Artigos

Introduction
The global burden of disabilities continues to grow, with 2.41 billion people experiencing conditions that would benefit from rehabilitation services1. Among these, musculoskeletal disorders were the biggest contributor (affecting approximately 1.71 billion people, causing an estimated 149 million Years Lived with Disability - YLDs), followed by sensory impairments (677 million people and 45 million YLDs), vision loss (329 million people and 21 YLDs)2 and hearing loss (403 million people and 24 million YLDs)1.
In Brazil, disabilities affect a substantial portion of the population, with 17.3 million people (8.4%) aged two years or older reporting impairments in 2019 3. Among older adults, this prevalence is notably higher, with one in four older adults reporting having this condition (24.8%)3. Given the rapid aging of the Brazilian population, the number of individuals with disabilities is expected to increase, further emphasizing the need for effective health policies and rehabilitation strategies 4.
The concept of disability has evolved over time, and the Social Model of Disability has gained prominence as a framework that shifts the focus from individual limitations to the societal barriers that restrict full participation. Rather than being solely a consequence of physical or sensory limitations, disability arises from environmental and social barriers that restrict full participation in society5,6. Obstacles such as inaccessible infrastructure, discriminatory practices, and insufficient healthcare services contribute significantly to the challenges faced by people with impairments 6,7.
In low-and middle-income countries, conditions associated with poverty, such as lack of access to health services, inadequate water or sanitation, and malnutrition, increase the risk of impairments8. On the other hand, living with a disability can contribute to social exclusion, limiting access to education and employment, while also increasing healthcare expenditures and deepening economic vulnerability 8–10.
Although recent studies in Brazil have explored social determinants of health11,12, gaps remain regarding the associations between specific types of impairments and disparities related to sex13–15, race13,16, income, and education level17–20. Recent research has yielded conflicting findings on these relationships, underscoring the need for further investigation into the sociodemographic inequalities associated with different impairments.
According to World Health Organization (WHO), 70% of cases are preventable or mitigable by adopting appropriate and timely measures21. Knowing the estimates for the prevalence of impairments, whether visual, hearing or physical, and the circumstances of these people's lives can assist specific interventions to minimize barriers in health care22 and allow for more effective planning of prevention, care and rehabilitation measures.
Considering the importance of monitoring the prevalence of impairments and the inconsistencies in findings regarding social and demographic disparities, this study aimed to estimate the prevalence of different types of impairments—specifically vision disorders, hearing loss, and physical impairments—while analyzing their associations with racial, education, income, and sex disparities.
Methods
Design and target population
A cross-sectional, population-based study was conducted using data from the Health Survey of the Municipality of Campinas (ISACamp 2014/15) with representative sample of the population, living in permanent private households in the urban area of the municipality of Campinas-SP, Brazil. The city of Campinas is located in the state of São Paulo (Southeast Brazil) with an estimated population in 2015 of 1,164,098 inhabitants.
Sampling and data collection
The Survey has a complex sampling design, in which the sample was obtained through probabilistic procedures by conglomerates and in two stages: census tracts and households. In the first stage, 70 census tracts were drawn with probability proportional to the number of households in each tract and an updated listing of addresses was carried out. In the second stage, there was a systematic drawing of households for each of the drawn tracts.
The study included persons aged ?10 and information were obtained on three age domains: adolescents (10–19 years), adults (20–59 years) and seniors (?60 years), for whom independent samples were drawn. Considering the estimated proportion of 0.50 (corresponding to the maximum sample variability), sampling error between four and five percentage points, 95% confidence level, and design effect equal to two, a minimum sample size of 1,000 individuals for adolescents and seniors and 1,400 for adults (n=3,400) was defined.
Based on the non-response rates of 27%, 22%, and 20%, respectively, for the three age groups (adolescents, adults, and seniors) verified in the previous survey (ISACamp 2008/09), the minimum sample size was calculated. Thus, 3,119 households were randomly selected for interviews with adolescents, 1,029 for adults, and 3,157 for seniors. We chose to interview all individuals in the household of the given age group, since this type of design is less expensive and very similar in accuracy when compared with intrahousehold selection23. Due to losses and refusals, 3021 people were interviewed (1,022 adolescents, 1,013 adults, and 986 older adults), with the highest percentage of losses/refusals in the adult domain.
