REVIEW ARTICLES
Strategies to health promotion in Brazilian elderly: a bibliometric study
Gesilani Júlia da Silva HonórioI; Haimée Emerich Lentz MartinsII; Joéli Fernanda BassoIII; Ângela Maria AlvarezIV; Betina Schlindwein MeirellesV; Silvia Maria de Azevedo dos SantosVI
I Physiotherapist, Phd in Nursing, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil, Email: gesilani@hotmail.com
II Nurse, Phd in Nursing, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil, Email: haimeelentz@hotmail.com
III Nurse. Phd in Nursing, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil, Email: joelifb@gmail.com
IV Phd in Nursing, Professor, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil, E-mail: alvarez@ccs.ufsc.br
V Phd in Nursing, Professor, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil, E-mail: betinam@nfr.ufsc.br
VI Phd in Nursing, Professor, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil, E-mail: silvia@ccs.ufsc.br
ABSTRACT
This study aimed at identifying strategies to promote health among Brazilian elderly. This research was established from a review of the following databases: Virtual Health Library, Regional Library of Medicine, Latin American Health Sciences and Medical Literature Analysis and Retrieval System Online. Method used the keywords health promotion and health of the elderly. It included original texts, in Portuguese language, released between January of 2006 and December of 2009, where 17 were selected. The results revealed quantitative approaches (nine studies) and qualitative (eight studies). The largest number of articles was found from 2006 up to 2008. More frequent health strategies: educational actions, physical activities and risk factor diagnosis. Only two articles cited interdisciplinary strategies. Health promotion among the Brazilian elderly is an integration process, which it will be need a strong investment in building strategies to integrate the National Policy of Health Promotion with the true reality of services.
Keywords: Elderly health; health promotion; public policies; bibliometrics.
INTRODUCTION
Brazil is going through a period of demographic and epidemiological transition. The drop in birth rates, increase in life expectancy and replacement of communicable diseases by non-communicable diseases external causes, for decades, increasing aging population1,2. The profile change also brings a change for the morbidity and mortality burden of the younger age groups for the elderly and the prevalence of morbidity on the mortality3.
Facing this reality, the public health policies began to cite technical guidelines for overall elderly care involving: health promotion, protection, and recovery4. There is, in this sense, a great deal of effort in the construction of a health care model that prioritizes actions for improving the quality of life and independence of these subjects4.
The letter of Ouro Preto, which deals with thesocial inequalities, gender and health of the elderly in Brazil, for example, presents a guiding axis of proposals, with emphasis on the right to health, income and social support5.
Is also seen as a priority for this population: the improvement of access as well as the quality of health care services provided in the Unified Health System (SUS), through the actions of promotion, information and health education; creation of opportunities for the incorporation of healthy habits; tobacco control; control of alcohol abuse; safe sex; and special care focused on the aging process6.
Health promotion and protection are the primary measures, being the general promotion, considered as the first level; already falls within the more selective individualized protection measures, identified as second-level7-9. It cannot be dissociated from health promotion to personal and social development, the targeted skills and attitudes favorable to health, with greater control over themselves and the environment10. Corroborating previous definitions, the Elderly Statute describes the importance of comprehensive health care for the elderly11.
However, the differences between what is recommended and the reality of Brazilian health services indicate the need for debates and research for the development of elderly health promotion1,12,13 .
Facing this reality, it is believed that there can be pointed out some of the existing gaps between the policies and the practice of the services and that, from them, they can be traced some interventions which make the recommended care possible, through the answer to the question: What are the strategies to promote elderly Brazilian health in the scientific production? Thus, we present the main objective of this study to answer this question.
METHODOLOGY
The research is grounded in bibliometric data published and used to measure the characteristics of certain topics, which somehow indicates its scientific production14. It is used to: analyze and evaluate sources diffusing the work; chronological evolution of scientific production, productivity of authors and institutions15.
In this study, the literature survey was done in the following databases: Virtual Health Library (VHL), Regional Library of Medicine (BIREME), Latin American Literature in Health Sciences (LILACS) and System Online search and analysis of medical literature (MEDLINE), through the combination of descriptors health promotion and health of the elderly. The research was conducted in the month of December 2010.
