Revista Enfermagem UERJ

RESEARCH ARTICLES

Outlooks on disability in older adults: health vulnerabilities

^I PhD in Nursing. Professor of the Undergraduate Course in Nursing and the Graduate Nursing Program at the Federal University of Santa Catarina. Member of the Research Group on the Elderly Health Care. Florianopolis, Santa Catarina, Brazil. E-mail: juliana.balbinot@ufsc.br
^II Nurse. PhD in Education. Professor of the Department and Graduate Nursing Program, Federal University of Santa Catarina. Leader of the Research Group on the Elderly Health Care. Florianopolis, Santa Catarina, Brazil E-mail: azevedosms@gmail.com
^III Nurse. Master's Student of the Graduate Program from the Community University of Chapecó. Professor in Nursing Department of the University of the State of Santa Catarina. Member of the Center for Research and Studies in Nursing, Lifestyle, Imaginary and Health. Santa Catarina, Brazil. E-mail: E-mail: nothaft@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.7464

ABSTRACT

This qualitative, descriptive study investigated perceptions among older adults, managers and health professionals as to the outlook for disability in the elderly. Semi-structured interviews were conducted of 18 older adults and questionnaires were applied to 17 managers and three health professionals, between June and December 2010 in Florianópolis, Santa Catarina, Brazil. Data analysis through dialectic hermeneutics apprehended the constituent components of three categories: the impact of disability on older adults' quality of life; social support networks; and naturalization of disability in the aging process. It was concluded that the impact of disability affects older adults' quality of life, while health professionals and managers consider it a natural part of the aging process. As regards care, there is a fragile support network, the biomedical model predominates, and Family Health Strategy teams' academic training and instruments are deficient. Keywords: Aging; elderly; social vulnerability; primary health care.

INTRODUCTION

Population aging is one of the biggest challenges for contemporary public health, especially in developing countries, where this phenomenon occurs in environment characterized by poverty and great social inequality¹. In addition, there is evidence of the lack of preparation of world public health against the continued and rapid increase in human longevity².

The aging process defines changes of biological, psychological and social order. And in many of these populations little has been done so that their limitations do not cause disabilities. Disability may arise from the lack and/or difficult access to care. The health status of the elderly can be determined by their morbidity and mortality profiles, presence of physical and cognitive deficits and the use of health services, among other more specific indicators¹. One of the conditions that can afflict the elderly is the physical disability.

Disability is the term used to define the absence or dysfunction of a psychic, physiological or anatomical structure of the human being³. In Brazil, physically disabled person is the one with full or partial change of one or more segments of the human body, resulting in the impairment of physical function, in the form of paraplegia, paraparesis, monoplegia, monoparesis, quadriplegia, tetraparesis, triplegia, triparesia, hemiplegia, hemiparesis, ostomy, amputation or absence of member, cerebral palsy, dwarfism, members with congenital or acquired deformities, except esthetic deformities and those that cause no difficulties for the performance of duties⁴.

The World Health Organization (WHO) estimates that about 10% of the population of any country in peacetime carries some kind of disability. Based on this percentage, it is estimated that in Brazil there are 16 million people with disabilities⁵. These two situations - being old and having a disability - constitute situations of vulnerability by themselves. Although the model of care for the elderly with disabilities advocates an interdisciplinary approach, in practice this has not yet been fully established. In addition, this model is usually not discussed in academia or valued by health policies and, consequently, health professionals find it very difficult to implement it.

Based on these, the appropriate coping with the demands caused by population aging will enable the effectuation of a comprehensive care for the elderly, combined with the practices of health promotion and disease prevention. Care for the elderly involves offering services that provide access and reception in an orderly and proper manner, respecting their limitations. In this process, primary health care must configure the entryway of the elderly to the health system, which will provide quality care and resoluteness.

This finding refers to the fact that health professionals, public health system managers and society as a whole must wake up to the need for new strategies to take care of these elderly. Health promotion strategies should be considered in order to create opportunities for equality of resources so that physically disabled elderly have support, access to information, life skills and opportunities to make healthy choices. The story of the elderly will be outlined through new studies, legislation and community action.

Therefore, this study aimed to: investigate the perceptions of the elderly, health managers and professionals in the primary health care on the prospects of disability in the elderly.

LITERATURE REVIEW

The theoretical framework of this study was based on the principles of the Unified Health System (SUS)⁵ and in the National Policy for People with Physical Disabilities⁶.

