores (≥ 60 años) del área urbana. Se utilizó regresión de Poisson con ajuste de varianza robusto. En 2008, el 20,2% recibió apoyo económico y el 54,9% atención; En 2016, 16,9% y 37,0%, respectivamente. En 2008, después de ajustar por características sociodemográficas y estado de salud, la probabilidad de recibir apoyo financiero fue 62%, 99% y 48% mayor entre las personas no jubiladas, las incapaces de realizar actividades de la vida diaria y las que no habían salido en el último mes, respectivamente. En 2016, la recepción de ayuda financiera fue 83% mayor para las mujeres. La probabilidad de recibir cuidados, en 2008, fue 53% mayor entre los ancianos con incapacidad para realizar actividades instrumentales y, en 2016, fue 84% mayor entre los residentes en el área de la Estrategia de Salud de la Familia. Considerando las asociaciones encontradas, es necesario fortalecer el apoyo financiero y asistencial a las personas mayores.

Palabras clave:
Anciano; Apoyo social; Apoyo financiero; Salud del anciano; Envejecimiento

Introduction

Demographic and epidemiological transitions are global events characterized by declining fertility rates, increased life expectancy, and changes in family structure and morbidity, disability, and death patterns^1-4. Population aging brings physical, economic, social, and psychological consequences, including new challenges and demands, such as the need for financial support and care^1,4. This situation must be addressed by society and policymakers to formulate public policies that promote and ensure a better quality of life and health status of older adults^1,4.

Social and economic factors stand out among the social determinants of health^4-8. On the other hand, the health situation of older adults⁹, such as the inability to perform activities, can also determine the receipt of social support¹⁰. Social support refers to the functionality and quality of individuals’ social networks when they need assistance in different areas and aspects throughout the life course¹¹. National and international literature emphasize that receiving financial and care support is positively related to demographic, socioeconomic, and health characteristics^4-12.

In Brazil, reducing inequalities by 2030 constitutes the Sustainable Development Goals, which aim to promote social, economic, and political inclusion for all, the implementation of adequate social protection measures and systems, and universal coverage of health services, including financial protection and access to essential services¹³. The likelihood of receiving financial support among older adults is higher among individuals living without a partner, with low income, and with poor self-rated health. However, receiving care is higher among women, those with high income, chronic illness, poor self-rated health, and inability to perform activities of daily living^4,7,9-11,14.

Despite the growing recognition of the importance of financial and care support, scientific literature has addressed chiefly social support as an explanatory variable, with less attention paid to its receipt as an outcome^15,16. Studies analyzing support as a dependent variable are still scarce, limiting understanding of the factors that influence its distribution among population groups. Furthermore, there is a predominance of cross-sectional studies, limiting the identification of causal relationships and trajectories over time. The lack of longitudinal studies is a gap highlighted in the literature.¹⁷ Although cross-sectional, this study contributes by exploring the perception of support received and analyzing the factors associated with receiving financial and care support, broadening the understanding of inequalities in this area. Another limitation in the literature concerns the heterogeneous measurement and definition of social support types, hindering comparisons between studies and the consolidation of evidence¹⁷.

Thus, investigating the receipt of financial and care support among older adults contributes to the formulation of public policies and the organization and planning of services, since it allows for a description based on the characteristics of the population, thus identifying social and health inequities, facilitating the confrontation of inequalities.^4-17 This study aimed to examine the receipt of financial and care social support by sociodemographic characteristics, health status, and primary health care (PHC) model in the cohort of older adults from Bagé, Rio Grande do Sul, from 2008 to 2016.

Methods

Study design

Cohort study with older adults (60 years or older) living in the urban area of Bagé, Rio Grande do Sul, Brazil, in 2008 and 2016/2017.

Data collection

Before beginning fieldwork, a pilot study was conducted with female older adults living in a long-term care facility in the municipality to evaluate the questionnaire’s application. The first data were collected in 2008, when 1,593 elderly individuals were interviewed.¹⁸ In both 2008 and 2016, respondents completed a structured questionnaire with pre-coded questions, which previously trained interviewers coordinated by field supervisors administered at the older adults’ homes.

Study location

The municipality of Bagé is located in the Brazilian South and has approximately 15% of residents aged 60 or over. It covers a little over 4,000 km², has a population density of 28.52 inhabitants per km², and a Municipal Human Development Index (MHDI) of 0.740¹⁹. In 2008, the municipality had 15 Brazilian Family Health Strategy (BFHS) teams, covering 51% of the population and five PHC units with a traditional care model, responsible for serving the remaining inhabitants^18,20.