Data collection instrument
The ISACamp 2014/15 questionnaire is structured into 13 thematic blocks and encompasses broad health subjects. It has predominantly closed questions and predefined alternatives. In this study, we analyzed information from the blocks concerning morbidity and impairment (Block C) and demographic and socioeconomic conditions (Block L). Data were collected by trained interviewers, with a direct approach to the selected individual and with the aid of tablets and software developed especially for this research. To ensure the inclusion of participants with communication difficulties, such as those with neurological or cognitive impairments, a family member or close caregiver answered the questions on their behalf. To minimize potential biases, proxies were selected based on their close contact with and extensive knowledge of the participant's daily routine.
Variables analyzed
The study’s dependent variables were:
a- The presence of visual impairment, assessed by the question “Do you have any visual problems / any difficulty in seeing?” And possible responses could be: (1) "Yes" or (2) "No." We considered individuals who reported blindness in one or two eyes and permanent difficulty seeing. To construct this variable, we used supplementary questions from the questionnaire in order to select only individuals who had visual impairment even with the use of glasses or lenses. These questions were: “Do you wear glasses and / or contact lenses to correct your visual problem?” (1) “Yes” or (2) “No” and “Do the glasses or the lens solve your difficulty in seeing / your visual problem? How much?” (1) “Yes, totally”; (2) “Yes, partially” or (3) “No”; Those who answered “yes, partially” or “no” to the last question were considered visually impaired.
b- The presence of hearing impairment was assessed by the question “Do you have difficulty hearing?” and the answer options were “Yes” or “No”. We considered individuals who reported deafness in one or two ears or who had severe hearing difficulties.
c- The presence of physical impairment, assessed by the question “Do you have any physical impairment such as paralysis or loss of any part of your body?” and the possible responses were “Yes” or “No.”
The independent variables used for analysis were:
a- Demographic and socioeconomic: sex (male and female), age group (10 to 19 years, 20 to 39 years, 40 to 59 years and 60 years or more), health insurance (yes or no), education level (zero to three, four to seven or eight years or more study years) and monthly household income per capita in minimum wages (less than one and more than one minimum wages) and self-reported skin color (white or black/brown; we excluded those who declared themselves as yellow (n=40) or indigenous (n=16) due to the small number in the sample). We used skin color as proxy of race, as it has been used in Brazil according to Brazilian Institute of Geography and Statistics24. We considered race, in our study, as a social construct, instead only the biologic way25.
Data analysis
All analyses in this study considered the weights of complex sample design, non-response rate and post-stratification, using the survey (svy) module of the STATA 14.0 software (Stata Corp., College Station, United States).
The prevalence of visual, hearing and physical impairments was estimated according to the independent variables and the differences were tested using the chi-square test, considering those with p<0.05 as statistically significant. Then, the prevalence ratios (PR) adjusted for sex and age and the corresponding confidence intervals (95% CI) were estimated using Poisson multiple regression.
Separate models were conducted for each dependent variable of the study. A Poisson multiple regression model was developed for each type of impairment, in which the independent variables that were statistically associated with the impairments with p?0.20 were initially entered in the model. Subsequently, we excluded, one by one, those that did not contribute significantly to the model (p<0.05).
Ethical aspects
The ISACamp 2014/15 project was approved by the Research Ethics Committee (CEP) of the School of Medical Sciences, State University of Campinas, under opinion No. 409.714 of Sep 30, 2013 - CAAE 20547513.2.0000.5404.
Results
Among the selected households, 4.6% resulted in refusals, while 3.2% were classified as other losses. Regarding the identified individuals eligible for interviews, 17.4% refused to participate, and 1.7% were classified as other losses. Consequently, the final sample consisted of 3,021 individuals aged 10 years or older, with a mean age of 41.0 years (95% CI: 40.1–41.9), and a predominance of females (54.7%; 95% CI: 52.9–56.5).