The SUS follows the same doctrine and the same organizational principles throughout the national territory, under the responsibility of the three autonomous spheres of government: federal, state and municipal. Its principles are: Universality, Equity and Comprehensiveness. In approaching the elderly, the principle of Universality is to ensure that all seniors have access to health care, as this is a right of every citizen and government duty. Equity, in turn, ensures that all citizens are equal before the system, so they should be served according to their needs. This is important because health services should consider that in every population there are groups of elderly people who live differently, have specific problems, different ways of living and meeting their needs⁵.

Thus, health services may assist in reducing inequalities in the country. Comprehensiveness consists of a set of health actions specific to the elderly that may be articulated and directed to the prevention of disease and the cure⁵.

Health services should work with a view to meet this individual as a whole, holistic being. The focus of attention should be focused on the health of people and not only on their disease. Thus, it will be possible to develop integrated actions for promotion, disease prevention and health recovery. It is noteworthy that primary health care has as one of its foundations allowing universal and continuous access to quality health services, reaffirming the SUS basic principles.

The preservation of these principles is relevant, given that it is in this system of care that older people with physical disabilities are included, even if marginally^5,6. Since one of the SUS premises is to enable the access of older people with disabilities to health care, there should be awareness that for this group such accessibility is a process. And this process should create opportunities for these people to participate in society, for them to be independent, and for them to have guaranteed the principle of equality, especially in issues relating to their life and health⁶.

In this context, over the years, national legislation has been improved, through laws, regulations and decrees in order to carry out the National Policy for People with Physic Disabilities. This policy is a tool that guides the health sector actions directed to this population and that primarily aims to rehabilitate people with deficiency in their functional capacity and their human performance. Although Brazil is one of the few countries in the world that has a specific legislation, people with disabilities are still quite excluded from society⁷. It is noticed that in the context of disability in the elderly, discussion is still incipient.

METHODOLOGY

This is a qualitative, descriptive study, with data collection carried out between June and December 2010. For the selection of the research scenario, we conducted a quantitative survey of elderly aged over 60 years old, through the Planning Sector of the Municipal Health Secretariat of Florianopolis, Santa Catarina, Brazil. This city has a population of 421,240 residents, and the population over 60 years old amounts to 48,894 people (11.5%)⁸.

In the health scope, the city is divided into five health districts (HD), covering 48 health centers. Of these, two HD were selected, which are located: on the Continente neighborhood and in the south of Florianopolis. The choice of these regions was due to geographical, social, epidemiological and cultural differences. In these districts, we selected a health center of each, using as criteria those with greater number of elderly people. So, we chose the Health Centre 1 (HC1) – which belongs to the HD Continente - that has in its coverage area 565 elderly (7.44% of total population) and the Health Centre 2 (HC2) – which belongs to the HD South - that has 126 elderly (7.49% of total population)⁸.

To develop the study, we invited the elderly with physical disabilities that use the selected HC, health professionals who work in these health centers and managers of Municipal Health Secretariat of Florianopolis. The participants were 18 seniors who met the inclusion criteria: having congenital or acquired disability for at least 1 year, aged 60 years old, absence of severe cognitive and/or mental changes (verified by applying the Mini-Mental State Examination - MMSE), who agreed to participate and signed the Informed Consent Form. To locate these subjects we actively searched for Family Health Strategy team (ESF) and Community Health Workers (CHW) through an instrument developed by one of the authors of this article. For data collection we used semi-structured interview. All interviews were audio-recorded and transcribed by the researcher.

To represent health professionals, three subjects (two nurses and a doctor) participated. Inclusion criteria were: working in the ESF, holding this position for over a year, accepting to participate and signing the Informed Consent Form. These two occupational categories were chosen because they integrate the minimum composition of the ESF team.

To represent managers, 17 people participated in the study. They met the inclusion criteria: working as manager at any level of the hierarchical structure (job management, director, advisory, department head or local coordinator), being in that position for over a year, accepting to participate and signing the Informed Consent Form.

For data collection of managers and health professionals we used a questionnaire developed by the researcher. This instrument was self-administered and therefore its delivery was made concurrently to scheduling a date for gathering it.

To protect the confidentiality and anonymity of the research subjects, we decided to identify them as user (U), to represent the elderly; P to represent health professionals and M to represent the health managers. With regard to managers, for each level of performance we used a specification: LM (local manager), RM (regional manager) and CM (center manager). We used hermeneutic dialectics as data analysis technique.