The following inclusion criteria were used: articles of original research, published in full text and in the Portuguese language, between January 2005 and December 2009. The exclusion criteria were: review articles of literature and theoretical reflections.
Of the 73 articles found in databases, seventeen 17 articles were selected to compose the sample on the basis of the inclusion and exclusion criteria. After determining the articles which would be part of the review, an exploratory reading of the material was performed16.
As a result they were transcribed to research forms of data classified as the relevant: identification of authors, titles of articles, goals and results, type of study, year of publication, and strategies for the health care of the elderly Brazilian population.
The interpretation of the data was descriptive and used simple frequency and percentage values.
RESULTS AND DISCUSSION
Before discussing the health promotion strategies used with the elderly Brazilians, we chose to identify the selected articles through their authors, titles and objectives and, even, the types of methodological approach and year of these publications. The descriptions of the authors, years, titles and objectives are found in Figures 1 and 2.
Initially by presenting the first nine works selected, observing diversification on the issues, but more focused on physical activity and nutritional status. See Figure 1.
The other eight works of the study, also with different topics, but mainly focused on the prevention of diseases and life habits, are listed in Figure 2.
Whereas the intervention strategies aimed at health promotion for the elderly will be discussed hereinafter, mentioned at this time are only more general comments about the analyzed studies.
There is greater concern is with disease prevention and with the elderly lifestyle. It also identifies that only 2 (11.7%) studies are focused on the institutionalized elderly, these being in the year of 2008: one of them, the twelfth work exposed, related to the condition psychotherapeutic treatment and elderly monitoring; another, the thirteenth work, on the body composition of the institutionalized elderly.
Among those who addressed risks for pathologies, were more frequently related to cardiovascular diseases. Another point raised was the functional capacity, which is actuality a concern for health longevity, given the low morbidity of the elderly2. This issue is identified in the eighth work demonstrated, published in 2008. Another indication related to functional capacity and autonomy, tenth article, with comparisons between the active Brazilian and Belgian elderly.
A single study deals with oral health and perceptions of the elderly on this subject, the first work indicated was published in 2007.
Moving on to discuss the methodological approaches, frequency was observed in 9 (53.9%) studies using the quantitative approach and 8 (46.1%) in the qualitative approach.
The qualitative studies showed the health and reality perceptions of an elderly group, and were classified into the following categories: exploratory descriptive and observational, being more frequent in the first group, with 7 (41.2%) studies. The quantitative research, in turn, presented themselves as evaluation studies with a numerical description, referring to the various situations of health and life of the elderly population. By its diversity they were divided into four subcategories: experimental studies, grade of membership, exploratory descriptive and cross-sectional, population-based, the latter being the most frequent, with 4 (23.5%) studies.
Methodologically, identifies that the qualitative approach was related with the reports of perception of health and disease, descriptions of experiences and actions of groups of elderly or training workshops. Already the quantitative approach identified health profiles, brought variable elderly health relations (such as physical activity, cardiovascular diseases, functional capacity) and description of particular situations in relation to services17,18. In this study, it was observed that balance between the approaches.
Upon evaluating the studies based on years of publication, none of the articles were identified on the topic from the year 2005. There has been an increase of publications between the years of 2006 and 2008, in which 2006 and 2007 presented, in each one of them, 3 (17.6 %) studies; in 2008, on the other hand, 8 (46.1 %) articles were published. In the year 2009, publications return to 3 (17.6 %) studies published.
An important factor in the evaluation of the publication years was the increase which occurred from 2006 to 2008. This may be associated with the implementation of the National Policy for Health Promotion (NPHP), in 2006, which has contributed a great deal to rethinking the process of elderly health care. In addition, there are also changes that accompany the aging population, related to the development of technologies aimed at the elderly health, change in gender relations and improve health levels19-21.
According to the Ministry of Health4, between the forms of dissemination and implementation of NPHP are: convening national mobilization to raise awareness of the development of health promotion actions and discuss the opportunities for training and continuing education of professionals for this proposal. Therefore, since 2006, there have existed centers of dissemination and implementation, which may explain the growing interest and research on the elderly health promotion determinants.