Table 1 presents the sociodemographic characteristics of the study population. Of the participants, 15.6% were aged 60 years or older, 33.6% identified as black or brown, and 45.2% had private health insurance. Additionally, 68.4% had at least eight years of education, and 42.8% lived in households with a per capita income below the minimum wage. Regarding impairments, 77.4% of participants reported no impairments, while 22.6% reported at least one impairment.
Table 2 details the prevalence of impairments according to sociodemographic variables. The most frequently reported impairment was visual impairment (15.2%; 95% CI: 13.0–17.7), followed by hearing impairment (8.1%; 95% CI: 6.8–9.6) and physical impairment (2.1%; 95% CI: 1.6–2.8). A significant increase in prevalence was observed across older age groups, particularly among individuals aged 60 years or older, where visual impairment reached 22.9% (95% CI: 19.4–27.0), hearing impairment 22.1% (95% CI: 19.0–25.6), and physical impairment 4.8% (95% CI: 3.5–6.5). Racial disparities were also evident in visual impairment, with a higher prevalence among black or brown individuals (19.3%; 95% CI: 16.0–23.0) compared to white individuals (12.9%; 95% CI: 10.8–15.5), p = 0.0005.
Regarding education level, participants with lower education (0 to 3 years) showed the highest prevalence of all impairments. Visual impairment was 30.9% (95% CI: 25.4–37.1) in this group, compared to 12.1% (95% CI: 9.9–14.7) among those with ?8 years of education (p < 0.0001). Similarly, hearing and physical impairments were significantly more common among individuals with lower education levels (18.5% and 9.3%, respectively; p < 0.0001).
Sex differences were found in physical impairment, with a higher prevalence among men (2.9%) compared to women (1.3%; p = 0.0030). Income was not significantly associated with impairments (p > 0.05).
Table 3 presents the prevalence ratios (PR) for each impairment type, adjusted for age and sex. Visual impairment was significantly associated with older age, black/brown race (PR = 1.6; 95% CI: 1.3–2.0), lack of health insurance (PR = 1.5; 95% CI: 1.2–2.0), and lower education level (PR = 2.0; 95% CI: 1.5–2.7 for 0 to 3 years of schooling). Hearing impairment was primarily associated with age, with PRs increasing significantly among older age groups (PR = 6.7; 95% CI: 5.0–9.0 for individuals aged 60 years or older), but showed no significant association with socioeconomic factors. Physical impairment showed the strongest associations, particularly with age (PR = 7.8; 95% CI: 3.7–16.4 for older adults), sex (higher in males, PR = 2.5; 95% CI: 1.5–4.1), lack of health insurance (PR = 2.5; 95% CI: 1.2–4.9), low education level (PR = 7.6; 95% CI: 3.8–15.3), and low income (PR = 2.1; 95% CI: 1.2–3.8).
Table 4 presents the final regression models for each impairment. After adjustments, visual impairment remained associated with older age, black/brown race (PR = 1.5; 95% CI: 1.2–1.8), and lower education levels. Hearing impairment remained exclusively associated with age, while physical impairment remained significantly associated with older age, male sex (PR=2.5; 95% CI: 1.5–4.0), and low education (PR = 4.7; 95% CI: 1.9–11.6).
Discussion
In this study, we detected disparities in visual and physical impairments by education level; in physical impairment by sex; and in visual impairment by race. It was found that 15.2% of the population of Campinas aged 10 years or more reported some visual impairment, 8.1% for hearing impairment, and 2.1% for physical impairment. Data for the municipality of São Paulo in 2015 show similar results for visual impairment (18.8%) and hearing impairment (7%)26. The prevalence of physical impairment observed in Campinas is higher than that observed for the Brazilian population in the National Health Survey (1.3%)27.