Sample selection and eligibility criteria

The SIGa-Bagé cohort sample included urban residents, proportionally distributed by the territory health service (Traditional or BFHS). Starting points were randomly selected to ensure equiprobability, skipping six households, where the households on the left were considered eligible. All residents aged 60 or older were considered eligible and invited to participate in the study. Institutionalized older adults (hospitals, long-term care facilities, and those deprived of liberty), with mental disabilities, and without a partner or guardian, were ineligible for the study. During the 2016 follow-up, all addresses were revisited, and an attempt was made to locate the new address in cases of change of place of residence. Interviewers made at least three attempts to interview or schedule an appointment with family members. For older adults with communication difficulties, a companion was requested to assist with data collection.¹⁸ Further details on sample size calculation and the sampling process can be found in the methodological article¹⁸.

Losses and refusals

Elderly individuals living in long-term care facilities, those deprived of liberty, those who moved from urban to rural areas or another municipality, and those who were not found at home after three attempts were considered losses. Individuals who verbally stated they no longer wished to participate in the study were considered refusals.

Dependent variables

Receiving financial support or care from family or others was the dependent variable in this study and was identified when older adults answered “yes” to each of the following questions: “Do you receive financial support from family or others?” and “Do you receive care from family or others?” Interviewers instructed older adults to consider family members who did or did not live in the same household. If older adults asked who “others” were, interviewers would describe them as neighbors, friends, caregivers, community workers, or other professionals.

Independent variables and instruments

The independent variables corresponding to the sociodemographic characteristics were age group (up to 74 years; 75 years or more), gender (male; female), marital status (with partner; without partner), living alone (no; yes), schooling years (illiterate; 1-7 years; 8 years or more), work in the last month (no; yes) and retirement pension (no; yes). To assess the health situation, the variables adopted were self-rated health (good/excellent; very poor/poor/fair), inability to perform basic activities of daily living (BADL) (independent; dependent); inability to perform instrumental activities of daily living (IADL) (independent; dependent) and leaving home in the last month (went out every day; went out once a week; went out between 2 and 4 times a week and did not go out on any day).

The inability to perform BADLs was assessed using the Katz Scale²¹, and older adults with least one negative response to questions about the ability to independently perform self-care tasks such as bathing, dressing, going to the bathroom, feeding themselves, and being continent were defined as dependent. IADLs were assessed using the Lawton and Brody Scale,^22, and dependent individuals were characterized by a negative response to at least one of the questions about tasks that enable community life, such as cleaning the house, handling small objects, shopping, preparing food, using the telephone, and managing finances. Regarding health services, the PHC model (traditional and BFHS) in the area where the elderly individual resided in 2008 was considered.

Data analysis

We performed descriptive analysis with absolute and relative frequencies. The chi-square test for heterogeneity and Fisher’s exact test were adopted in the bivariate analysis as per the assumptions. Poisson regression with robust variance adjustment was used to calculate crude and adjusted prevalence ratios (PR) and their respective 95% confidence intervals (95%CI). Hierarchical modeling was performed in the multivariate analysis.

Initially, variables associated with the outcomes under study (p < 0.20) were included in the model to consider potential confounding factors. In the modeling stage, independent variables were included from the distal (first) to the proximal (third) levels, in the following order: sociodemographic factors; health status; and care model (variable included only in the outcome analyses, care receipt). A significance level of 5% (p < 0.05) was adopted. Analyses were performed using the Stata statistical program, version 15.1.

Ethical aspects

The Research Ethics Committee of the Faculty of Medicine of the Federal University of Pelotas approved the study (File N° 15/08/2008, Opinion no. 678.664/2014). Ethical principles were ensured through the Informed Consent Form, guaranteeing the right to not participate in the research and anonymity in the dissemination of results.

Results

In 2008, almost all the older adults (1,592 of 1,593 respondents) answered questions regarding receipt of financial or care support. In 2016/2017, 638 deaths (40.1%) were identified via information systems or family reports, leaving 955 older adults alive (59.9%). Seven hundred thirty-five of these (77.0%) were effectively interviewed, with losses and refusals totaling 220¹⁸. However, 711 responded to the outcomes studied in the 2016 follow-up.

Regarding the characterization of the sample included in this study in the 2008 follow-up (n = 1,593), we found that most older adults were in the age group of up to 74 years (68.8%); 62.8% were female; 51.3% lived with a partner, and 54.5% had one to seven schooling years. Approximately 82.0% of the total did not live alone; about 72.0% were retired, and approximately 87.0% did not work; 53.5% were covered by the BFHS; 41.2% self-rated their health situation as very poor/poor/fair; 10.6% were incapable of performing BADLs; 34.2% were incapable of performing IADLs and 14.9% did not leave home any day in the last month (data not shown in the tables).

