ABSTRACT

OBJECTIVE

The objective of this study was to analyze the association between the socioeconomic characteristics and the access to or use of health services among older adults.

METHODS

This is a systematic review of the literature. The search has been carried out in the databases PubMed, LILACS and Web of Science, without restriction of dates and languages; however we have included only articles published in Portuguese, English, and Spanish. The inclusion criteria were: observational design, socioeconomic factors as variables of interest in the analysis of the access to or use of health services among older adults, representative sample of the target population, adjustment for confounding factors, and no selection bias.

RESULTS

We have found 5,096 articles after deleting duplicates and 36 of them have been selected for review after the process of reading and evaluating the inclusion criteria. Higher income and education have been associated with the use and access to medical appointments in developing countries and some developed countries. The same association has been observed in dental appointments in all countries. Most studies have shown no association between socioeconomic characteristics and the use of inpatient and emergency services. We have identified greater use of home visits in lower-income individuals, with the exception of the United States.

CONCLUSIONS

We have observed an unequal access to or use of health services in most countries, varying according to the type of service used. The expansion of the health care coverage is necessary to reduce this unequal access generated by social inequities.

Aged; Health Services Accessibility; Socioeconomic Factors; Health Systems; Health Inequalities; Review

INTRODUCTION

Access to health services is one of the main factors in the analysis of the quality and performance of health systems¹⁴14. Donabedian A. The seven pillars of quality. Arch Pathol Lab Med. 1990;114(11):1115-8.,⁵⁸58. Viacava F, Ugá MAD, Porto S, Laguardia J, Moreira RS. Avaliação de desempenho de sistemas de saúde: um modelo de análise. Cienc Saude Coletiva. 2012;17(4):921-4. https://doi.org/10.1590/S1413-81232012000400014
https://doi.org/10.1590/S1413-8123201200... . Access is a set of dimensions that describe the adjustment between the individual and the health care system, i.e., it intermediates the relationship between demand and entry in the service⁴³43. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19(2):127-40. https://doi.org/10.1097/00005650-198102000-00001
https://doi.org/10.1097/00005650-1981020... . The use of health services comprises all direct contact with these services and can be understood as the evidence that access has been reached⁵⁵55. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica. 2004;20 Suppl 2:S190-8. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... . Although related, the access to and the use of health services are not synonymous, as seem in much of the literature.

The older adults are among the population groups that use health services the most⁵⁴54. Travassos C, Viacava F, Pinheiro R, Brito A. Utilização dos serviços de saúde no Brasil: gênero, características familiares e condição social. Rev Panam Salud Publica. 2002;11(5-6):365-73. https://doi.org/10.1590/S1020-49892002000500011
https://doi.org/10.1590/S1020-4989200200... . Aging is associated with increased prevalence of diseases and disabilities. For this reason, it is a phase of life in which the use of health services tends to increase⁵⁶56. Travassos C, Viacava F. Acesso e uso de serviços de saúde em idosos residentes em áreas rurais, Brasil, 1998 e 2003. Cad Saude Publica. 2007;23(10):2490-502. https://doi.org/10.1590/S0102-311X2007001000023
https://doi.org/10.1590/S0102-311X200700... .

Socioeconomic characteristics can influence the patterns of use of health services. Persons with better socioeconomic conditions can obtain more easily health care services than poorer individuals. This social inequality in the access tends to be greater in countries with a private health system, in which persons have to pay for health care and insurance plans or out-of-pocket, than in countries with universal system¹³13. Doorslaer E, Masseria C, Koolman X. Inequalities in access to medical care by income in developed countries. CMAJ. 2006;174(2):177-83. https://doi.org/10.1503/cmaj.050584
https://doi.org/10.1503/cmaj.050584... . In the United States, a country with predominantly private health system, the older adults belonging to the highest quintile have twice the chance to consult a doctor compared to the older adults of the lowest quintile. In France, which has a universal system, such difference is not seen²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... .

Education can also exert an important influence on the access to and use of health services. In addition to the strong association with income, persons with higher education tend to have greater ease in recognizing a health need and seek the care service⁵⁵55. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica. 2004;20 Suppl 2:S190-8. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... ,⁵⁷57. Travassos C, Castro M. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, editor. Políticas e sistema de saúde no Brasil. Rio de Janeiro (RJ): Fiocruz; 2008. p.215-46..

Despite the reduction of social inequalities with increasing age, these inequalities tend to persist, even to a lesser degree, and can influence the access to health services among the older adults. Moreover, the value of health insurance plans and contracts increases according to age, favoring the access of the wealthier older population²⁴24. Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the elderly: a European overview. Social Sci Med. 2003;57(5):861-73. https://doi.org/10.1016/S0277-9536(02)00454-9
https://doi.org/10.1016/S0277-9536... .

In addition to the individual characteristics, social inequalities in the access to and use of health services are also an expression of the characteristics of the health system. The availability of diagnostic and therapeutic equipment and services, the geographical distribution, the mechanisms for the financing of services, and their organization represent characteristics of the system that may facilitate or hinder the access to health services³⁵35. McIntyre D, Mooney G. The economics of health equity. New York: Cambridge University; 2007.,⁵³53. Travassos C, Viacava F, Fernandes C, Almeida CS. Desigualdades geográficas e sociais na utilização de serviços de saúde no Brasil. Cienc Saude Coletiva. 2000;5(1):133-49. https://doi.org/10.1590/S1413-81232000000100012
https://doi.org/10.1590/S1413-8123200000... ,⁵⁷57. Travassos C, Castro M. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, editor. Políticas e sistema de saúde no Brasil. Rio de Janeiro (RJ): Fiocruz; 2008. p.215-46..

The objective of this study was to analyze the association between the socioeconomic characteristics and the access to or use of health services among older adults.

METHODS

This is a systematic review of the literature with articles indexed in electronic bases of the American National Library of Medicine and the National Institutes of Health (PubMed), the Web of Science, and the Virtual Health Library (VHL), using references of the Latin American and Caribbean Health Sciences Literature (LILACS).

The descriptors used to select the studies have been chosen based on Health Sciences Descriptors (DeCS) and Medical Subject Headings (Mesh terms), and other relevant terms on the subject (highlighted in italics): (“schooling attainment” OR “family income” OR “income” OR “Socioeconomic position” OR “Socioeconomic level” OR “Economic level” OR “Assets index” OR “Poverty” OR “Deprivation” OR “Schooling” OR “education”) and (“health services accessibility” OR “health services utilization” OR “access to health services”) and (“elderly” OR “major adults “ OR “older people” OR “aged” OR “older adults”). We have also examined the reference list of the selected studies.

The searches have been conducted without language and date restriction, to find all the existing articles; however we have included only articles published in Portuguese, English, and Spanish, because of the familiarity with the language. The databases were consulted in May 2015 and the articles were moved to the software Endnote X 7.2. The duplicates have been deleted.

The inclusion criteria were: (i) any observational design, not necessarily population-based; (ii) socioeconomic factors related to income and education as variables of interest in the analysis of the access to or use of health services among older adults; (iii) adjustment for confounding factors, at least for gender and age; and (iv) no selection bias (we considered as selection bias when reported by the author, or studies with losses greater than 50%). We have included articles that considered in their analysis of the access or use: public or private services, including medical appointments, specialist appointments, dental appointments, hospitalization, emergency services, and home visits. The articles that have assessed problems of access to or use of health services without specification have also been included. All types of measures have been considered. We have excluded the works regarding access to drugs and surgeries. We have also excluded studies relating the access or use with variables other than the socioeconomic ones.

We have included one article with persons aged over 45 years²⁵25. Jiang Y, Wang Y, Zhang L, Li Y, Wang X, Ma S. Access to healthcare and medical expenditure for the middle-aged and elderly: observations from China. PloS One. 2013;8(5):e64589. https://doi.org/10.1371/journal.pone.0064589
https://doi.org/10.1371/journal.pone.006... and three with individuals aged over 50 years²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,¹⁶16. Elwell-Sutton TM, Jiang CQ, Zhang WS, Cheng KK, Lam TH, Leung GM, et al. Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study. Health Policy Plan. 2013;28(5):467-79. https://doi.org/10.1093/heapol/czs077
https://doi.org/10.1093/heapol/czs077... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... , as they are cohorts whose goal has been to evaluate events in the older population²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,¹⁵15. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84. https://doi.org/10.1136/jech.52.6.377
https://doi.org/10.1136/jech.52.6.377... or they are cross-sectional studies that have the older adults as their main focus²⁵25. Jiang Y, Wang Y, Zhang L, Li Y, Wang X, Ma S. Access to healthcare and medical expenditure for the middle-aged and elderly: observations from China. PloS One. 2013;8(5):e64589. https://doi.org/10.1371/journal.pone.0064589
https://doi.org/10.1371/journal.pone.006... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... .

We have read the title of the articles and deleted those unrelated to the subject of access to and use of health services. The abstracts were read and deleted as they did not meet the inclusion criteria. Articles whose titles and abstracts did not provide clarity regarding their inclusion or exclusion were kept for the next step to read them in full. We have selected the articles read in full that met the criteria. The process has been conducted by two researchers independently. Disagreements were discussed between the pair until a consensus.

We have found 5,096 articles after deleting duplicates. Of these, 4,873 were excluded after reading the titles and 162 eliminated after reading the summary. Of the 61 articles analyzed in their entirety, 33 have not met the inclusion criteria. Of these, three were descriptive, eighteen were not adjusted for gender and age, two had loss greater than 50%, six carried out a joint analysis of adults and older persons, in two the outcome was not the use or access, and two were excluded because they were available only in German or Korean. From the search in the references of the selected articles, eight were included, amounting to 36 articles selected for this review (Figure). Table 1 presents an overview of the studies.