The literature shows major variation in the prevalence found in surveys due to the use of different conceptual frameworks regarding the impairments, different data collection methods or different investigated age groups27. For example, a study conducted in China involving 6,725 individuals who underwent a clinical evaluation found prevalence of visual impairment of 1.7% for adults aged 50–59 years and 29.9% among individuals aged 80 or more28. A systematic review between 1980 and 2012 showed that the prevalence of visual impairment can range from 5% or less in high-income countries to 18–23% in studies carried out in Africa, Oceania and South Asia29. In the case of hearing impairment, the prevalence can range from 1.5% in populations aged 6–13 years in South Africa to 47% in individuals aged 57–87 years in the United States30. A Dutch national survey involving 62,352 individuals assessed self-reported physical impairment and found a prevalence of 1.7% in the population aged up to 24 years and 44% in individuals aged over 75 years 31.
This study proves a common finding in the literature, which is the gradual increase in prevalence with advancing age for all assessed impairments14. The prevalence of visual impairment increases in earlier ages, being already observed in the age group of 20–39 years. In the case of hearing and physical impairment, there was increase with age from 40 years, reaching very high prevalence after 60 years. Occupational factors could be associated with this increased risk of hearing impairment32 and physical impairment33 in adults. With advancing age, seniors who already use refractive correction may not notice the worsening of their visual acuity or may face logistical restrictions that prevent them from seeking ophthalmologic care in order to review their prescription13, as well as to receive care and correction for hearing and physical impairments.
Our findings showed higher prevalence of visual impairment compared with hearing and physical impairments. The WHO’s Global Eye Health Action Plan 2014–2019 shows that if only the two main causes of visual impairment were considered a priority and control measures were implemented, providing refractive services and cataract surgeries, two-thirds of the persons with visual impairment could recover their vision21.
We also observed that visual impairments are more frequent in black/brown individuals and in those with lower education level. In the analyses carried out in this research, education level excluded the significance of income and health insurance, but it did not eliminate the association with race, showing the possible issues of discrimination by race or skin color in visual impairment. The predominance of visual impairment in black/brown persons is information available in some populational studies conducted in other countries, such as the USA34, England and Australia35; however, Brazilian studies still did not confirm this association14,27. The Salisbury Eye Evaluation Study34 in the USA found that, in all age groups, African Americans were 1.5 times more likely to have visual impairment compared with white participants. In addition, the prevalence of cataract and refraction errors was twice as high in the black population and the chances of glaucoma and diabetic retinopathy were seven times higher, with fewer operations and visits to the doctor compared with whites13,34.
In this study, it was found that physical and visual impairments are associated with lower education level. According to Ergin & Kunst33, education is considered a prominent marker of resources early in life. The education level often reflects individual resources and has a significant role in promoting the individual's abilities, impacting their skills, job opportunities and earnings, acting as a route of transmission of resources through generations, in addition to being an important predictor of good health in old age33. Thus, individuals with impairments and their households are at an important social disadvantage, in a cycle in which low education level and low income can predispose to the occurrence of impairments and worse living and education conditions that, in turn, further aggravate the health situation when the impairment is already installed.
Hearing losses were not associated with socioeconomic variables, only age showed to be significantly associated with it, with strongly increased PR in the older adults population, like the findings of a previous study carried out in the municipality of São Paulo17. With aging, atrial blood supply is impaired due to the action of atherosclerosis plaques in small local blood vessels, leading to gradual deterioration of hearing36. Aging-related hearing loss is characterized by the sum of a variety of physiological degenerations that can include damage caused by exposure to noise, infectious diseases (such as rubella and meningitis) and medical treatments, among others36,37. Lin et al38 in their study using data from the National Health and Nutritional Examination Survey in the United States reported that non-modifiable risk factors, such as age, race and sex, are stronger determinants of hearing loss status, when compared with environmental and socioeconomic factors.
In contrast, stronger associations were found in physical impairment, with higher PRs for males, adults and seniors and education level of less than 3 years of study. The association between physical impairment and male sex is present in the scientific literature14. However, divergences are still found in relation to this information. Studies carried out with older populations (>55 years) in the United States, Taiwan, Korea, Mexico, China, Indonesia and Bolivia show a higher prevalence of physical impairment in females39,40. On the other hand, studies evaluating adult populations, in addition to seniors, and using more specific indicators of physical impairment, such as loss of limbs/paralysis, found higher prevalence in males14,41. This finding is justified by the greater exposure of men to risky occupations, labor and traffic accidents, situations of violence, practice of extreme sports, due to having a higher prevalence of risky behaviors and less care with health and control of diseases, among others14. It is also known that most factors that trigger the process that leads to physical impairments can be avoided or mitigated, such as those that lead to paralysis (traffic accidents, strokes, nerve injuries) or loss of limbs (vascular diseases, diabetes, labor, or traffic accidents)14. This reinforces the need to develop preventive actions and measures to reduce or eliminate external causes and the environmental and social factors that aggravate this impairment.