Regarding the characterization of the 2016/17 follow-up sample (n=735), we found that most older adults were 75 or older (57.8%); 65.3% were women; and approximately 58.0% lived without a partner (single, widowed, and separated); around 56.0% had 1-7 schooling years; almost 76.0% did not live alone; 79.7% were retired; approximately 94.0% did not work; 54.4% were covered by the BFHS; 46.3% self-rated their health situation as very poor/poor/fair; 13.5% were unable to perform BADLs; 39.6% were unable to perform IADLs, and 19.0% did not leave home any day in the last month (data not shown in the tables).

The frequency of receiving financial support and care in 2008 was 20.2% (95%CI 18.3-22.3) and 54.9% (95%CI 51.4-56.3), respectively, while in 2016 it was 16.9% (95%CI 14.3-19.9) and 37.0% (95% CI 33.5-40.6) (Table 1). There was a decrease in the receipt of care of approximately 18.0 percentage points in the eight years (from 2008 to 2016/17), and this difference was statistically significant (Table 1).

Table 1
Frequency of receiving financial support and care among older adults living in the urban area of Bagé (RS), Brazil, 2008-2016/17.

		2008				2016/17
	N*	%†	95%CI‡		N*	%†	95%CI‡
Receiving financial support
No	1,270	79.8	77.7-81.7		589	83.1	80.1-85.7
Yes	322	20.2	18.3-22.3		120	16.9	14.3-19.9
Receiving care
No	734	46.1	43.7-48.6		446	63.0	59.4-66.5
Yes	858	53.9	51.4-56.3		262	37.0	33.5-40.6

• ^* N: absolute frequency; ^† %: relative frequency ; ^‡ 95%CI: 95% confidence interval.
• Source: Authors.

Table 2 presents the crude and adjusted analysis of receipt of financial support by sociodemographic characteristics. In the 2008 follow-up, after adjusted analysis, it was observed that the frequency of receiving financial support was 28.0% higher among older adults who lived without a partner (PR=1.28; 95%CI 1.05-1.56), 62.0% higher among non-retired individuals (PR = 1.62; 95%CI 1.32-1.94), and 50.0% higher among those who did not work (PR = 1.50; 95%CI 1.03-2.17) (p < 0.05). Also, after adjusting for confounding factors, in the 2016 follow-up, women were 83.0% more likely to receive financial support than men (PR = 1.83; 95%CI 1.23-2.73) (p < 0.05).

Table 2
Gross and adjusted analysis of receipt of financial support by sociodemographic characteristics of older adults living in an urban area of Bagé (RS), Brazil, 2008-2016/17.

Sociodemographic characteristics	Receives financial support from family and others
	2008						2016
	Sample description		Crude		Adjusted		Sample description		Crude		Adjusted
	N*	%†	PR‡	95%CI§	PR‡	95%CI§	N*	%†	PR‡	95%CI§	PR‡	95%CI§
Age group				p = 0.016		p = 0.872				p = 0,516
Up to 74 years	1,096	68.8	Ref.		Ref.		310	42.2	Ref.		-	-
75+	497	31.2	1.28	1.05; 1.56	0.98	0.78; 1.23	425	57.8	0.90	0.65; 1.24	-	-
Gender				p = 0.001		p = 0.208				p = 0.003		p = 0.003
Male	593	37.2	Ref.		Ref.		255	34.7	Ref.		Ref.
Female	1,000	62.8	1.44	1.15; 1.70	1.17	0.92; 1.49	480	65.3	1.85	1.24; 2.76	1.83	1.23; 2.73
Marital status				p = 0.001		p = 0.015				p = 0.102		p = 0.729
With partner	816	51.3	Ref.		Ref.		310	42.4	Ref.		Ref.
Without partner	776	48.7	1.40	1.15; 1.71	1.28	1.05; 1.56	421	57.6	1.33	0.95; 1.87	1.07	0.74; 1.55
Schooling				p = 0.005		p = 0.170				p = 0.848		-
Illiterate	382	24.0	1.56	1.16; 2.10	1.28	0.95; 1.72	153	20.8	1.15	0.70; 1.90	-	-
1-7 years	868	54.5	1.18	0.89; 1.5	1.06	0.81; 1.40	413	56.2	1.06	0.70; 1.61	-	-
8+ years	342	21.5	Ref.		Ref.		169	23.0	Ref.		-	-
Living alone				p = 0.378		-				p = 0.406		-
No	1,313	20.6	Ref.		-	-	558	75.9	Ref.		-	-
Yes	280	17.6	0.89	0.68; 1.16	-	-	177	24.1	1.17	0.81; 1.68	-	-
Retirement pension				p < 0.001		p < 0.001				p = 0.027		p = 0.186
No	451	28.3	1.58	1.30; 1.93	1.62	1.32; 1.94	149	20.3	1.16	0.54; 2.48	1.28	0.89; 1.84
Yes	1,142	71.7	Ref.		Ref.		584	79.7	Ref.		Ref.
Work in the last month				p = 0.017		p = 0.033				p = 0.700		-
No	1,392	87.4	1.56	1.08; 2.25	1.50	1.03; 2.17	681	94.3	1.16	0.54; 2.48	-	-
Yes	200	12.6	Ref.		Ref.		41	5.7	Ref.		-	-