Selected articles have been evaluated and scored according to the methodological criteria proposed by Downs and Black¹⁵15. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84. https://doi.org/10.1136/jech.52.6.377
https://doi.org/10.1136/jech.52.6.377... . The original version consists of twenty-seven items. This article has used the adapted version with seventeen items, considering the questions relevant to observational studies: 1) Is the hypothesis/objective of the study clearly defined?; 2) Are the main outcomes measured clearly described in the introduction or methods?; 3) Are the characteristics of the individuals clearly described?; 4) Is the distribution of the main confounding factors on the subject to be compared clearly described?; 5) Are the main findings of the study described?; 6) Does the study provide estimates of random variability of the data for the main outcomes (measures of variability)?; 7) Are the characteristics of the patients who were monitoring losses/losses/refusals described?; 8) Are the values of p described “accurately” rather than, for example, p < 0.05, except for p < 0.001?; 9) Are the subjects invited to participate in the research representative of the population from which they were recruited?; 10) If any of the results of the study was based on “data dredging”, is it clearly done?; 11) Are the statistical tests suitable to evaluate the main outcomes?; 12) Is the main outcome measured using accurate criteria/equipment (valid and replicable)?; 13) Were the study participants recruited in the same time period?; 14) Were the groups to be compared obtained from the same population?; 15) Are the confounding adjustments appropriate in the analysis from where the main findings were obtained?; 16) Are the monitoring losses taken into account?; 17) Does the study have enough power to detect an important clinical effect when the value of the probability for the difference due to chance is less than 5%? The question addressed receive one point for “yes” and zero for “no”, except question 4 (0 = “no”, 1 = “partially”, and 2 = “yes”), resulting in a score from zero to eighteen points.

Data extraction has been performed using a spreadsheet prepared by the authors considering the information: author, year, location, sample, objective, design, outcome(s), exposure, recall period considered in the report of access to or use of health services, measure of confidence interval and effect, adjustments made, score using the method of Downs and Black¹⁵15. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84. https://doi.org/10.1136/jech.52.6.377
https://doi.org/10.1136/jech.52.6.377... , and if the article used a theoretical model to base the hierarchical analysis of the data⁵⁹59. Victora CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol. 1997;26(1):224-7. https://doi.org/10.1093/ije/26.1.224
https://doi.org/10.1093/ije/26.1.224... , if this approach was carried out.

The descriptive synthesis of the selected articles has been carried out according to their general characteristics, related to the information obtained by the spreadsheet. The data were discussed under the context of the health system of the countries where the studies were conducted.

Based on the measure of effect, the results of the studies were classified as ‘pro-rich’ effect (greater access to or use of health services associated with higher income and/or higher education), ‘pro-poor’ effect (greater access to or use of health services associated with lower income and/or lower education), and ‘no difference’ (the results showed no association between income and/or education and access to or use of health services).

RESULTS

The studies are dated from 1981 to 2014; three are from the 1980s, nine from the 1990s, and 24 from the 2000s, covering a wide range of countries (36 articles in 23 countries). Three studies have been conducted in more than one country²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... . Most have been conducted in developed countries¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... ,⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,⁹9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... ,¹⁰10. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153-69. https://doi.org/10.1353/hpu.2010.0451
https://doi.org/10.1353/hpu.2010.0451... ,¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... ,²¹21. Freedman VA, Rogowski J, Wickstrom SL, Adams J, Marainen J, Escarce JJ. Socioeconomic disparities in the use of home health services in a medicare managed care population. Health Serv Res. 2004;39(5):1277-97. https://doi.org/10.1111/j.1475-6773.2004.00290.x
https://doi.org/10.1111/j.1475-6773.2004... ,³¹31. Lupi-Pegurier L, Clerc-Urmes I, Abu-Zaineh M, Paraponaris A, Ventelou B. Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality. Health Policy. 2011;103(2-3):160-7. https://doi.org/10.1016/j.healthpol.2011.09.011
https://doi.org/10.1016/j.healthpol.2011... ,³⁶36. Murata C, Yamada T, Chen CC, Ojima T, Hirai H, Kondo K. Barriers to health care among the elderly in Japan. Int J Environ Res Public Health. 2010;7(4):1330-41. https://doi.org/10.3390/ijerph7041330
https://doi.org/10.3390/ijerph7041330... ,⁴⁰40. Osterberg T, Lundgren M, Emilson CG, Sundh V, Birkhed D, Steen B. Utilization of dental services in relation to socioeconomic and health factors in the middle-aged and elderly Swedish population. Acta Odontol Scand. 1998;56(1):41-7. https://doi.org/10.1080/000163598423054
https://doi.org/10.1080/000163598423054... ,⁴²42. Park JM. Health status and health services utilization in elderly Koreans. Int J Equity Health. 2014;13(1):73. https://doi.org/10.1186/s12939-014-0073-7
https://doi.org/10.1186/s12939-014-0073-... ,⁴⁸48. Sibbritt DW, Byles JE, Tavener MA. Older Australian women’s use of dentists: a longitudinal analysis over 6 years. Australas J Ageing. 2010;29(1):14-20. https://doi.org/10.1111/j.1741-6612.2010.00396.x
https://doi.org/10.1111/j.1741-6612.2010...

49. Strain LA. Physician visits by elderly: testing the Andersen-Newman framework. Can J Sociol. 1990;15(1):19-37. https://doi.org/10.2307/3341171
https://doi.org/10.2307/3341171... -⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶⁴64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... -⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... (n = 21); of these, 11 have specifically studied the United States⁵5. Auchincloss AH, Van Nostrand JF, Ronsaville D. Access to health care for older persons in the United States: personal, structural, and neighborhood characteristics. J Aging Health. 2001;13(3):329-54. https://doi.org/10.1177/089826430101300302
https://doi.org/10.1177/0898264301013003... ,⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,⁹9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... ,¹⁰10. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153-69. https://doi.org/10.1353/hpu.2010.0451
https://doi.org/10.1353/hpu.2010.0451... ,¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... ,²¹21. Freedman VA, Rogowski J, Wickstrom SL, Adams J, Marainen J, Escarce JJ. Socioeconomic disparities in the use of home health services in a medicare managed care population. Health Serv Res. 2004;39(5):1277-97. https://doi.org/10.1111/j.1475-6773.2004.00290.x
https://doi.org/10.1111/j.1475-6773.2004... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964...

64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... -⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... . Of the studies conducted in developing countries⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... ,⁶6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100... ,⁸8. Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care. 2008;46(9):930-7. https://doi.org/10.1097/MLR.0b013e318179254c
https://doi.org/10.1097/MLR.0b013e318179... ,¹¹11. Borges-Yáñez SA, Gómez-Dantés H. [Use of health services by a population of 60-year olds and older in Mexico]. Salud Publica Mex. 1998;40(1):13-23. Spanish.,¹⁶16. Elwell-Sutton TM, Jiang CQ, Zhang WS, Cheng KK, Lam TH, Leung GM, et al. Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study. Health Policy Plan. 2013;28(5):467-79. https://doi.org/10.1093/heapol/czs077
https://doi.org/10.1093/heapol/czs077... ,²⁴24. Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the elderly: a European overview. Social Sci Med. 2003;57(5):861-73. https://doi.org/10.1016/S0277-9536(02)00454-9
https://doi.org/10.1016/S0277-9536... ,²⁷27. Lima-Costa MF, Guerra HL, Firmo JOA, Vidigal PG, Uchoa E, Barreto SM. The Bambuí Health and Aging Study (BHAS): private health plan and medical care utilization by older adults. Cad Saude Publica. 2002;18(1):177-86. https://doi.org/10.1590/S0102-311X200200010001828.
https://doi.org/10.1590/S0102-311X200200...

28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... -²⁹29. Lima-Costa MF, Barreto SM, Firmo JOA, Uchoa E. Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS). Rev Panam Salud Publica. 2003;13(6):387-94. https://doi.org/10.1590/S1020-49892003000500007
https://doi.org/10.1590/S1020-4989200300... ,³⁴34. Matos DL, Giatti L, Lima-Costa MF. Fatores sócio-demográficos associados ao uso de serviços odontológicos entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2004;25(5):1290-7. https://doi.org/10.1590/S0102-311X2004000500023
https://doi.org/10.1590/S0102-311X200400... ,⁴⁴44. Pinheiro RS, Travassos C. Estudo da desigualdade na utilização de serviços de saúde por idosos em três regiões da cidade do Rio de Janeiro. Cad Saude Publica. 1999;15(3):487-96. https://doi.org/10.1590/S0102-311X1999000300005
https://doi.org/10.1590/S0102-311X199900... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁴⁷47. Sánchez-García S, Fuente-Hernández J de la, Juárez-Cedillo T, Mendoza JM, Reyes-Morales H, Solórzano-Santos F et al. Oral health service utilization by elderly beneficiaries of the Mexican Institute of Social Security in Mexico city. BMC Health Serv Res. 2007;7(1):211. https://doi.org/10.1186/1472-6963-7-211
https://doi.org/10.1186/1472-6963-7-211... ,⁵²52. Thumé E, Facchini LA, Wyshak G, Campbell P. The utilization of home care by the elderly in Brazil’s primary health care system. Am J Public Health. 2011;101(5):868-74. https://doi.org/10.2105/AJPH.2009.184648
https://doi.org/10.2105/AJPH.2009.184648... ,⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... (n = 15), approximately two-thirds (n = 9) have specifically studied Brazil⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... ,⁶6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100... ,⁸8. Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care. 2008;46(9):930-7. https://doi.org/10.1097/MLR.0b013e318179254c
https://doi.org/10.1097/MLR.0b013e318179... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... ,²⁹29. Lima-Costa MF, Barreto SM, Firmo JOA, Uchoa E. Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS). Rev Panam Salud Publica. 2003;13(6):387-94. https://doi.org/10.1590/S1020-49892003000500007
https://doi.org/10.1590/S1020-4989200300... ,³⁰30. Louvison MC, Lebrao ML, Duarte YA, Santos JL, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saude Publica. 2008;42(4):733-40. https://doi.org/10.1590/S0034-89102008000400021
https://doi.org/10.1590/S0034-8910200800... ,³⁴34. Matos DL, Giatti L, Lima-Costa MF. Fatores sócio-demográficos associados ao uso de serviços odontológicos entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2004;25(5):1290-7. https://doi.org/10.1590/S0102-311X2004000500023
https://doi.org/10.1590/S0102-311X200400... ,⁴⁴44. Pinheiro RS, Travassos C. Estudo da desigualdade na utilização de serviços de saúde por idosos em três regiões da cidade do Rio de Janeiro. Cad Saude Publica. 1999;15(3):487-96. https://doi.org/10.1590/S0102-311X1999000300005
https://doi.org/10.1590/S0102-311X199900... ,⁵²52. Thumé E, Facchini LA, Wyshak G, Campbell P. The utilization of home care by the elderly in Brazil’s primary health care system. Am J Public Health. 2011;101(5):868-74. https://doi.org/10.2105/AJPH.2009.184648
https://doi.org/10.2105/AJPH.2009.184648... .