It is necessary to highlight here that the WHO, by means of the proposal of Sustainable Development Goals (SDG), addresses the social variables here related to the higher prevalence of impairments. The SDGs are a set of 17 initiatives to promote the prosperity and protection of the planet42. Thus, the reduction of poverty (SDG #ONE); quality education (SDG #FOUR); gender equality (SDG #FIVE); and the reduction of inequities (SDG #TEN) are important components of this WHO strategy to which the results found in this research are aligned, reinforcing the importance of these variables in the social context. The results of this study directly support the need for investment in social improvements to reduce the prevalence, social disparities and impact of impairments in society.
In Brazil, studies analyzing the types of impairments do not focus on the issue of social disparities, which is the main point of this research. However, the analysis of the results of this study must consider some limitations. Due to the cross-sectional design, this study cannot determine whether impairments lead to socioeconomic disadvantages or if pre-existing social inequalities increase impairment risk. Longitudinal studies are needed to clarify these associations. Another limitation is the inability to distinguish whether impairments resulted from preventable or treatable conditions, accidents, or congenital factors. This distinction is important for tailoring health policies and rehabilitation efforts. In addition, the prevalence of impairments in this study was determined according to the informants perception, involving no diagnostic confirmation, with the possibility of underestimating the prevalence, especially in the case of hearing losses. Despite that, some authors have observed that the use of a single question regarding the self-report of hearing loss can represent both a sensitive (74%) and a specific (72%) screening tool, overcoming cultural and language barriers and proving effective in studies using large samples43.
This study allows us to know the prevalence and life circumstances of people with impairment, as well as existing social disparities. These findings point to the need of specific interventions to minimize barriers to accessing health care and allow for more effective planning of prevention, care and rehabilitation measures. In addition, the need for more research involving gender, race, education, and income differences among people with impairment is reinforced.
The results of this study showed that the variables sex, race and education level have different association processes in relation to visual, hearing and physical impairments. In this sense, race and education level are related to visual impairment, sex and education level with physical impairment, and none of them with hearing impairment. The action of age is very strong in the three types of impairments studied. This research enables us to better understand the profile of persons with impairments considering the underlying social disparities and providing opportunity for a more adequate design of health care and social assistance policies. In addition, the findings of this study contribute to enhance the discussion about health disparities among persons with impairments.






REFERENCES
1. Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020 Dec 19;396(10267):2006–17.
2. Bourne RRA, Steinmetz JD, Flaxman S, Briant PS, Taylor HR, Resnikoff S, et al. Trends in prevalence of blindness and distance and near vision impairment over 30 years: An analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021 Feb 1;9(2):e130–43.
3. Pesquisa Nacional de Saúde (2019). Instituto Brasileiro de Geografia e estatística (IBGE). PNS 2019: país tem 17,3 milhões de pessoas com algum tipo de deficiência. https://censoagro2017.ibge.gov.br/agencia-sala-de-imprensa/2013-agencia-de-noticias/releases/31445-pns-2019-pais-tem-17-3-milhoes-de-pessoas-com-algum-tipo-de-deficiencia. 2019.
4. Montoro Pazzini Watfe G, Fajersztajn L, Ribeiro E, Rossi Menezes P, Scazufca M. Prevalence of Older Adult Disability and Primary Health Care Responsiveness in Low-Income Communities. Life. 2020 Aug 5;10(8):133.