• ^* N: crude frequency; ^† %: relative frequency; ^‡ PR: prevalence ratio; ^§ 95%CI: 95% confidence interval; ^|| Ref.: reference group.
• Source: Authors.

In 2008, older adults with an inability to perform BADLs were 99.0% (PR = 1.99; 95%CI 1.59-2.49) more likely to receive financial assistance than those without an incapacity. Those who did not leave home any day in the last month were 48.0% more likely to receive financial assistance than those who went out daily (PR = 1.48; 95%CI; 1.11-1.96) (p < 0.05). In 2016, older adults with an inability to perform BADLs were 67.0% more likely to receive financial assistance than those without an incapacity (PR = 1.67; 95%CI 1.13-2.49) (p < 0.05) (Table 3).

Table 3
Crude and adjusted analysis of receipt of financial support by health status of older adults living in an urban area of Bagé (RS), Brazil, 2008-2016/17.

Health status	Receives financial support from family and others
	2008						2016
	Sample description		Crude		Adjusted		Sample description		Crude		Adjusted
	N*	%†	PR‡	95%CI§	PR‡	95%CI§	N*	%†	PR‡	95%CI§	PR‡	95%CI§
Health status assessment				p = 0.205		-				p = 0.929		-
Good/Excellent	906	58.8	Ref.		-	-	382	53.7	Ref.		-	-
Very poor/Poor/Fair	634	41.2	1.14	0.93; 1.40	-	-	329	46.3	1.02	0.60; 1.74	-
BADL¶				p < 0.001		p < 0.001				p = 0.010		p = 0.011
Independent	1,424	89.4	Ref.		Ref.		627	86.5	Ref.		Ref.
Dependent	169	10.6	1.97	1.56; 2.47	1.99	1.59; 2.49	98	13.5	1.70	1.14; 2.55	1.67	1.13; 2.49
IADL**				p < 0.001		p = 0.405				p = 0.033		p = 0.412
Independent	1,045	65.8	Ref.		Ref.		434	60.5	Ref.		Ref.
Dependent	544	34.2	1.43	1.18; 1.74	1.11	0.87; 1.41	284	39.5	1.43	1.03;1.98	1.17	0.80; 1.70
Left home in the last month				p < 0.001		p = 0.002				p = 0.566		-
Left home every day	569	35.7	Ref.		Ref.		274	37.9	Ref.		-	-
Left home once a week	351	22.0	0.90	0.67; 1.21	0.82	0.61; 1.10	103	14.3	1.32	0.83; 1.51	-
Left home 2-4 times a week	435	27.4	1.01	0.77; 1.31	0.97	0.74; 1.25	207	28.6	0.99	0.65; 1.51	-	-
Did not leave home	238	15.9	1.84	1.43; 2.36	1.48	1.11; 1.96	139	19.2	1.20	0.77; 1.89	-	-

• ^* N: crude frequency; ^† %: relative frequency; ^‡ PR: prevalence ratio; ^§ 95%CI: 95% confidence interval; ^|| Ref.: reference group; ^¶ BADL: basic activities of daily living; ^** IADL: instrumental activities of daily living.
• Source: Authors.

In 2008, after adjustments, the prevalence of receiving care was 13.0% higher among older adults aged 75 years or older (PR = 1.13; 95%CI 1.02-1.24), 18.0% higher for females (PR = 1.18; 95%CI 1.05-1.31) and 19.0% higher for older adults who lived without a partner (PR = 1.19; 95%CI 1.07-1.32) (p < 0.05). Older adults who lived alone were 34.0% less likely to receive care than those who did not live alone (PR = 0.66; 95%CI 0.56-0.77) (p < 0.001). In 2016, older adults who did not work received approximately 35.0% less care than those who worked (PR = 0.65; 95%CI 0.46-0.92) (Table 4).