Thirty-three studies have used cross-sectional design¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900...

5. Auchincloss AH, Van Nostrand JF, Ronsaville D. Access to health care for older persons in the United States: personal, structural, and neighborhood characteristics. J Aging Health. 2001;13(3):329-54. https://doi.org/10.1177/089826430101300302
https://doi.org/10.1177/0898264301013003...

6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100...

7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25...

8. Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care. 2008;46(9):930-7. https://doi.org/10.1097/MLR.0b013e318179254c
https://doi.org/10.1097/MLR.0b013e318179...

9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995...

10. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153-69. https://doi.org/10.1353/hpu.2010.0451
https://doi.org/10.1353/hpu.2010.0451...

11. Borges-Yáñez SA, Gómez-Dantés H. [Use of health services by a population of 60-year olds and older in Mexico]. Salud Publica Mex. 1998;40(1):13-23. Spanish.-¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,²¹21. Freedman VA, Rogowski J, Wickstrom SL, Adams J, Marainen J, Escarce JJ. Socioeconomic disparities in the use of home health services in a medicare managed care population. Health Serv Res. 2004;39(5):1277-97. https://doi.org/10.1111/j.1475-6773.2004.00290.x
https://doi.org/10.1111/j.1475-6773.2004... ,²⁴24. Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the elderly: a European overview. Social Sci Med. 2003;57(5):861-73. https://doi.org/10.1016/S0277-9536(02)00454-9
https://doi.org/10.1016/S0277-9536... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300...

29. Lima-Costa MF, Barreto SM, Firmo JOA, Uchoa E. Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS). Rev Panam Salud Publica. 2003;13(6):387-94. https://doi.org/10.1590/S1020-49892003000500007
https://doi.org/10.1590/S1020-4989200300...

30. Louvison MC, Lebrao ML, Duarte YA, Santos JL, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saude Publica. 2008;42(4):733-40. https://doi.org/10.1590/S0034-89102008000400021
https://doi.org/10.1590/S0034-8910200800... -³¹31. Lupi-Pegurier L, Clerc-Urmes I, Abu-Zaineh M, Paraponaris A, Ventelou B. Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality. Health Policy. 2011;103(2-3):160-7. https://doi.org/10.1016/j.healthpol.2011.09.011
https://doi.org/10.1016/j.healthpol.2011... ,³⁴34. Matos DL, Giatti L, Lima-Costa MF. Fatores sócio-demográficos associados ao uso de serviços odontológicos entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2004;25(5):1290-7. https://doi.org/10.1590/S0102-311X2004000500023
https://doi.org/10.1590/S0102-311X200400... ,³⁶36. Murata C, Yamada T, Chen CC, Ojima T, Hirai H, Kondo K. Barriers to health care among the elderly in Japan. Int J Environ Res Public Health. 2010;7(4):1330-41. https://doi.org/10.3390/ijerph7041330
https://doi.org/10.3390/ijerph7041330... ,⁴⁰40. Osterberg T, Lundgren M, Emilson CG, Sundh V, Birkhed D, Steen B. Utilization of dental services in relation to socioeconomic and health factors in the middle-aged and elderly Swedish population. Acta Odontol Scand. 1998;56(1):41-7. https://doi.org/10.1080/000163598423054
https://doi.org/10.1080/000163598423054... ,⁴²42. Park JM. Health status and health services utilization in elderly Koreans. Int J Equity Health. 2014;13(1):73. https://doi.org/10.1186/s12939-014-0073-7
https://doi.org/10.1186/s12939-014-0073-... ,⁴⁴44. Pinheiro RS, Travassos C. Estudo da desigualdade na utilização de serviços de saúde por idosos em três regiões da cidade do Rio de Janeiro. Cad Saude Publica. 1999;15(3):487-96. https://doi.org/10.1590/S0102-311X1999000300005
https://doi.org/10.1590/S0102-311X199900... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁴⁷47. Sánchez-García S, Fuente-Hernández J de la, Juárez-Cedillo T, Mendoza JM, Reyes-Morales H, Solórzano-Santos F et al. Oral health service utilization by elderly beneficiaries of the Mexican Institute of Social Security in Mexico city. BMC Health Serv Res. 2007;7(1):211. https://doi.org/10.1186/1472-6963-7-211
https://doi.org/10.1186/1472-6963-7-211... ,⁴⁹49. Strain LA. Physician visits by elderly: testing the Andersen-Newman framework. Can J Sociol. 1990;15(1):19-37. https://doi.org/10.2307/3341171
https://doi.org/10.2307/3341171... ,⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... ,⁵²52. Thumé E, Facchini LA, Wyshak G, Campbell P. The utilization of home care by the elderly in Brazil’s primary health care system. Am J Public Health. 2011;101(5):868-74. https://doi.org/10.2105/AJPH.2009.184648
https://doi.org/10.2105/AJPH.2009.184648... ,⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964...

64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... -⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... , and three are of the cohort type¹⁶16. Elwell-Sutton TM, Jiang CQ, Zhang WS, Cheng KK, Lam TH, Leung GM, et al. Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study. Health Policy Plan. 2013;28(5):467-79. https://doi.org/10.1093/heapol/czs077
https://doi.org/10.1093/heapol/czs077... ,²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... ,⁴⁸48. Sibbritt DW, Byles JE, Tavener MA. Older Australian women’s use of dentists: a longitudinal analysis over 6 years. Australas J Ageing. 2010;29(1):14-20. https://doi.org/10.1111/j.1741-6612.2010.00396.x
https://doi.org/10.1111/j.1741-6612.2010... . The score of the studies according to the method of Downs and Black ranged from 11 to 17. Among the criteria of Downs and Black, the most frequently found limitations are: absence of description of losses and refusals, little clarity in the description of the confounding factors, no presentation of estimates of random variability of the data, and no presentation of the exact values of p.

The studies have worked with large samples: from 401⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964... to 30,499¹⁶16. Elwell-Sutton TM, Jiang CQ, Zhang WS, Cheng KK, Lam TH, Leung GM, et al. Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study. Health Policy Plan. 2013;28(5):467-79. https://doi.org/10.1093/heapol/czs077
https://doi.org/10.1093/heapol/czs077... . The age of the older adults has also varied. Fourteen articles have studied older persons aged over 60 years and other 14 articles have studied persons aged over 65 years, representing the majority of the studies selected. An article has examined older persons aged over 62 years⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... , another from 65 to 74 years⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... , one from 70 to 75 years⁴⁸48. Sibbritt DW, Byles JE, Tavener MA. Older Australian women’s use of dentists: a longitudinal analysis over 6 years. Australas J Ageing. 2010;29(1):14-20. https://doi.org/10.1111/j.1741-6612.2010.00396.x
https://doi.org/10.1111/j.1741-6612.2010... , and one 70 years and over⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... . We have included in this review one article with persons aged over 45 years²⁵25. Jiang Y, Wang Y, Zhang L, Li Y, Wang X, Ma S. Access to healthcare and medical expenditure for the middle-aged and elderly: observations from China. PloS One. 2013;8(5):e64589. https://doi.org/10.1371/journal.pone.0064589
https://doi.org/10.1371/journal.pone.006... and three with individuals aged over 50 years²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,¹⁶16. Elwell-Sutton TM, Jiang CQ, Zhang WS, Cheng KK, Lam TH, Leung GM, et al. Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study. Health Policy Plan. 2013;28(5):467-79. https://doi.org/10.1093/heapol/czs077
https://doi.org/10.1093/heapol/czs077... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... .

Most of the publications have studied the use of health services; of these, 16 have studied more than one outcome. Of the health services investigated in the association with socioeconomic aspects, medical appointment has been studied by 16 studies¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,⁹9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... ,¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... ,⁴²42. Park JM. Health status and health services utilization in elderly Koreans. Int J Equity Health. 2014;13(1):73. https://doi.org/10.1186/s12939-014-0073-7
https://doi.org/10.1186/s12939-014-0073-... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁴⁹49. Strain LA. Physician visits by elderly: testing the Andersen-Newman framework. Can J Sociol. 1990;15(1):19-37. https://doi.org/10.2307/3341171
https://doi.org/10.2307/3341171... ,⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... ,⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964...

64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... -⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... , 15 have studied hospitalization¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,⁶6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100...

7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25...

8. Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care. 2008;46(9):930-7. https://doi.org/10.1097/MLR.0b013e318179254c
https://doi.org/10.1097/MLR.0b013e318179... -⁹9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... ,¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,²⁵25. Jiang Y, Wang Y, Zhang L, Li Y, Wang X, Ma S. Access to healthcare and medical expenditure for the middle-aged and elderly: observations from China. PloS One. 2013;8(5):e64589. https://doi.org/10.1371/journal.pone.0064589
https://doi.org/10.1371/journal.pone.006... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... ,²⁹29. Lima-Costa MF, Barreto SM, Firmo JOA, Uchoa E. Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS). Rev Panam Salud Publica. 2003;13(6):387-94. https://doi.org/10.1590/S1020-49892003000500007
https://doi.org/10.1590/S1020-4989200300... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964...

64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... -⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... and one third of the publications (n = 12) has studied the use of dental appointments²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... ,⁶6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... ,³¹31. Lupi-Pegurier L, Clerc-Urmes I, Abu-Zaineh M, Paraponaris A, Ventelou B. Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality. Health Policy. 2011;103(2-3):160-7. https://doi.org/10.1016/j.healthpol.2011.09.011
https://doi.org/10.1016/j.healthpol.2011... ,³⁴34. Matos DL, Giatti L, Lima-Costa MF. Fatores sócio-demográficos associados ao uso de serviços odontológicos entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2004;25(5):1290-7. https://doi.org/10.1590/S0102-311X2004000500023
https://doi.org/10.1590/S0102-311X200400... ,⁴⁰40. Osterberg T, Lundgren M, Emilson CG, Sundh V, Birkhed D, Steen B. Utilization of dental services in relation to socioeconomic and health factors in the middle-aged and elderly Swedish population. Acta Odontol Scand. 1998;56(1):41-7. https://doi.org/10.1080/000163598423054
https://doi.org/10.1080/000163598423054... ,⁴⁷47. Sánchez-García S, Fuente-Hernández J de la, Juárez-Cedillo T, Mendoza JM, Reyes-Morales H, Solórzano-Santos F et al. Oral health service utilization by elderly beneficiaries of the Mexican Institute of Social Security in Mexico city. BMC Health Serv Res. 2007;7(1):211. https://doi.org/10.1186/1472-6963-7-211
https://doi.org/10.1186/1472-6963-7-211... ,⁴⁸48. Sibbritt DW, Byles JE, Tavener MA. Older Australian women’s use of dentists: a longitudinal analysis over 6 years. Australas J Ageing. 2010;29(1):14-20. https://doi.org/10.1111/j.1741-6612.2010.00396.x
https://doi.org/10.1111/j.1741-6612.2010... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964... . Two studies⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... have evaluated the use of emergency services, five the home care¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,²¹21. Freedman VA, Rogowski J, Wickstrom SL, Adams J, Marainen J, Escarce JJ. Socioeconomic disparities in the use of home health services in a medicare managed care population. Health Serv Res. 2004;39(5):1277-97. https://doi.org/10.1111/j.1475-6773.2004.00290.x
https://doi.org/10.1111/j.1475-6773.2004... ,⁵²52. Thumé E, Facchini LA, Wyshak G, Campbell P. The utilization of home care by the elderly in Brazil’s primary health care system. Am J Public Health. 2011;101(5):868-74. https://doi.org/10.2105/AJPH.2009.184648
https://doi.org/10.2105/AJPH.2009.184648... ,⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... , two specialist appointments¹⁰10. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153-69. https://doi.org/10.1353/hpu.2010.0451
https://doi.org/10.1353/hpu.2010.0451... ,⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... , three outpatient appointments⁸8. Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care. 2008;46(9):930-7. https://doi.org/10.1097/MLR.0b013e318179254c
https://doi.org/10.1097/MLR.0b013e318179... ,²⁵25. Jiang Y, Wang Y, Zhang L, Li Y, Wang X, Ma S. Access to healthcare and medical expenditure for the middle-aged and elderly: observations from China. PloS One. 2013;8(5):e64589. https://doi.org/10.1371/journal.pone.0064589
https://doi.org/10.1371/journal.pone.006... ,³⁰30. Louvison MC, Lebrao ML, Duarte YA, Santos JL, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saude Publica. 2008;42(4):733-40. https://doi.org/10.1590/S0034-89102008000400021
https://doi.org/10.1590/S0034-8910200800... , and four the use of any health service⁶6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100... ,¹¹11. Borges-Yáñez SA, Gómez-Dantés H. [Use of health services by a population of 60-year olds and older in Mexico]. Salud Publica Mex. 1998;40(1):13-23. Spanish.,¹⁶16. Elwell-Sutton TM, Jiang CQ, Zhang WS, Cheng KK, Lam TH, Leung GM, et al. Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study. Health Policy Plan. 2013;28(5):467-79. https://doi.org/10.1093/heapol/czs077
https://doi.org/10.1093/heapol/czs077... ,⁴⁴44. Pinheiro RS, Travassos C. Estudo da desigualdade na utilização de serviços de saúde por idosos em três regiões da cidade do Rio de Janeiro. Cad Saude Publica. 1999;15(3):487-96. https://doi.org/10.1590/S0102-311X1999000300005
https://doi.org/10.1590/S0102-311X199900... .

Two articles have as outcome problems of access (yes/no)⁵5. Auchincloss AH, Van Nostrand JF, Ronsaville D. Access to health care for older persons in the United States: personal, structural, and neighborhood characteristics. J Aging Health. 2001;13(3):329-54. https://doi.org/10.1177/089826430101300302
https://doi.org/10.1177/0898264301013003... ,²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... and one³⁶36. Murata C, Yamada T, Chen CC, Ojima T, Hirai H, Kondo K. Barriers to health care among the elderly in Japan. Int J Environ Res Public Health. 2010;7(4):1330-41. https://doi.org/10.3390/ijerph7041330
https://doi.org/10.3390/ijerph7041330... has used ‘delay care’ (delay or interruption of the search for the health service or care) as outcome. Lima-Costa²⁹29. Lima-Costa MF, Barreto SM, Firmo JOA, Uchoa E. Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS). Rev Panam Salud Publica. 2003;13(6):387-94. https://doi.org/10.1590/S1020-49892003000500007
https://doi.org/10.1590/S1020-4989200300... has studied the main complaint or dissatisfaction when seeking medical attention.

The recall period adopted in the interviews has shown differences, ranging from two weeks to five years. Of the works that have addressed the use of dental, hospitalization, and specialist appointments, eight²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... ,⁶6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100... ,³¹31. Lupi-Pegurier L, Clerc-Urmes I, Abu-Zaineh M, Paraponaris A, Ventelou B. Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality. Health Policy. 2011;103(2-3):160-7. https://doi.org/10.1016/j.healthpol.2011.09.011
https://doi.org/10.1016/j.healthpol.2011... ,⁴⁷47. Sánchez-García S, Fuente-Hernández J de la, Juárez-Cedillo T, Mendoza JM, Reyes-Morales H, Solórzano-Santos F et al. Oral health service utilization by elderly beneficiaries of the Mexican Institute of Social Security in Mexico city. BMC Health Serv Res. 2007;7(1):211. https://doi.org/10.1186/1472-6963-7-211
https://doi.org/10.1186/1472-6963-7-211... ,⁴⁸48. Sibbritt DW, Byles JE, Tavener MA. Older Australian women’s use of dentists: a longitudinal analysis over 6 years. Australas J Ageing. 2010;29(1):14-20. https://doi.org/10.1111/j.1741-6612.2010.00396.x
https://doi.org/10.1111/j.1741-6612.2010... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964... , 14¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,⁶6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100... ,⁸8. Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care. 2008;46(9):930-7. https://doi.org/10.1097/MLR.0b013e318179254c
https://doi.org/10.1097/MLR.0b013e318179... ,⁹9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... ,¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,²⁴24. Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the elderly: a European overview. Social Sci Med. 2003;57(5):861-73. https://doi.org/10.1016/S0277-9536(02)00454-9
https://doi.org/10.1016/S0277-9536... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... ,²⁹29. Lima-Costa MF, Barreto SM, Firmo JOA, Uchoa E. Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS). Rev Panam Salud Publica. 2003;13(6):387-94. https://doi.org/10.1590/S1020-49892003000500007
https://doi.org/10.1590/S1020-4989200300... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964...

64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... -⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... , and two¹⁰10. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153-69. https://doi.org/10.1353/hpu.2010.0451
https://doi.org/10.1353/hpu.2010.0451... ,⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... have used 12 months, respectively. For home visit, one article has used three months⁵²52. Thumé E, Facchini LA, Wyshak G, Campbell P. The utilization of home care by the elderly in Brazil’s primary health care system. Am J Public Health. 2011;101(5):868-74. https://doi.org/10.2105/AJPH.2009.184648
https://doi.org/10.2105/AJPH.2009.184648... , and the other has considered 12 months. For medical appointments, 14 studies have considered 12 months before the interview¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,⁹9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... ,¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁴⁹49. Strain LA. Physician visits by elderly: testing the Andersen-Newman framework. Can J Sociol. 1990;15(1):19-37. https://doi.org/10.2307/3341171
https://doi.org/10.2307/3341171... ,⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... ,⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964...

64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... -⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... , one has considered 15 days¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... , and one has considered 24 months⁴²42. Park JM. Health status and health services utilization in elderly Koreans. Int J Equity Health. 2014;13(1):73. https://doi.org/10.1186/s12939-014-0073-7
https://doi.org/10.1186/s12939-014-0073-... .

In relation to socioeconomic exposure, 21 of the studies have evaluated income and education at the same time in the model¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... ,⁵5. Auchincloss AH, Van Nostrand JF, Ronsaville D. Access to health care for older persons in the United States: personal, structural, and neighborhood characteristics. J Aging Health. 2001;13(3):329-54. https://doi.org/10.1177/089826430101300302
https://doi.org/10.1177/0898264301013003... ,⁸8. Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care. 2008;46(9):930-7. https://doi.org/10.1097/MLR.0b013e318179254c
https://doi.org/10.1097/MLR.0b013e318179...