5. Tom Shakespeare. Disability: the basics. 1st edition. Routledge; 2018. 1–196 p.
6. Oliver M. The social model of disability: thirty years on. Disabil Soc. 2013 Oct;28(7):1024–6.
7. James W, Lamons K, Spilka R, Bustamante C, Scanlon EM, Chini JJ. Hidden walls: STEM course barriers identified by students with disabilities. In: 2019 Physics Education Research Conference Proceedings. American Association of Physics Teachers; 2020.
8. Banks LM, Kuper H, Polack S. Poverty and disability in low-and middle income countries: A systematic review. PLoS One. 2017 Dec 1;12(12).
9. Trani J-F, Loeb M. Breaking the vicious circle of disability and extreme poverty. 2012;24:S19-S52. Available from: http://www.ilo.org/inclusion
10. Mitra S, Posarac A, Vick B. Disability and Poverty in Developing Countries: A Multidimensional Study. World Dev. 2013 Jan;41(1):1–18.
11. Fiorati RC, Elui VMC. Social determinants of health, inequality and social inclusion among people with disabilities. Rev Lat Am Enfermagem. 2015 Apr;23(2):329–36.
12. Barreto MCA, Araújo LF, Castro SS de. Relação de fatores pessoais e ambientais com a prevalência de deficiências físicas adquiridas no Brasil - estudo de base populacional. Cien Saude Colet. 2022 Apr;27(4):1435–42.
13. Fisher DE, Shrager S, Shea SJ, Burke GL, Klein R, Wong6 TY, et al. Visual Impairment in White, Chinese, Black and Hispanic Participants from the Multi-Ethnic Study of Atherosclerosis Cohort. Ophthalmic Epidemiol. 2015;22(5):321–32.
14. Castro SS de, César CLG, Carandina L, Barros MBA, Alves MCGP, Goldbaum M. Visual, hearing, and physical disability: prevalence and associated factors in a population-based study. Cad Saude Publica. 2008;24(8):1773–82.
15. Instituto Brasileiro de Geografia e Estatística (IBGE). Brasil tem 18,6 milhões de pessoas com deficiência, indica pesquisa divulgada pelo IBGE e MDHC. Ministério dos Direitos Humanos e Cidadania. 2023.
16. Minority Rights Group International. A Situação das Pessoas Negras com Deficiência no Brasil [Internet]. 2023 [cited 2025 Feb 15]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://minorityrights.org/app/uploads/2023/12/mrg-brief-brazil-port-1.pdf?utm_source=chatgpt.com
17. Paiva KM de, Cesar CLG, Alves MCGP, Barros MB de A, Carandina L, Goldbaum M. Aging And Self-reported Hearing Loss: A Population-based Study. Caderno de Saúde Pública. 2011;27(7):1292–300.
18. Ulldemolins AR, Lansingh VC, Valencia LG, Carter MJ, Eckert KA. Social inequalities in blindness and visual impairment: A review of social determinants. Indian J Ophthalmol. 2012;60(5):368–75.
19. Instituto Brasileiro de Geografia e Estatistica - IBGE. Pessoas com deficiência têm menor acesso à educação, ao trabalho e à renda. Estatísticas sociais. 2023.
20. Oliveira DG, Shimano SGN, Salomão AE, Pereira K. Evaluation of socioeconomic profile, professional training and health status of people with visual impairment. Rev Bras Oftalmol. 2017;76(5).
21. World Health Organization (WHO). Universal eye health: a global action plan 2014-2019. 2013;1–28. Available from: http://dx.doi.org/10.1016/j.jsames.2011.03.003%0Ahttps://doi.org/10.1016/j.gr.2017.08.001%0Ahttp://dx.doi.org/10.1016/j.precamres.2014.12.018%0Ahttp://dx.doi.org/10.1016/j.precamres.2011.08.005%0Ahttp://dx.doi.org/10.1080/00206814.2014.902757%0Ahttp://dx.
22. Assi L, Shakarchi AF, Sheehan OC, Deal JA, Swenor BK, Reed NS. Assessment of Sensory Impairment and Health Care Satisfaction Among Medicare Beneficiaries. JAMA Netw Open. 2020 Nov 13;3(11):e2025522.