Table 4
Crude and adjusted analysis of receiving care by sociodemographic characteristics of older adults residing in an urban area of Bagé (RS), Brazil, 2008-2016/17.

Sociodemographic characteristics	Receives care from family and/or others
	2008						2016
	Sample description		Crude		Adjusted		Sample description		Crude		Adjusted
	N*	%†	PR‡	95%CI§	PR‡	95%CI§	N*	%†	PR‡	95%CI§	PR‡	95%CI§
Age group				p < 0.001		p = 0.019				p = 0.079		p = 0.074
Up to 74 years	1,096	68.8	Ref.||		Ref.||		310	42.2	Ref.||		Ref.||
75+	497	31.2	1.31	1.20; 1.44	1.13	1.02; 1.24	425	57.8	0.84	0.70; 1.02	0.88	0.72; 1.07
Gender				p < 0.001		p = 0.004				p = 0.234		-
Male	593	37.2	Ref.||		Ref.||		255	34.7	Ref.||		-	-
Female	1,000	62.8	1.21	1.09; 1.34	1.18	1.05; 1.31	480	65.3	0.89	0.73; 1.08	-	-
Marital status				p < 0.001		p = 0.001				p = 0.247		-
With partner	816	51.3	Ref.||		Ref.||		310	42.4	Ref.||		-	-
Without partner	776	48.7	1.18	1.08; 1.30	1.19	1.07; 1.32	421	57.6	0.89	0.74; 1.08	-	-
Schooling				p = 0.002		p = 0.580				p = 0.590		-
Illiterate	382	24.0	1.27	1.10; 1.45	1.07	0.94; 1.22	153	20.8	1.13	0.84; 1.52	-	-
1-7 years	868	54.5	1.12	0.98; 1.27	1.07	0.92;1.24	413	56.2	1.13	0.88; 1.46	-	-
8+ years	342	21.5	Ref.||		Ref.||		169	23.0	Ref.||		-	-
Living alone				p < 0.001		p < 0.001				p = 0.141		p = 0.178
No	1,313	20.6	Ref.||		Ref.||		558	75.9	Ref.||		Ref.||
Yes	280	17.6	0.69	0.59; 0.80	0.66	0.56; 0.77	177	24.1	0.89	0.66; 1.06	0.85	0.66; 1.08
Retirement pension				p = 0.659		-				p = 0.605		-
No	451	28.3	1.02	0.93; 1.13	-	-	149	20.3	0.71	0.51; 0.97	-	-
Yes	1,142	71.7	Ref.||		-	-	584	79.7	Ref.||		-	-
Work in the last month				p = 0.057		p = 0.865				p = 0.030		p = 0.016
No	1,392	87.4	1.16	1.00; 1.36	1.01	0.87; 1.18	681	94.3	0.71	0.51; 0.97	0.65	0.46; 0.92
Yes	200	12.6	Ref.||		Ref.||		41	5.7	Ref.||		Ref.||

• ^* N: crude frequency; ^† %: relative frequency; ^‡ PR: prevalence ratio; ^§ 95%CI: 95% confidence interval; ^|| Ref.: reference group.
• Source: Authors.

In 2008, those with an inability to perform IADLs were 53.0% more likely to receive care than those without an inability, after adjustments (PR = 1.53; 95%CI 1.39-1.69) (p < 0.001). The probability of receiving care was 20.0% lower among those who did not leave home any day in the last month than those who went out every day (PR = 0.80; 95%CI 0.70-0.92) (p < 0.001).

The adjusted analysis for potential confounding factors in 2016 showed that older adults living in an area covered by the BFHS were 84.0% more likely to receive care than those living in traditional areas (PR = 1.84; 95%CI 1.47-2.29) (p < 0.001). Older adults with instrumental disabilities of daily living received 56.0% more care than those without disabilities (PR = 1.56; 95%CI 1.28-1.89) (p < 0.001). Older adults who did not leave home any day in the last month were approximately 40.0% less likely to receive care than those who left home daily (PR = 0.61; 95%CI 0.46-0.80) (p < 0.05) (Table 5).

Table 5
Crude and adjusted analysis of receiving care by care model and health status of older adults living in an urban area of Bagé (RS), Brazil, 2008-2016/17.