9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... -¹⁰10. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153-69. https://doi.org/10.1353/hpu.2010.0451
https://doi.org/10.1353/hpu.2010.0451... ,²¹21. Freedman VA, Rogowski J, Wickstrom SL, Adams J, Marainen J, Escarce JJ. Socioeconomic disparities in the use of home health services in a medicare managed care population. Health Serv Res. 2004;39(5):1277-97. https://doi.org/10.1111/j.1475-6773.2004.00290.x
https://doi.org/10.1111/j.1475-6773.2004... ,²⁴24. Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the elderly: a European overview. Social Sci Med. 2003;57(5):861-73. https://doi.org/10.1016/S0277-9536(02)00454-9
https://doi.org/10.1016/S0277-9536... ,³⁰30. Louvison MC, Lebrao ML, Duarte YA, Santos JL, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saude Publica. 2008;42(4):733-40. https://doi.org/10.1590/S0034-89102008000400021
https://doi.org/10.1590/S0034-8910200800... ,³¹31. Lupi-Pegurier L, Clerc-Urmes I, Abu-Zaineh M, Paraponaris A, Ventelou B. Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality. Health Policy. 2011;103(2-3):160-7. https://doi.org/10.1016/j.healthpol.2011.09.011
https://doi.org/10.1016/j.healthpol.2011... ,³⁴34. Matos DL, Giatti L, Lima-Costa MF. Fatores sócio-demográficos associados ao uso de serviços odontológicos entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2004;25(5):1290-7. https://doi.org/10.1590/S0102-311X2004000500023
https://doi.org/10.1590/S0102-311X200400... ,⁴⁰40. Osterberg T, Lundgren M, Emilson CG, Sundh V, Birkhed D, Steen B. Utilization of dental services in relation to socioeconomic and health factors in the middle-aged and elderly Swedish population. Acta Odontol Scand. 1998;56(1):41-7. https://doi.org/10.1080/000163598423054
https://doi.org/10.1080/000163598423054... ,⁴²42. Park JM. Health status and health services utilization in elderly Koreans. Int J Equity Health. 2014;13(1):73. https://doi.org/10.1186/s12939-014-0073-7
https://doi.org/10.1186/s12939-014-0073-... ,⁴⁴44. Pinheiro RS, Travassos C. Estudo da desigualdade na utilização de serviços de saúde por idosos em três regiões da cidade do Rio de Janeiro. Cad Saude Publica. 1999;15(3):487-96. https://doi.org/10.1590/S0102-311X1999000300005
https://doi.org/10.1590/S0102-311X199900... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁴⁷47. Sánchez-García S, Fuente-Hernández J de la, Juárez-Cedillo T, Mendoza JM, Reyes-Morales H, Solórzano-Santos F et al. Oral health service utilization by elderly beneficiaries of the Mexican Institute of Social Security in Mexico city. BMC Health Serv Res. 2007;7(1):211. https://doi.org/10.1186/1472-6963-7-211
https://doi.org/10.1186/1472-6963-7-211... ,⁴⁹49. Strain LA. Physician visits by elderly: testing the Andersen-Newman framework. Can J Sociol. 1990;15(1):19-37. https://doi.org/10.2307/3341171
https://doi.org/10.2307/3341171... ,⁵²52. Thumé E, Facchini LA, Wyshak G, Campbell P. The utilization of home care by the elderly in Brazil’s primary health care system. Am J Public Health. 2011;101(5):868-74. https://doi.org/10.2105/AJPH.2009.184648
https://doi.org/10.2105/AJPH.2009.184648... ,⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... ,⁶⁴64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... , nine have analyzed only education⁶6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100... ,⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,¹¹11. Borges-Yáñez SA, Gómez-Dantés H. [Use of health services by a population of 60-year olds and older in Mexico]. Salud Publica Mex. 1998;40(1):13-23. Spanish.,¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,⁴⁸48. Sibbritt DW, Byles JE, Tavener MA. Older Australian women’s use of dentists: a longitudinal analysis over 6 years. Australas J Ageing. 2010;29(1):14-20. https://doi.org/10.1111/j.1741-6612.2010.00396.x
https://doi.org/10.1111/j.1741-6612.2010... ,⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... , and six only income¹⁶16. Elwell-Sutton TM, Jiang CQ, Zhang WS, Cheng KK, Lam TH, Leung GM, et al. Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study. Health Policy Plan. 2013;28(5):467-79. https://doi.org/10.1093/heapol/czs077
https://doi.org/10.1093/heapol/czs077... ,²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... ,²⁹29. Lima-Costa MF, Barreto SM, Firmo JOA, Uchoa E. Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS). Rev Panam Salud Publica. 2003;13(6):387-94. https://doi.org/10.1590/S1020-49892003000500007
https://doi.org/10.1590/S1020-4989200300... ,³⁶36. Murata C, Yamada T, Chen CC, Ojima T, Hirai H, Kondo K. Barriers to health care among the elderly in Japan. Int J Environ Res Public Health. 2010;7(4):1330-41. https://doi.org/10.3390/ijerph7041330
https://doi.org/10.3390/ijerph7041330... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964... . Eleven have used total household income¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁵5. Auchincloss AH, Van Nostrand JF, Ronsaville D. Access to health care for older persons in the United States: personal, structural, and neighborhood characteristics. J Aging Health. 2001;13(3):329-54. https://doi.org/10.1177/089826430101300302
https://doi.org/10.1177/0898264301013003... ,⁹9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... ,¹⁰10. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153-69. https://doi.org/10.1353/hpu.2010.0451
https://doi.org/10.1353/hpu.2010.0451... ,²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... ,²¹21. Freedman VA, Rogowski J, Wickstrom SL, Adams J, Marainen J, Escarce JJ. Socioeconomic disparities in the use of home health services in a medicare managed care population. Health Serv Res. 2004;39(5):1277-97. https://doi.org/10.1111/j.1475-6773.2004.00290.x
https://doi.org/10.1111/j.1475-6773.2004... ,²⁹29. Lima-Costa MF, Barreto SM, Firmo JOA, Uchoa E. Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS). Rev Panam Salud Publica. 2003;13(6):387-94. https://doi.org/10.1590/S1020-49892003000500007
https://doi.org/10.1590/S1020-4989200300... ,³¹31. Lupi-Pegurier L, Clerc-Urmes I, Abu-Zaineh M, Paraponaris A, Ventelou B. Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality. Health Policy. 2011;103(2-3):160-7. https://doi.org/10.1016/j.healthpol.2011.09.011
https://doi.org/10.1016/j.healthpol.2011... ,⁴⁹49. Strain LA. Physician visits by elderly: testing the Andersen-Newman framework. Can J Sociol. 1990;15(1):19-37. https://doi.org/10.2307/3341171
https://doi.org/10.2307/3341171... ,⁵²52. Thumé E, Facchini LA, Wyshak G, Campbell P. The utilization of home care by the elderly in Brazil’s primary health care system. Am J Public Health. 2011;101(5):868-74. https://doi.org/10.2105/AJPH.2009.184648
https://doi.org/10.2105/AJPH.2009.184648... , six per capita household income¹⁶16. Elwell-Sutton TM, Jiang CQ, Zhang WS, Cheng KK, Lam TH, Leung GM, et al. Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study. Health Policy Plan. 2013;28(5):467-79. https://doi.org/10.1093/heapol/czs077
https://doi.org/10.1093/heapol/czs077... ,²⁵25. Jiang Y, Wang Y, Zhang L, Li Y, Wang X, Ma S. Access to healthcare and medical expenditure for the middle-aged and elderly: observations from China. PloS One. 2013;8(5):e64589. https://doi.org/10.1371/journal.pone.0064589
https://doi.org/10.1371/journal.pone.006... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... ,³⁴34. Matos DL, Giatti L, Lima-Costa MF. Fatores sócio-demográficos associados ao uso de serviços odontológicos entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2004;25(5):1290-7. https://doi.org/10.1590/S0102-311X2004000500023
https://doi.org/10.1590/S0102-311X200400... ,³⁶36. Murata C, Yamada T, Chen CC, Ojima T, Hirai H, Kondo K. Barriers to health care among the elderly in Japan. Int J Environ Res Public Health. 2010;7(4):1330-41. https://doi.org/10.3390/ijerph7041330
https://doi.org/10.3390/ijerph7041330... ,⁴⁴44. Pinheiro RS, Travassos C. Estudo da desigualdade na utilização de serviços de saúde por idosos em três regiões da cidade do Rio de Janeiro. Cad Saude Publica. 1999;15(3):487-96. https://doi.org/10.1590/S0102-311X1999000300005
https://doi.org/10.1590/S0102-311X199900... , five individual income³⁰30. Louvison MC, Lebrao ML, Duarte YA, Santos JL, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saude Publica. 2008;42(4):733-40. https://doi.org/10.1590/S0034-89102008000400021
https://doi.org/10.1590/S0034-8910200800... ,⁴⁰40. Osterberg T, Lundgren M, Emilson CG, Sundh V, Birkhed D, Steen B. Utilization of dental services in relation to socioeconomic and health factors in the middle-aged and elderly Swedish population. Acta Odontol Scand. 1998;56(1):41-7. https://doi.org/10.1080/000163598423054
https://doi.org/10.1080/000163598423054... ,⁴²42. Park JM. Health status and health services utilization in elderly Koreans. Int J Equity Health. 2014;13(1):73. https://doi.org/10.1186/s12939-014-0073-7
https://doi.org/10.1186/s12939-014-0073-... ,⁶⁴64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964... , two the wealth index²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... , and one the economic level according to the Brazilian Association of Research Companies (ABEP)⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... . Salinas et al.⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... have used the self-reported economic situation (excellent/very good/good, average, bad) and Sanchez-Garcia et al.⁴⁷47. Sánchez-García S, Fuente-Hernández J de la, Juárez-Cedillo T, Mendoza JM, Reyes-Morales H, Solórzano-Santos F et al. Oral health service utilization by elderly beneficiaries of the Mexican Institute of Social Security in Mexico city. BMC Health Serv Res. 2007;7(1):211. https://doi.org/10.1186/1472-6963-7-211
https://doi.org/10.1186/1472-6963-7-211... have analyzed paid work, dichotomously, as exposure.