The study was approved by the Ethics Committee of the Federal University of Santa Catarina, under Protocol 695/10.

RESULTS AND DISCUSSION

Profile of participants

As for sociodemographic characteristics, in relation to the elderly population studied, the average age was 76 years old, with a predominance of females. The average educational level of respondents was 2.3 years of study, the average monthly family income ranged from one to three minimum wages (12 seniors) at the time of this study. Regarding marital status, there was prevalence of married elderly, represented by eight participants, followed by widowed ones. Regarding family composition, there was a greater distribution of elderly living with their spouse (six), followed by those living with spouse and children (three seniors). Regarding the type of disability there was prevalence of acquired deficiency (17 elderly).

In relation to managers: five were central, 10 regional and two local managers. The average age was 38 years old, in relation to gender, there was prevalence of females. As for education, only five had graduation, three had master and nine had some specialization. The professional category with most participants was nursing, followed by doctors, psychologist and dentist. The professional activity time was 13 years. The length of work time in the institution was 8.7 years and in the current position was 4.2 years.

In relation to health professionals, one was a doctor and two were nurses. The mean age was 38.6 years old, there was prevalence of females. As for education, one had expertise and the others, only graduation. The professional activity time was 10.6 years. The length of work time in the institution and occupation of the current position was 5 years.

Study Categories

The data analysis allowed the formation of a main theme in the form of three categories, namely: The impact of disability in the quality of life of the elderly; Social support networks; Naturalization of disability in the aging process.

In the category The impact of disability in the quality of life of the elderly, it is shown how the disability interferes with the autonomy, dependence/independence, with the limitations, with the development/personal fulfillment of the elderly and how it impacts on their quality of life.

In relation to the elderly who related physical disabilities to their way of life, it is evident that they should be kept with their family and the community as much as possible, with functional independence and autonomy⁹. In the elderly context, health would involve, in a broad sense, the result of the balance between the various dimensions of the functional capacity of the elderly, which does not necessarily mean absence of problems in all dimensions¹⁰. This can be seen in statements:

I live well with it. I accepted and I have to accept it. It's a pity because I lost a little freedom; I used to walk a lot [...]. (U7)

My life is normal, good. I can't do almost anything, but I'm happy. I live calmly [...]. (U10)

These findings are in agreement with the assumption that identity is not a biological fact, but a historical construction. Rethinking the past, considering an individual as a subject, is a key part of the construction of the symbolic dimension of the social process¹¹.

However, living with dependence can, at times, promote discouragement to the family and to the elderly¹².

My life is sadness! It is only in this bed. I can't do anything [...] but we have to settle for what God gives to us. I need help for everything, to clean up, to bath, to eat [...]. (U8)

My life is now practically over [...] I used to do everything. I want so badly to walk, even if it was just a little. Not to depend on others, but I can't. It's tough [...]. (U11)

Despite the experiences of inability be part of the way of life of these people, they need to have skills to overcome their difficulties and carry out their actions in the world¹³. We must reflect on the fact that the interdependence and care are necessary not only on the condition of disability, but at various times in people's lives.

Some studies indicate that people with some kind of dependence feel useless because they need others to carry out their daily basic activities: this situation is consuming for both caregivers and those who are cared^14,15.

In this category, we intend to show that the universe of physically disabled elderly is large, far beyond what it is investigated when the disability is only counted as a severe impairment of motor skills. Behavioral and social changes, especially in health, can allow that multiple settings are implemented, so that these physical and bodily restrictions are not an obstacle in the lives of elderly.

The category Social support networks comprises the sum of all the relationships that the elderly consider as significant in their living with physical disabilities and that give social support to them, and that can also contribute to their health care. This network includes: family members, caregivers, friends, neighbors, community relations, services and health professionals. Social support includes policies and social support networks, and aims to contribute to the well-being of people, especially in the case of older people with physical disabilities.

My life, with the grace of God, is good. Very good, with the help of my angel (refers to the caregiver) [...]. (U4)

My life is good. God is so good to me. He gave me this husband, my children... [...]. (U5)

It was evident that the elderly perceived an appreciation of life and family life after disability and that they could rely on family support. The family network gives support for the care and demands arising from disability. It was also found that the caregiver is an important figure in maintaining the independence of the elderly.

This finding was also present in a study¹⁴ that points out that the family is characterized by the dynamics of relationships, persevering for humanization and socialization, and that it is the foundation to support and care provided to the elderly.