Health status	Receives care from family and/or others
	2008						2016
	Sample description		Crude		Adjusted		Sample description		Crude		Adjusted
	N*	%†	PR‡	95%CI§	PR‡	95%CI§	N*	%†	PR‡	95%CI§	PR‡	95%CI§
PHC model type				p = 0.101		p = 0.210				p < 0.001		p < 0.001
Traditional	741	46.5	Ref.||		Ref.||		355	45.6	Ref.||		Ref.||
BFHS**	852	53.5	1.08	0.99; 1.18	1.06	0.97; 1.16	400	54.4	1.85	1.49; 2.30	1.84	1.47; 2.29
Health status assessment				p = 0.002		p = 0.087				p = 0.929		-
Good/Excellent	906	58.8	Ref.||		Ref.||		382	53.7	Ref.||		-	-
Very poor/Poor/Fair	634	41.2	1.16	1.06; 1.28	1.08	0.99; 1.19	329	46.3	1.02	0.60; 1.74	-	-
BADL¶				p < 0.001		p = 0.238				p = 0.103		p = 0.598
Independent	1,424	89.4	Ref.||		Ref.||		627	86.5	Ref.||		Ref.||
Dependent	169	10.6	1.57	1.43; 1.72	1.08	0.95; 1.22	98	13.5	1.24	0.96; 1.62	1.08	0.82; 1.43
IADL††				p < 0.001		p < 0.001				p < 0.001		p < 0.001
Independent	1,045	65.8	Ref.||		Ref.||		434	60.5	Ref.||		Ref.||
Dependent	544	34.2	1.66	1.52; 1.80	1.53	1.39; 1.69	284	39.5	1.60	1.32; 1.93	1.56	1.28; 1.89
Left home in the last month				p = 0.002		p < 0.001				p = 0.159		p = 0.004
Left home every day	569	35.7	Ref.||		Ref.||		274	37.9	Ref.||		Ref.||
Left home once a week	351	22.0	0.95	0.84; 1.08	0.78	0.68; 0.88	103	14.3	1.03	0.78; 1.35	0.89	0.68; 1.16
Left home 2-4 times a week	435	27.4	0.92	0.82; 1.04	0.83	0.74; 0.93	207	28.6	0.82	0.64; 1.04	0.77	0.61; 0.98
Did not leave home	238	15.9	1.18	1.04; 1.33	0.80	0.70; 0.92	139	19.2	0.78	0.58; 1.04	0.61	0.46; 0.80

• ^* N: crude frequency; ^† %: relative frequency; ^‡ PR: prevalence ratio; ^§ 95%CI: 95% confidence interval; ^|| Ref.: reference group; ^¶ BADL: basic activities of daily living; ^** BFHS: Brazilian Family Health Strategy; ^†† IADL: instrumental activities of daily living.
• Source: Authors.

Discussion

This study’s findings showed an association between receiving financial support and care by sociodemographic and health characteristics of older adults at two points in time. In 2008, receiving financial support was associated with marital status, retirement, and employment, controlling for potential confounders. Functional disabilities were observed as a common characteristic associated with greater receipt of financial and care support in 2008 and 2016. Older individuals with IADL disabilities and who had not left home any day in the last month stood out as common characteristics associated with receiving care in both follow-ups. In 2016, the relevance of the BFHS healthcare model in receiving care support was confirmed.

The frequency of receiving financial support was 20.2% in 2008 and 16.9% in 2016. These results are similar to recent findings published in international and national studies. An international study found a ten percentage point reduction (from 20.0% to 10.0%) in the receipt of financial assistance among Mexican older adults over a decade.²³ A study of older adults living in rural areas found a variation in the frequency of receiving financial assistance from 10.8% to 20.8%²⁴.

Regarding the frequency of receiving care, it was 54.9% in 2008 and 37.0% in 2016. Corroborating the finding of the last follow-up, a national study in Rio de Janeiro with 369 older women found a prevalence of 31.5%²⁵. We should emphasize that the literature contains a wide variation in the operational definition and measurement of the receipt of social support, hindering the comparison of results and may explain the discrepancy between the results of this study and other findings in the literature.

One of the hypotheses for the decrease in care receipt, in the case of a cohort study, can be attributed to the non-independence of the sample. Older adults may end up living alone, losing their partners or family members, thus reducing their social support network and having a decreased perception of receiving care, in addition to the possibility of survivorship bias.

In demographic terms, the probability of receiving care support was higher among very old seniors (75 years or older) and women, confirming previous findings in the literature^14,26. The demand for care due to the older adult’s health situation increases with age. However, there is a declining perception of support, mainly due to the reduced social network, not only because of the deaths of family members and friends but also the increased physical disabilities that hinder older adults’ movement and search for help¹⁴.