Thirty studies have investigated education level in association with the use of health services. This variable has been analyzed by most studies according to the education level in categories (16 studies). One study has considered literacy (yes, no) and two have considered if the persons have attended school, dichotomously. Eleven articles have used the variable of years of study, being five of them categorically, five continuously, and one dichotomously (more and less than six years of study). Wallace et al.⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... have considered only the education of the head of the family.

Of the 36 selected publications, 17 have used the hierarchical model in the analysis¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... ,⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,⁹9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,³⁰30. Louvison MC, Lebrao ML, Duarte YA, Santos JL, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saude Publica. 2008;42(4):733-40. https://doi.org/10.1590/S0034-89102008000400021
https://doi.org/10.1590/S0034-8910200800... ,³¹31. Lupi-Pegurier L, Clerc-Urmes I, Abu-Zaineh M, Paraponaris A, Ventelou B. Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality. Health Policy. 2011;103(2-3):160-7. https://doi.org/10.1016/j.healthpol.2011.09.011
https://doi.org/10.1016/j.healthpol.2011... ,⁴⁰40. Osterberg T, Lundgren M, Emilson CG, Sundh V, Birkhed D, Steen B. Utilization of dental services in relation to socioeconomic and health factors in the middle-aged and elderly Swedish population. Acta Odontol Scand. 1998;56(1):41-7. https://doi.org/10.1080/000163598423054
https://doi.org/10.1080/000163598423054... ,⁴²42. Park JM. Health status and health services utilization in elderly Koreans. Int J Equity Health. 2014;13(1):73. https://doi.org/10.1186/s12939-014-0073-7
https://doi.org/10.1186/s12939-014-0073-... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁴⁸48. Sibbritt DW, Byles JE, Tavener MA. Older Australian women’s use of dentists: a longitudinal analysis over 6 years. Australas J Ageing. 2010;29(1):14-20. https://doi.org/10.1111/j.1741-6612.2010.00396.x
https://doi.org/10.1111/j.1741-6612.2010... ,⁴⁹49. Strain LA. Physician visits by elderly: testing the Andersen-Newman framework. Can J Sociol. 1990;15(1):19-37. https://doi.org/10.2307/3341171
https://doi.org/10.2307/3341171... ,⁵²52. Thumé E, Facchini LA, Wyshak G, Campbell P. The utilization of home care by the elderly in Brazil’s primary health care system. Am J Public Health. 2011;101(5):868-74. https://doi.org/10.2105/AJPH.2009.184648
https://doi.org/10.2105/AJPH.2009.184648... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964...

64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... -⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... . Of these, 12 have adopted the behavioral theoretical model of Andersen¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,⁹9. Blazer LK, Mansfield PK. A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. J Adv Nurs. 1995;21(2):305-13. https://doi.org/10.1111/j.1365-2648.1995.tb02527.x
https://doi.org/10.1111/j.1365-2648.1995... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,³⁰30. Louvison MC, Lebrao ML, Duarte YA, Santos JL, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saude Publica. 2008;42(4):733-40. https://doi.org/10.1590/S0034-89102008000400021
https://doi.org/10.1590/S0034-8910200800... ,⁴²42. Park JM. Health status and health services utilization in elderly Koreans. Int J Equity Health. 2014;13(1):73. https://doi.org/10.1186/s12939-014-0073-7
https://doi.org/10.1186/s12939-014-0073-... ,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁴⁹49. Strain LA. Physician visits by elderly: testing the Andersen-Newman framework. Can J Sociol. 1990;15(1):19-37. https://doi.org/10.2307/3341171
https://doi.org/10.2307/3341171... ,⁶¹61. Wan TTH, Odell BG. Factors Affecting the Use of Social and Health Services Among the Elderly. Ageing Soc. 1981;1(1):95-115. https://doi.org/10.1017/S0144686X81000068
https://doi.org/10.1017/S0144686X8100006... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964...

64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... -⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... , and one has used the theoretical model proposed by the Project of Development of Methodology for Evaluating the Performance of the Brazilian Health System (PROADESS)⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... . The variables used in the adjustment have included from demographic variables and health need to behavioral variables.

Brazil (n = 9) and United States (n = 11) have been the countries with the largest number of publications in this review and those which presented a higher number of studies with association between higher income and education and use of medical appointments (30% and 60%, respectively), showing a pro-rich effect. Similar trend has been observed in studies conducted in Mexico⁴⁷47. Sánchez-García S, Fuente-Hernández J de la, Juárez-Cedillo T, Mendoza JM, Reyes-Morales H, Solórzano-Santos F et al. Oral health service utilization by elderly beneficiaries of the Mexican Institute of Social Security in Mexico city. BMC Health Serv Res. 2007;7(1):211. https://doi.org/10.1186/1472-6963-7-211
https://doi.org/10.1186/1472-6963-7-211... ,⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... , Chile⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... , and Uruguay⁶⁰60. Wallace SP, Gutiérrez VF. Equity of access to health care for older adults in four major Latin American cities. Rev Panam Salud Publica. 2005;17(5-6):394-409. https://doi.org/10.1590/S1020-49892005000500012
https://doi.org/10.1590/S1020-4989200500... . In European countries, we have found the same direction in effect between these variables in Austria, Greece, Germany, Belgium, Denmark, Italy, Switzerland, and Sweden²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... (Table 2).

Income and education have shown no effect on hospitalization in eight studies and four have found a pro-poor effect. The three studies identified⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964... have shown no association between socioeconomic factors and emergency use. The use of home care in Brazil and Canada was higher in low-income persons and the use of dental appointment in all studies has been associated with higher income and mainly higher education, even in European countries.

Regarding specialist appointment, two studies¹⁰10. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153-69. https://doi.org/10.1353/hpu.2010.0451
https://doi.org/10.1353/hpu.2010.0451... ,⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... have identified pro-rich effect in Norway, Finland, and USA.

Problems of access have been associated with the highest income and education in two studies⁵5. Auchincloss AH, Van Nostrand JF, Ronsaville D. Access to health care for older persons in the United States: personal, structural, and neighborhood characteristics. J Aging Health. 2001;13(3):329-54. https://doi.org/10.1177/089826430101300302
https://doi.org/10.1177/0898264301013003... ,²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... , both conducted in the United States (Table 2). Persons with lower income and education presented a higher chance to report problems in the access, compared to individuals with higher income and education⁵5. Auchincloss AH, Van Nostrand JF, Ronsaville D. Access to health care for older persons in the United States: personal, structural, and neighborhood characteristics. J Aging Health. 2001;13(3):329-54. https://doi.org/10.1177/089826430101300302
https://doi.org/10.1177/0898264301013003... ,²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... . In Japan, low-income citizens presented a higher chance to postpone or interrupt their search for health care (delay care)³⁶36. Murata C, Yamada T, Chen CC, Ojima T, Hirai H, Kondo K. Barriers to health care among the elderly in Japan. Int J Environ Res Public Health. 2010;7(4):1330-41. https://doi.org/10.3390/ijerph7041330
https://doi.org/10.3390/ijerph7041330... .

DISCUSSION

The association between socioeconomic factors and the access to or use of health services has varied according to the countries and type of service used. Inequality in the access to medical appointments has been identified in developing countries and in some developed countries. Increased use of dental appointments in the older population with better socioeconomic conditions has been identified in all countries. The association of socioeconomic factors with hospitalization and emergency use has been little evident: 11 studies have shown equal access⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... ,²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... ,²²22. Goodridge D, Hawranik P, Duncan V, Turner H. Socioeconomic disparities in home health care service access and utilization: a scoping review. Int J Nurs Stud. 2012;49(10):1310-9. https://doi.org/10.1016/j.ijnurstu.2012.01.002
https://doi.org/10.1016/j.ijnurstu.2012.... ,²⁹29. Lima-Costa MF, Barreto SM, Firmo JOA, Uchoa E. Socioeconomic position and health in a population of Brazilian elderly: the Bambuí Health and Aging Study (BHAS). Rev Panam Salud Publica. 2003;13(6):387-94. https://doi.org/10.1590/S1020-49892003000500007
https://doi.org/10.1590/S1020-4989200300... ,³⁶36. Murata C, Yamada T, Chen CC, Ojima T, Hirai H, Kondo K. Barriers to health care among the elderly in Japan. Int J Environ Res Public Health. 2010;7(4):1330-41. https://doi.org/10.3390/ijerph7041330
https://doi.org/10.3390/ijerph7041330... ,⁴²42. Park JM. Health status and health services utilization in elderly Koreans. Int J Equity Health. 2014;13(1):73. https://doi.org/10.1186/s12939-014-0073-7
https://doi.org/10.1186/s12939-014-0073-... ,⁴⁴44. Pinheiro RS, Travassos C. Estudo da desigualdade na utilização de serviços de saúde por idosos em três regiões da cidade do Rio de Janeiro. Cad Saude Publica. 1999;15(3):487-96. https://doi.org/10.1590/S0102-311X1999000300005
https://doi.org/10.1590/S0102-311X199900... ,,⁴⁶46. Salinas JJ, Al Snih S, Markides K, Ray LA, Angel RJ. The rural-urban divide: health services utilization among older Mexicans in Mexico. J Rural Health. 2010;26(4):333-41. https://doi.org/10.1111/j.1748-0361.2010.00297.x
https://doi.org/10.1111/j.1748-0361.2010... ,⁶³63. Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chávez MN. Health services utilization among the noninstitutionalized elderly. J Health Soc Behav. 1983;24(4):325-37. https://doi.org/10.2307/213639964
https://doi.org/10.2307/213639964... . A pro-poor effect has been presented on the use of home visit. The use of this type of care was higher among the richest and most educated only in the United States²¹21. Freedman VA, Rogowski J, Wickstrom SL, Adams J, Marainen J, Escarce JJ. Socioeconomic disparities in the use of home health services in a medicare managed care population. Health Serv Res. 2004;39(5):1277-97. https://doi.org/10.1111/j.1475-6773.2004.00290.x
https://doi.org/10.1111/j.1475-6773.2004... .