In contrast to these findings, the following statements demonstrate dissatisfaction in meeting the needs of the elderly in relation to the public health system.

[...] whenever we need a doctor and other things, we have no success. It's tough [...]. (U11)

[...] the health center is very poor; it only has those simple medicines [...] it doesn't have what we need [...]. (U5)

The increase of degenerative chronic diseases and their sequelae widen the challenge of taking care of the elderly¹⁵, due to functional dependence. In this context, health actions nowadays are focused on health promotion and disease prevention, in a search for healthy and sustainable aging.

Thus, for the effectuation of elderly care, it will be necessary the transformation of the hegemonic paradigm¹⁶ of medicine, to a social and environmental model¹⁷ that considers the disease from a broader perspective, analyzing various other processes involved in the health profile of the elderly.

The research subjects reported that the doctor is their reference as the caregiver of their health, showing that health care is focused on doctors and that it is difficult to separate health from the figure of this worker, reaffirming the hegemony of the biomedical model¹⁸. This limitation reinforces the biomedical model¹⁹, focused on the disease, disability and its limitations.

I like the health center because doctors come quite often in the patients' houses [...]. (U15)

The only thing we receive a little better service there in the health center is medical care [...]. (U11)

However, users recognize the work of nurses. They perceive that this professional has worked with health promotion, disease prevention and rehabilitation of the elderly ²⁰ with physical disability.

The nurse often comes here to measure the pressure and give flu vaccine [...]. (U14)

The nurse came here at home to make my dressing [...]. (U5)

As a member of ESF, the nurse has a broader view of the elderly and about nursing care for them in several instances, including: biological, psychosocial, psychological, among others. The nurse interacts with the interdisciplinary team, playing activities to promote health and protection of these old people ²¹, and they are truly recognized in their role.

The category Naturalization of disability in the aging process comprises the various concepts that permeate the disability as a relevant event to the aging process. It includes how health professionals are trained to the practice of health care of elderly, in addition to the dynamics and interfaces of primary health care in the studied city.

In general, managers and healthcare professionals who participated in the research have a view that the disability is part of the aging process, and it is considered, then, a natural occurrence.

[...] the physically disabled elderly is a person who has wearing biological and physiological limitations caused by chronological advancement of organic structures, and/ or by trauma that lead to loss of senses, inserted in isolated and collective contexts that reflect on their living conditions [...]. (RM5)

[...] the physically disabled elderly cannot meet their needs alone and depends on others to walk, or to perform other activities, such as bathing, feeding, and others [...]. (CM4)

Many of these ideas have been acquired from the academic background, combined with the lack of training and continuing education in the field of aging.

This was also found in other scientific studies that indicate that training in the field of health care of the elderly faces certain obstacles, such as the shortage of gerontogeriatric content in curricula²², the lack of specific fields for the practice²³ and the inexperience of the academic staff.

The vulnerabilities are a set of situations that can make the elderly frail. According to the World Health Organization (WHO), the frail elderly are those who have one or more of the following characteristics: age above 80 years old; living alone; women (especially single and widowed); those living in institutions; those who are socially isolated; those who do not have children; those with severe limitations or disabilities; couples in which one spouse is disabled or sick; those with scarce resources^24,25.

Thus, it can be said that physical disability is a situation of vulnerability to which the elderly are exposed and it could progress to a situation of dependence. However, the elderly may have a physical disability without being dependent on others for care. Various conditions and situations permeate these situations and should be evaluated and considered in the care process.

CONCLUSION

Reflecting on aging, dependence and vulnerabilities is to rethink about this great challenge imposed to society by the demands of an aging population, which is a Brazilian and a worldwide phenomenon. In this new scenario, the demand for public health services is expected to increase.

It should be understood that dependence is not equivalent to old age, and that its prevention permeates the field of health. It also includes the socio-economic and cultural sphere in which elderly are inserted. Strategies such as the perpetuation of healthy habits throughout the population extending to the access to basic health services, education, culture and recreation are essential to achieve an active aging.

Finally, some more obvious insights that emerged from this research and that contributed to the loss and/or decreased effectiveness of care to the elderly with physical disabilities are: the deficient health support network for the elderly; the lack of training for the FHS teams in the elderly area; the deficit in academic training in the scope of health care of the elderly and the prevalence of the biomedical model in primary care. The main limitation of this study was the low participation of health professionals, who did not agreed to participate.

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