Regarding gender, studies confirm that women receive financial support and care more frequently^4,14,25. Sousa et al. found a statistically significant association between greater receipt of social support among older women, those who lived without a partner, and those who did not work²⁵. Researchers state that men are more restrictive in their social relationships, focusing on their partner and closest relatives⁴. In contrast, women generally have larger social networks and offer more social support than men⁴. The difference between social and gender roles may be directly related to the findings: women are culturally assigned the role of caring for the home, family, or children, while men are assigned the role of providing, despite current changes in women’s roles in society and within the home⁴.

Regarding sociodemographic characteristics, current scientific knowledge shows that the values of benefits such as retirement are insufficient and do not meet the needs of older adults, leaving many to become financially dependent, especially on their children^4,9,17. According to international studies, the participation of older adults in work is a consequence of financial deprivation and lack of support²⁷. In general, older adults spend on healthcare, mainly medication⁹.

Research reveals that older adults are partially or totally financially dependent on another person. The authors stated that financial risk and lack of social support can cause older adults to abandon treatment for some illness or condition due to the need to pay for healthcare^9,17. Authors suggest that retirement can have a protective effect against lack of access to healthcare, increasing access to healthcare, and reducing catastrophic expenditures. Notably, social security encompasses health, pensions, and social assistance. The independence of older adults is directly related to socioeconomic and health issues, such as work and functional capacity^28-33.

The 2008 adjusted analysis showed that older adults who lived alone were 32% less likely to receive care from family or others than those who did not live alone. Aligned with these findings, authors point out that older adults who live alone are three times more likely to experience a lack of perceived care than those who do not live alone²⁵.

According to national literature, in general, older adults who live with family members assume the role of providing financial support and are the family heads^29,33. A study using data from the National Household Sample Survey indicated that living with other people is an indication of poverty and an attempt to combat it by increasing household income. It also showed that receiving a minimum wage through government policies such as the continuous benefit, retirement, or pension is important in determining the older adult’s family arrangement³⁰.

Authors portray income as a two-way street in determining the family configuration of the household, since on the one hand, receiving an income can provide older adults with the autonomy and independence of living alone and, on the other hand, families in vulnerable situations come together in the same residence to share the benefit, often being the main income³⁰.

This study’s findings corroborate national and international literature regarding the relationship between older adults’ functional disability and receiving financial support or care^11,14,33,34 A Chinese study showed in the multivariate analysis, after adjusting for demographic and socioeconomic characteristics, that older adults with disabilities were 135% more likely to receive financial support than those without disabilities³³.

Another study showed that the greater the level of dependence of older adults with age, the greater their expenditure on medications or health interventions, thus requiring financial support³². Therefore, some socioeconomic, demographic, and public policy determinants are of paramount importance in achieving equity in health financing for older adults⁸. Researchers point out that lower income and insufficient service provision, especially in healthcare, limit independence, fail to meet health needs, and deteriorate living conditions²⁵.

International research showed, after controlling for demographic, socioeconomic, and health factors, that older adults with an inability to perform activities were 4.2 times more likely to receive nursing care than those without dependency¹⁴. The same authors showed that receiving nursing care is more frequent among women, older seniors, those living without a partner, those with dependency to perform basic activities of daily living, and those with a negative self-rated health¹⁴.

Aging is accompanied by changes in health status, such as the development of functional and psychosocial disabilities that increase the demand for support from family, friends, and society¹⁴. A national study conducted in PHC identified that individuals with a physical illness, especially a more severe one, tend to expand their social support network³³. Authors show that dependent older adults receive more support, not only in material terms but also in terms of care¹¹. These findings corroborating those of Nunes et al. (2017), who state in the analysis adjusted for sociodemographic, behavioral and health condition factors that the probability of receiving home care in the last three months among older adults was 150.0% and 61.0% higher among those with incapacity for IADL and BADL, respectively, when compared to those without disabilities³⁴.

Despite the scarcity of quantitative studies that address the importance of the healthcare model provided to older adults and their perception of care, some researchers highlight the relevance of access to healthcare services in contributing to a high perception of social support^14,25. Individuals living in areas covered by the BFHS are encouraged to operate a family and community support network through coordinating actions that advocate comprehensive and continuous care for individuals according to older adults’ health needs, bringing professionals closer to users, thus increasing the social support network^14,25. Associating the care model with the receipt of care showed relevance as individuals age in the present study. Notably, there is a need for public policymakers to organize and establish programs that favor social support for older adults in the community and, especially, in their homes¹⁴.