Socioeconomic inequalities in the access and use are related to individual characteristics, which affect the need and search for health services by the individual. They are also associated with contextual variables, especially in relation to the characteristics and form of organization of the health system, which can reinforce or hinder social inequalities in the access to health services⁵³53. Travassos C, Viacava F, Fernandes C, Almeida CS. Desigualdades geográficas e sociais na utilização de serviços de saúde no Brasil. Cienc Saude Coletiva. 2000;5(1):133-49. https://doi.org/10.1590/S1413-81232000000100012
https://doi.org/10.1590/S1413-8123200000... ,⁵⁷57. Travassos C, Castro M. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, editor. Políticas e sistema de saúde no Brasil. Rio de Janeiro (RJ): Fiocruz; 2008. p.215-46.. It is essential to discuss the findings of this systematic review considering the context of the health systems of each country under study.

Brazil and United States are the countries that have presented the highest number of articles and most studies have pointed inequalities in the use of medical appointments²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,⁶6. Barros MB, Francisco PM, Lima MG, Cesar CL. Social inequalities in health among the elderly. Cad Saude Publica. 2011;27 Suppl 2:S198-208. https://doi.org/10.1590/S0102-311X2011001400008
https://doi.org/10.1590/S0102-311X201100... ,⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,¹²12. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38(3):320-30. https://doi.org/10.1093/geront/38.3.320
https://doi.org/10.1093/geront/38.3.320... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... ,³⁹39. Oliver A, Mossialos E. Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health. 2004;58(8):655-8. https://doi.org/10.1136/jech.2003.017731
https://doi.org/10.1136/jech.2003.017731... ,⁴⁴44. Pinheiro RS, Travassos C. Estudo da desigualdade na utilização de serviços de saúde por idosos em três regiões da cidade do Rio de Janeiro. Cad Saude Publica. 1999;15(3):487-96. https://doi.org/10.1590/S0102-311X1999000300005
https://doi.org/10.1590/S0102-311X199900... ,⁶⁴64. Wolinsky FD, Coe RM. Physician and hospital utilization among noninstitutionalized elderly adults: an analysis of the Health Interview Survey. J Gerontol. 1984;39(3):334-41. https://doi.org/10.1093/geronj/39.3.334
https://doi.org/10.1093/geronj/39.3.334... ,⁶⁵65. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol. 1991;46(6):S345-57. https://doi.org/10.1093/geronj/46.6.S345
https://doi.org/10.1093/geronj/46.6.S345... . These countries present similarities in the form of access to services for the older population, despite differences in the predominant funding of the health systems (Brazil – universal public system; United States – private system) and coverage of public services. In the United States, the older adults aged 65 years and over are covered by public insurance, Medicare, which helps in the reduction of individual spending, but it does not cover all medical expenses³⁷37. Noronha JCD, Ugá MAD. O sistema de saúde dos Estados Unidos. In: Buss PM, Labra ME, editors. Sistemas de saúde continuidades e mudanças: Argentina, Brasil, Chile, Espanha, Estados Unidos, México e Québec. Rio de Janeiro (RJ): Editora Fiocruz; 1995. p.177-218.. Thus, the citizen can be covered by Medicare or private insurance. In Brazil, the older adults can use the public system (Unified Health System – SUS), which faces challenges in ensuring universal access, or have health insurance or private plan⁴¹41. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011;377(9779):1778-97. https://doi.org/10.1016/S0140-6736(11)60054-8
https://doi.org/10.1016/S0140-6736(11)60... . This conformation of the health system could allow greater access to those who can pay for the service or health plan. This increases the iniquities in the use of health services and justifies the findings.

A study of Fitzpatrick et al.²⁰20. Fitzpatrick AL, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health. 2004;94(10):1788-94. https://doi.org/10.2105/AJPH.94.10.1788
https://doi.org/10.2105/AJPH.94.10.1788... has shown that 22.3% of the older population in the United States have reported financial costs as an important barrier in the access to medical appointments, followed by transport problems (21%); the problems of access have been more frequent in lower-income individuals. Lima-Costa²⁷27. Lima-Costa MF, Guerra HL, Firmo JOA, Vidigal PG, Uchoa E, Barreto SM. The Bambuí Health and Aging Study (BHAS): private health plan and medical care utilization by older adults. Cad Saude Publica. 2002;18(1):177-86. https://doi.org/10.1590/S0102-311X200200010001828.
https://doi.org/10.1590/S0102-311X200200... has shown that having health insurance is associated with the largest number of visits to the doctor (four or more) in the last 12 months in the Brazilian older population.

Allin et al.²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... have shown greater difference in the use of medical appointments by the older population in Austria, Germany, and Sweden, where the use is greater by persons of higher income or education. The health system is a compulsory social insurance in these countries. In the other countries of universal system, such as Canada¹1. Allan DE, Funk LM, Reid RC, Cloutier-Fisher D. Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1). Can J Aging. 2011;30(1):69-82. https://doi.org/10.1017/S0714980810000760
https://doi.org/10.1017/S071498081000076... ,⁴⁹49. Strain LA. Physician visits by elderly: testing the Andersen-Newman framework. Can J Sociol. 1990;15(1):19-37. https://doi.org/10.2307/3341171
https://doi.org/10.2307/3341171... France²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... , Spain²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... ,¹⁸18. Fernández-Mayoralas G, Rodríguez V, Rojo F. Health services accessibility among Spanish elderly. Soc Sci Med. 2000;50(1):17-26. https://doi.org/10.1016/S0277-9536(99)00247-6
https://doi.org/10.1016/S0277-9536... , with the exception of Brazil and Italy, the studies have found no association, suggesting a better performance of the system in these countries in reducing inequalities in the access to health services.

A similar result has been found in a study with the adult population in developed countries¹³13. Doorslaer E, Masseria C, Koolman X. Inequalities in access to medical care by income in developed countries. CMAJ. 2006;174(2):177-83. https://doi.org/10.1503/cmaj.050584
https://doi.org/10.1503/cmaj.050584... . We have observed less inequality in the countries with universal system and greater pro-rich inequality in the United States and Mexico in the use of health services, two countries without universal coverage of the population.

Two studies have found increased number of specialist appointments in persons with higher income and education¹⁰10. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153-69. https://doi.org/10.1353/hpu.2010.0451
https://doi.org/10.1353/hpu.2010.0451... ,⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... . Van Doorslaer et al.¹³13. Doorslaer E, Masseria C, Koolman X. Inequalities in access to medical care by income in developed countries. CMAJ. 2006;174(2):177-83. https://doi.org/10.1503/cmaj.050584
https://doi.org/10.1503/cmaj.050584... have found the same in all the countries of the Organization for Economic Cooperation and Development (OECD) in relation to the adult population, with the exception of England. Despite the different characteristics of the system between the countries, wealthier adults are more likely to consult a specialist than the poor and, in most countries, more often. This may be a reflection of the difficulty of articulation between the primary and secondary level of the health system, restricting the access to the specialist. In this way, wealthy persons can consult a specialist using the private system. Authors⁵⁰50. Suominen-Taipale AL, Koskinen S, Martelin T, Holmen J, Johnsen R. Differences in older adults’ use of primary and specialist care services in two Nordic countries. Eur J Public Health. 2004;14(4):375-80. https://doi.org/10.1093/eurpub/14.4.375
https://doi.org/10.1093/eurpub/14.4.375... suggest that persons with higher education are able to persuade the general practitioner to forward them even when the complaint could be cared for at the primary level.

There has been little evidence of inequality in the use of inpatient services. Studies performed in the United States⁷7. Bazargan M, Bazargan S, Baker RS. Emergency department utilization, hospital admissions, and physician visits among elderly African American persons. Gerontologist. 1998;38(1):25-36. https://doi.org/10.1093/geront/38.1.25
https://doi.org/10.1093/geront/38.1.25... ,³⁸38. Nunes BP, Thume E, Tomasi E, Duro SM, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saude Publica. 2014;48(6):968-76. https://doi.org/10.1590/S0034-8910.2014048005388
https://doi.org/10.1590/S0034-8910.20140... and Brazil⁸8. Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care. 2008;46(9):930-7. https://doi.org/10.1097/MLR.0b013e318179254c
https://doi.org/10.1097/MLR.0b013e318179... ,²⁸28. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saude Publica. 2003;19(3):745-57. https://doi.org/10.1590/S0102-311X2003000300007
https://doi.org/10.1590/S0102-311X200300... have identified greater use in the poorest socioeconomic groups. This result can be due to the severity with which social groups seek hospital services. Poor individuals may have further complications or comorbidities as they have less access to preventive services, increasing the need for hospitalization, compared to rich individuals³3. Andrade MV, Noronha K, Menezes RM, Souza MN, Reis CDB, Martins DR et al. Desigualdade socioeconômica no acesso aos serviços de saúde no Brasil: um estudo comparativo entre as regiões brasileiras em 1998 e 2008. Econ Apl. 2013;17(4):623-45. https://doi.org/10.1590/S1413-80502013000400005
https://doi.org/10.1590/S1413-8050201300... . Wang et al.⁶²62. Wang HH, Wang JJ, Lawson KD, Wong SY, Wong MC, Li FJ et al. Relationships of multimorbidity and income with hospital admissions in 3 health care systems. Ann Fam Med. 2015;13(2):164-7. https://doi.org/10.1370/afm.1757
https://doi.org/10.1370/afm.1757... have observed an increase in the likelihood of hospitalization, according to the number of chronic conditions, and public funding of the service has been associated with greater use by poorer individuals.