23. Alves MCGP, Escuder MML, Claro RM, da Silva NN. Selection within households in health surveys. Rev Saude Publica. 2014;48(1):86–93.
24. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico 2010. Características da População e dos Domicílios. [Internet]. IBGE. 2010 [cited 2020 May 21]. p. 1–270. Available from: http://censo2010.ibge.gov.br/
25. Krieger N. Discrimination and health inequities. International Journal of Health Services. 2014 Oct 1;44(4):643–710.
26. Boletim ISA Capital 2015 no 16. Deficiência na cidade de São Paulo: CEInfo. CEInfo. 2018. 1–38 p.
27. Malta DC, Stopa SR, Canuto R, Gomes NL, Mendes VLF, de Goulart BNG, et al. Self-reported prevalence of disability in Brazil,according to the National Health Survey,2013. Ciência e Saúde Coletiva. 2016;21(10):3253–64.
28. Chen X, Zhou D, Shen J, Wu Y, Sun Q, Dong J, et al. Prevalence and causes of visual impairment in adults in Binhu district, Wuxi, China. Medical Science Monitor. 2018;24:317–23.
29. Stevens GA, White RA, Flaxman SR, Price H, Jonas JB, Keeffe J, et al. Global prevalence of vision impairment and blindness: Magnitude and temporal trends, 1990-2010. Ophthalmology [Internet]. 2013;120(12):2377–84. Available from: http://dx.doi.org/10.1016/j.ophtha.2013.05.025
30. Pascolini D, Smith A. Hearing impairment in 2008: A compilation of available epidemiological studies. Int J Audiol. 2009;48(7):473–85.
31. Picavet HS, Hoeymans N. Physical disability in The Netherlands: prevalence, risk groups and time trends. Public Health. 2002;116(4):231–7.
32. Lie A, Skogstad M, Johannessen HA, Tynes T, Mehlum IS, Nordby KC, et al. Occupational noise exposure and hearing: a systematic review. Int Arch Occup Environ Health. 2016;89(3):351–72.
33. Ergin I, Kunst AE. Regional inequalities in self-rated health and disability in younger and older generations in Turkey: The contribution of wealth and education. BMC Public Health. 2015;15(1):1–11.
34. Muñoz B, West SK, Rubin GS, Schein OD, Quigley HA, Dressler SB, et al. Causes of blindness and visual impairment in a population of older Americans: The Salisbury eye evaluation study. Archives of Ophthalmology. 2000;118(6):819–25.
35. Cumberland PM, Rahi JS. Visual function, social position, and health and life chances the UK Biobank study. JAMA Ophthalmol. 2016;134(9):959–66.
36. Hudspeth AJ. Hearing and deafness. Neurobiol Dis. 2000;7(5):511–4.
37. Baraldi GDS, de Almeida LC, Borges ACDC. Hearing loss in aging. Braz J Otorhinolaryngol [Internet]. 2007;73(1):64–70. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-33947603283&partnerID=40&md5=69c395f21153d5d10dd7877526583448
38. Lin FR, Thorpe R, Gordon-Salant S, Ferrucci L. Hearing loss prevalence and risk factors among older adults in the United States. Journals of Gerontology - Series A Biological Sciences and Medical Sciences. 2011;66 A(5):582–90.
39. Felicia V W, Crimmins EM. Female disability disadvantage: a global perspective on sex differences in physical function and disability. Ageing Soc. 2016;36(6):1136–56.
40. Murtagh KN, Hubert HB. Gender differences in physical disability among an elderly cohort. Am J Public Health. 2004;94(8):1406–11.
41. Singal N, Bhatti F, Malik R. Counting the invisible: understanding the lives of people with disabilities in Pakistan. RECOUP . 2009;23(23):1–33.
42. United Nations. Open Working Group (OWG). Introduction and Proposed Goals and Targets on Sustainable Development for the Post 2015 Development Agenda. 2015;1–15. Available from: https://www.un.org/sustainabledevelopment/sustainable-development-goals/
43. Torre III P, Moyer CJ, Haro NR. The accuracy of self-reported hearing loss in older Latino-American adults. Int J Audiol. 2006;45(10):559–62.