The political and economic crisis, with austerity measures following Dilma Rousseff’s impeachment, initiated under the Temer administration and maintained by Bolsonaro, prioritized anti-democratic, authoritarian, and regressive agendas, with cuts to social policies and the removal of labor and social security rights^35,36. There has been a growing commodification and loss of social rights³⁵, although the Unified Health System (SUS) and its programs have contributed to addressing health inequalities.

Constitutional Amendment no. 95 froze primary spending for 20 years, affecting SUS funding and the population’s health, in a backdrop of population growth, aging, and increased demand for care. The new National Primary Care Policy is part of this agenda of setbacks, proposing changes in the work of community health workers and fragmented care. We also observe a declining number of pharmacies and municipalities in the Farmácia Popular Program, the elimination of multidisciplinary teams, changes in financing with Previne Brasil, and the discontinued the Mais Médicos Program^38,39.

The BFHS covers more than 130 million people in Brazil, focusing on at-risk groups, ensuring an equitable public health system despite the challenges⁴⁰. The BFHS plays a relevant role in recognizing social, economic, and health vulnerabilities. In various care aspects, it can track and identify the need for financial support and care for individuals, families, and communities. We should emphasize that efforts among managers must be made to formulate and implement a National Care Policy, requiring not only the family to assume the role of care, but also the State, which is increasingly less active, to take responsibility for tackling social, economic, and health inequalities.

Decision-making and some strategies, such as increasing BFHS coverage, preserving the work process of community workers, providing multidisciplinary teams linked to family health teams, advancing the implementation of telemedicine, increasing spaces for social interaction, such as social centers for older adults, and guaranteeing the Farmácia Popular Program, are potential solutions to the challenges⁴¹. Furthermore, it is essential to review current social security and labor reforms and reflect that health systems are forms of social protection and rights guaranteed by the Federal Constitution⁴².

On a positive note, the analysis of receipt of financial support and care as a dependent variable stands out, exploring its variation per sociodemographic and health characteristics. This approach is innovative, given the national knowledge production on social support over the last five years. Another point is the description of the direction and magnitude of receipt of financial support and care using Poisson regression with robust variance.

The results stand out for their relevance, especially for vulnerable older adults, given the consequences of the COVID-19 pandemic. The cross-sectional analysis of the cohort of older adults across two periods helps highlight aspects relevant to the formulation and guidance of public policies, such as universal retirement, social benefits, and the BFHS care model.

Potential limitations should be considered. Bidirectionality and reverse causality may occur in some associations between outcomes and socioeconomic and health characteristics, because, although this is a cohort study, the analyses were cross-sectional at each follow-up. Another limitation concerns the lack of independence of the study samples (cohort). Losses due to death, refusal, and inability to locate were observed in the 2016 follow-up, which may have generated survival bias.

There may also have been a loss of statistical power to examine the associations. Some associations may not have been evidenced. Regarding the operationalization of the dependent variables, the subjectivity of the term “others” in the measurement question may have hampered the estimates and the characterization of the support received, as participants may not consider the role of the State in receiving financial support or care, even if they consider the role of community health workers. In some cases, the report may be more about the individual’s belonging to the community than an important component in the implementation of care by managers and government officials. Finally, the lack of characterization of who received older adults’ support limited the knowledge of who benefited.

The Brazilian population’s aging encompasses important social and public health issues, in addition to the demographic and epidemiological transition, marked by the greater number of women in the labor market, the decreased availability of care for older adults due to smaller family sizes, and growing marital separations and chronic degenerative diseases⁸. There is a need to implement care policies for the elderly population, expand BFHS coverage, and recommend that managers establish and guarantee social security policies to reduce social and health inequalities.

Conclusion

We conclude that receiving financial support and care varied by sociodemographic characteristics, health status, and the primary care model. We underscore the importance of reflecting on the social role of older adults in the family, reinforcing the need to strengthen interactions and social support throughout life. Given the economic difficulties and deficient income distribution and social security process, the State must expand and update social protection policies, including strengthening family support to ensure an improved quality of life and health of older adults.

Regarding the practice of healthcare professionals, collecting this information (receipt of financial support and care) is essential when providing care to older adults. The results presented are expected to contribute to broadening the discussion and formulating social security and public health strategies, besides promoting, preventing, and monitoring the health status of older adults.

Acknowledgments

This work was conducted with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001.

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• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vânia de Matos Fonseca

Publication Dates

• Publication in this collection
  06 Oct 2025
• Date of issue
  Sept 2025

History

• Received
  14 Mar 2023
• Accepted
  11 May 2025
• Published
  13 May 2025