Significant differences in the likelihood of visits to the dentist have been observed in developed countries, suggesting greater use in the older population with better socioeconomic conditions. The same has been found by Tennestedt⁵¹51. Tennstedt SL, Brambilla DL, Jette AM, McGuire SM. Understanding dental service use by older adults: sociobehavioral factors vs need. J Public Health Dent. 1994;54(4):211-9. https://doi.org/10.1111/j.1752-7325.1994.tb01217.x
https://doi.org/10.1111/j.1752-7325.1994... in the United States. According to the study, persons with higher education have reported higher number of visits to the dentist in the last year. In Brazil, older individuals with higher education and income showed higher prevalence of recent use of dental service¹⁹19. Ferreira CO, Antunes JLF, Andrade FB. Fatores associados à utilização dos serviços odontológicos por idosos brasileiros. Rev Saude Publica. 2013;47 Suppl 3:90-7. https://doi.org/10.1590/S0034-8910.2013047004721
https://doi.org/10.1590/S0034-8910.20130... . Systematic review studies prepared by Holm-Pedersen et al.²³23. Holm-Pedersen P, Vigild M, Nitschke I, Berkey DB. Dental care for aging populations in Denmark, Sweden, Norway, United Kingdom, and Germany. J Dent Educ. 2005;69(9):987-97. have also found disparities in the use of dental appointments in relation to income and have pointed out the costs for dental treatment as an important barrier for the access mainly for lower-income persons in Denmark, Germany, Sweden, Norway, and United Kingdom. This may be due to the fact that most public health systems do not cover dental services or cover them partially, offered mostly by private insurers or obtained out-of-pocket.

The use of home visits in Brazil and Canada has shown inequality in favor of the poorest, and there has been a pro-rich inequality in the United States. The greater use by poorer and less educated persons probably happens because of policies with a focus on equity. A similar result has been found by a systematic review prepared by Goodridge et al.²²22. Goodridge D, Hawranik P, Duncan V, Turner H. Socioeconomic disparities in home health care service access and utilization: a scoping review. Int J Nurs Stud. 2012;49(10):1310-9. https://doi.org/10.1016/j.ijnurstu.2012.01.002
https://doi.org/10.1016/j.ijnurstu.2012.... According to the review, persons with low income and lower education tend to be more prone to receive health care at home than persons with better socioeconomic level in Canada.

Health systems, including public health programs, are in themselves an important social determinant. By extending public services, the health care system can ensure equal treatment for all social groups and, consequently, combat existing inequalities in the health conditions generated by social inequities, exercising a compensatory mechanism⁵⁷57. Travassos C, Castro M. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, editor. Políticas e sistema de saúde no Brasil. Rio de Janeiro (RJ): Fiocruz; 2008. p.215-46.,^aa Portal DSS Brasil. O setor saúde na redução das desigualdades em saúde. Rio de Janeiro: Centro de Estudos, Políticas e Informações sobre Determinantes Sociais da Saúde; 2011 [cited 2015 Jul 2]. Available from: http://cmdss2011.org/site/2011/08/o-papel-do-setor-saude-na-reducao-das-desigualdades-de-saude/ .

The effectiveness of policies and strategies to reduce inequalities in health has been presented in studies¹⁷17. Fang R, Kmetic A, Millar J, Drasic L. Disparities in chronic disease among Canada’s low-income populations. Prev Chronic Dis. 2009;6(4):A115.,²⁶26. Kaplan MS, Huguet N, Feeny DH, McFarland BH. Self-reported hypertension prevalence and income among older adults in Canada and the United States. Soc Sci Med. 2010;70(6):844-9. https://doi.org/10.1016/j.socscimed.2009.11.019
https://doi.org/10.1016/j.socscimed.2009... . A comparison between the distributions of the prevalence of hypertension shows a social gradient in the United States and the absence of this pattern in Canada, probably a result of the universal health coverage and policies directed to socially vulnerable segments in this country²⁶26. Kaplan MS, Huguet N, Feeny DH, McFarland BH. Self-reported hypertension prevalence and income among older adults in Canada and the United States. Soc Sci Med. 2010;70(6):844-9. https://doi.org/10.1016/j.socscimed.2009.11.019
https://doi.org/10.1016/j.socscimed.2009... .

Of the studies that have used hierarchical model in the analysis (n = 17), 11 have used the theoretical model of Andersen, and one has adopted the model developed by PROADESS. The Behavioral Model of Andersen is one of the pioneers and has been developed to evaluate and understand the behavior of the use of health services by individuals⁵⁷57. Travassos C, Castro M. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, editor. Políticas e sistema de saúde no Brasil. Rio de Janeiro (RJ): Fiocruz; 2008. p.215-46.. It covers predisposing factors, enabling factors, and health need. The model proposed by PROADESS establishes a chain of hierarchical determinants. These determinants influence, distally or proximally, the use of services, which include individual characteristics, health problems, and self-perception of health⁴4. Araújo CS, Lima RC, Peres MA, Barros AJD. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saude Publica. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... .

Most of the reviewed studies have evaluated the use of health services as outcome. Two have evaluated problems of access and one has assessed the demand satisfied. Many studies adopt the use as a proxy for access to health services. However, some authors argue that access is not equivalent to the simple use of the health service³⁸38. Nunes BP, Thume E, Tomasi E, Duro SM, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saude Publica. 2014;48(6):968-76. https://doi.org/10.1590/S0034-8910.2014048005388
https://doi.org/10.1590/S0034-8910.20140... ,³⁹39. Oliver A, Mossialos E. Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health. 2004;58(8):655-8. https://doi.org/10.1136/jech.2003.017731
https://doi.org/10.1136/jech.2003.017731... ,⁵⁵55. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica. 2004;20 Suppl 2:S190-8. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... . The use can be understood as the evidence that access has been reached. However, rates of use do not allow the determination of the degree to which the services were not used, although they have been necessary³⁸38. Nunes BP, Thume E, Tomasi E, Duro SM, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saude Publica. 2014;48(6):968-76. https://doi.org/10.1590/S0034-8910.2014048005388
https://doi.org/10.1590/S0034-8910.20140... . In the use of health services, the populations who were unable to obtain medical care (lack of access) and those that did not need health services, are considered in the same category – no use of health services. We need other ways to measure access to define more clearly the extent to which the demand is being satisfied or not.

The joint evaluation of the studies shows contrasts in the thematic approach, such as the recall period of the use of the services and the measurement of the variables of education and income, implying different methods of analysis. This can influence the measure of the effect found.

The way of measuring the outcome can also have different implications, making it difficult to compare the situations studied. Some studies have evaluated the use of inpatient services dichotomously (yes; no). Other studies have used nights of hospitalization, which may reflect the complexity of the problem and the level of health of the persons. This is because it is expected that disadvantaged persons will have worse health conditions, who may require more nights of hospitalization³3. Andrade MV, Noronha K, Menezes RM, Souza MN, Reis CDB, Martins DR et al. Desigualdade socioeconômica no acesso aos serviços de saúde no Brasil: um estudo comparativo entre as regiões brasileiras em 1998 e 2008. Econ Apl. 2013;17(4):623-45. https://doi.org/10.1590/S1413-80502013000400005
https://doi.org/10.1590/S1413-8050201300... ,³²32. Mackenbach JP, Stirbu I, Roskam AJR, Schaap MM, Menvielle G, Leinsalu M, Kunst AE. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008;358(23):2468-81. https://doi.org/10.1056/NEJMsa0707519
https://doi.org/10.1056/NEJMsa0707519... .

The analysis of the association between socioeconomic factors and the use of health services among older adults has some complications. The first is the difficulty of measuring the socioeconomic status in the older population. Among the persons who are retired, income and occupation status lose their meaning, making the older adults more similar in relation to that variable, which dilutes the measure of the effect²2. Allin S, Masseria C, Mossialos E. Measuring socioeconomic differences in use of health care services by wealth versus by income. Am J Public Health. 2009;99(10):1849-55. https://doi.org/10.2105/AJPH.2008.141499
https://doi.org/10.2105/AJPH.2008.141499... . Another difficult is the selection of survivors⁴⁵45. Rothman KJ, Greenland S. Modern epidemiology. 2nd ed. Philadelphia: Lippincott-Raven; 1998.. The poorest populations present a higher morbidity and mortality rate than the average³³33. Marmot M. Social determinants of health inequalities. Lancet. 2005;365(9464):1099-104. https://doi.org/10.1016/S0140-6736(05)74234-3
https://doi.org/10.1016/S0140-6736(05)74... . In this way, the survivors tend to have better socioeconomic conditions and are healthier than those who have died, which makes the population less heterogeneous and reduces the measure of the effect.

This systematic review presents limitations, such as the absence of a third researcher for the final decision of the articles to be included in this systematic review. The selection of articles only in Portuguese, English, and Spanish can also be a limitation of the study; however, we think this is a minor effect, as only two works have not been included because they have been published in another language.

The findings of this review have shown lower use of health services and problems of access by older persons with lower income and education, varying to a greater or lesser extent according to the country and type of service used. This fact points to inequalities in the access. Dental services have shown the greatest inequality in the use. Universal health systems have shown the greatest potential to reduce inequalities in the use of services, being a reference for countries wishing to strengthen their focus on equity.

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