Another hypothesis is the National Health Policy for the Elderly, promulgated in 1999 and settled in 2006, which guarantees them social rights, creating conditions to promote autonomy, integration and effective participation in society6,22.
It is still possible to see that in 2009 the number of items is equal to the years 2006 and 2007, during which the NPHP had recently been established, and there was only the experience of other countries with health-promoting actions. This fact draws attention, because one would expect that the more the society approached the aging of the population, greater would be the interest in strategies to promote health for this segment.
It is with this appointment which arrives at primary focus of this study that is to discuss the strategies for health promotion used in the analyzed articles.
Whereas these determinants and constraints are well defined in theory, we need to know what health promotion strategies are being identified in reality for the services directed to the elderly population, which can be found in Table 1.
Among the 17 articles analyzed, only 2 (11.7 %) mentioned joint interdisciplinary strategies for the promotion of health in the elderly, being that the others addressed isolated actions.
Firstly, it is worth mentioning the conceptual expansion in health over the course of history. In 1986, the First World Conference on Health Promotion, health is discussed as a responsibility not just individual, but social4; from that moment on, the world joint efforts to improve their individual and collective health indicators.
In Brazil, the movement of health reform and the consequent implementation of the Unified Health System (SUS), which talked about the determinants and constraints of the health and disease process, resulted in the National Policy for Health Promotion, in 2006. This can be defined as an effort to face the challenges of health production in a scenario socio-historical increasingly complex, requiring reflection and continuous qualification of health practices and health system4.
With the objective of promoting the quality of life and reduce the health related vulnerability and the risks to its determinants and constraints, the NPHP serves as a subsidy for the health practices facing the different populations21,22 . It is also important to emphasize that primary care is not a fixed organizational structure or level of care, but it must be a combination of essential characteristics, such as: easily accessible in the community; professionals for the attitude of promotion; comprehensive actions and quality; care for determining aspects of health problems, as well as social; active subjects and partners in the management of their own health2.
In reference to health intervention strategies that have been studied in the reviewed articles, is observed as the most frequent educational intervention, followed by supervised physical activity and the diagnosis of disease risk profile, according to Table 1.
On educational practices, they can currently take place in coexistence groups, groups in primary health care units, as well as the actions of Open Universities of the Third Age, identifying higher scores for quality of life in the elderly participants of these institutions23.
Another factor present in the interventions found in articles and the practice of physical activity, which is directly related to a fundamental factor for the elderly population, the functional capacity24,25 which has been inversely correlated with the mobility, showing the necessity of providing adequate exercise opportunities for the elderly26. Furthermore, the functional capacity evaluation is important to identify commitment and need for help in attitudes maintenance and promotion of their own health, as well as management of the home for the elderly, leading public policy attention to health and social programs for these individuals25.
It is noted that some interventions studied in the literature turn to the specific health protection, since this is a second level of primary prevention against pathogens, or building barriers against environmental agents7,9; thus the factor highlighted as diagnosing disease risk profile would fit in this regard.
The main interventions identified in the analyzed studies demonstrate that to promote an ideal life for the elderly should consider important characteristics, such as health conditions, disease, functionality and motivation27. The elderly should be encouraged to perform physical , social and intellectual activity allowing them to to live an active and satisfactory lifestyle27. However, for that happen this broad approach interdisciplinary action is extremely important, however, as already noted, few articles have focused this joint action in order to promote health. This fact coincides with what is observed in clinical practice, in which many services do not present a multi professional and interdisciplinary team, with difficulty of developing structured support networks which reach all of the elderly28.
CONCLUSION
The demographic and epidemiological transition by which Brazil and the consequent aging of the population indicate the need to create effective strategies for the promotion of health.
Policies are created and, through them, and determinants of health conditions drawing strategies. However, as noticed in the analyzed studies, the health promotion strategies are punctual and compete on the same level as the disease risk diagnosis and biomedical characteristics.
To overcome this situation, it is concluded that it is necessary to invest in the construction of strategies that really meet the health needs of the Brazilian elderly population, not only through the implementation of NPHP principles, but its appropriation by health professionals.
It is expected, before this great challenge, knowing that the currently used strategies are an invitation to practitioners and scholars accepting the principles of health promotion.
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Received: 21.03.2012
Approved: 18.01.2013