摘要：Objectives. We investigated deprivation and inequalities in life expectancy and healthy life expectancy by location in Rio de Janeiro, Brazil. Methods. We conducted a health survey of 576 adults in 2006. Census tracts were stratified by income level and categorization as a slum. We determined health status by degree of functional limitation, according to the approach proposed by the World Health Organization. We calculated healthy life expectancies by Sullivan's method with abridged life table. Results. We found the worst indicators in the slum stratum. The life expectancy at birth of men living in the richest parts of the city was 12.8 years longer than that of men living in deprived areas. For both men and women older than age 65 years, healthy life expectancy was more than twice as high in the richest sector as in the slum sector. Conclusions. Our analysis detailed the excess burden of poor health experienced by disadvantaged populations of Rio de Janeiro. Policy efforts are needed to reduce social inequalities in health in this city, especially among the elderly. Recent studies on health inequality have focused on individual characteristics such as education, income, or ethnicity, as well as group characteristics, to explain social and spatial variations in health. 1 – 7 Highlighting inequalities at the local level is especially important, because social and environmental conditions have been shown to be significant determinants of health status. 8 The majority of geographical health studies have analyzed mortality data, largely because they are readily accessible. However, increased longevity in developed countries has resulted in a greater emphasis on the quality of the later years. 9 , 10 A long life does not necessarily mean a healthy life, as an increase in years lived is often accompanied by an increase in chronic morbidity and disability. 11 As such, it is generally agreed upon that mortality indicators alone are insufficient to appropriately characterize the state of a population's health. 12 Newer, more relevant indicators such as quality-adjusted life years and disability-adjusted life years, which combine mortality data with morbidity and disability data, provide methods to investigate and compare the burden of diseases. 13 Over the past 4 decades, different health indicators that consider morbidity, functional limitations, and disabilities along with mortality have been proposed. 14 – 16 A single measure of morbidity and mortality obtained by the Sullivan method (healthy life expectancy) 17 has been the most frequently used. 14 It estimates the number of years a person of a given population may expect to enjoy full health. Variations of this measure are established by different definitions of healthy, which are usually based on self-perceived health, long-term illness or disability, and functional or cognitive limitations. The summarized measures of morbidity and mortality obtained by the Sullivan method have been adopted for monitoring health inequalities in many developed countries. 18 In the United Kingdom, the regional variation in healthy life expectancy (as measured by limiting long-standing illness) has been found to be much greater than are the regional variations in life expectancy. 19 Studies in other countries have produced similar findings. 20 , 21 Substantial inequalities in healthy life years among persons aged 50 years were also found in European Union countries, with greater variation in healthy life expectancy than in life expectancy. 22 In Brazil, differences in mortality across regions have been well documented, often with a steep north–south gradient. 23 , 24 These inequalities persist; the more prosperous southern states have lower infant mortality and higher life expectancies. Small-area variations in health indicators in large Brazilian cities are also evident, reflecting socioeconomic and environmental inequalities. 25 – 28 In Rio de Janeiro, Brazil, mortality studies have established an association between adverse health outcomes and residential concentration of poverty. The worst health indicators were found in the sector of the city with the highest concentration of slum residents, which also had an extremely high homicide rate. 29 A geographic study in Goiânia, a newly urbanized city of Brazil, also detected a spatial cluster of violent deaths on its outskirts. 30 This cluster had a significantly higher proportion of people with the lowest educational level and income and the worst housing conditions in the city. Whether these conditions are associated with differences in quality of life for older adults has been less well studied. In Brazil, healthy life expectancy was estimated for the total adult population 31 , 32 and for the elderly in the city of São Paulo, 33 but this measure has not been used to monitor inequalities in quality of life among older persons. We examined deprivation and inequalities in total life expectancy and healthy life expectancy by location in the municipality of Rio de Janeiro. We calculated healthy life expectancy with the approach developed by the World Health Organization (WHO), 34 in which healthy status is established by degree of functional limitation, with data from a survey carried out in the city during 2006.
