Popular education, health promotion and active aging: an integrative literature review

Population ageing is a global phenomenon and requires actions to promote well-being and prevent illnesses and unnecessary hospital admissions. The objective of this study was to identify education and health promotion actions aimed at promoting active aging. An integrative literature review was conducted of relevant articles written in Portuguese, English and Spanish published between 2005 and August 2018 using the following electronic databases and virtual libraries: Lilacs, MEDLINE, SciELO, and BVS. The initial search resulted in 2,069 articles, of which 33 met the inclusion criteria. The analysis showed that the actions identified by the review promoted the adoption of healthy habits and participation of older people, characterizing them as actions that promote active aging. However, the actions were limited almost exclusively to this age group, which may lead to age segregation, and focused on old age rather than adopting a life course perspective of active aging. Despite the importance of these actions, only 11 were evaluated, suggesting that the evaluation of education and health promotion actions to demonstrate effectiveness and promote replication in other locations or services is not very common practice.

introduction Population aging is a global phenomenon that began in high-income countries and is now gaining pace in middle and low-income countries, including Brazil. Despite being desirable and one of humanity's greatest triumphs, the pace of population aging has dramatic social, economic, political, and health implications 1,2 . The most notable demographic changes have occurred at the extremes of the age spectrum, with a reduction in the proportion of people aged under 15 and an increase in the proportion of people aged 65 and over, from 5.5% in 2000 to a forecasted 10.7% in 2025 3,4 , 18.7% in 2030, and 32.9% in 2060 3,4 . This is set to lead to a fourfold increase in the old-age dependency ratio (the number of older people compared to the economically active population 5 ) up to 2050, requiring new policy measures 5 to address the problem of rising pension expenditures and falling revenues for the pension system. These changes will also affect country epidemiological profiles and morbidity and mortality indicators 3,4 and be accompanied by a shift in disease patterns.
In response to the vulnerabilities and specific needs of older people, policies such as the Older Persons Statute 6 , National Health Policy for Older Persons 7 , and National Policy for Older Persons 8 have emerged. These policies seek to uphold the rights of older people, including the right to life and health, by focusing on health promotion and disease prevention and ensuring the protection, autonomy and dignity 6 of older people and their effective integration and participation in society. Despite being clearly established under law, health policies often fail to uphold and guarantee the rights of older people in practice.
Although studies of population aging tend to focus on its public health implications, there are a number of national and international movements that emphasize the social role of older people 9 and develop popular education and health promotion actions aimed at promoting active aging.
Although there are various understandings of the concept 10,11 , health education (HE) may be said to be a process that contributes to the deepening of health knowledge. However, it tends to be a vertical process aimed at changing health behaviors in which responsibility for health is placed mainly on the individual, thus disregarding a range of factors and social determinants of health that hinder the adoption of healthy habits.
HE entered a new phase with the adoption of popular health education (PHE), a term brought from popular education refined by the educator Paulo Freire 12,13 in the 1960s. PHE is shaped around pedagogical practice "with" rather than "for" the population in order to develop autonomy in a participatory manner 12 . PHE recognizes the value of health service users and "popular" knowledge, and seeks to establish horizontal relations between health professionals and the community and local social movements. PHE is a political and educational process that transforms and emancipates individuals and groups 12-14 . The definition of health promotion proposed by the Ottawa Charter 15 and exhaustively used in the health literature incorporates the idea of empowerment, suggesting that it should increase the options available to people to exercise control over their own health and listing a number of prerequisites for health and emphasizing the importance of public participation and intersectoral integration. This approach faces a number of obstacles in practice, since major structural changes are required to tackle the primary socioeconomic determinants of health (income, housing, employment, education inequalities) and enable people to achieve their fullest health potential. These changes are increasingly difficult to implement in Brazil given the prevailing neoliberal economic model and rising threats to democracy.
To address these and other concerns and considering the need to provide quality care for ageing populations, in 2005, the World Health Organization (WHO) launched its active ageing policy framework, defining active aging as "the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age". The word "active" refers to "continuing participation in social, economic, cultural, spiritual and civic affairs, not just the ability to be physically active or to participate in the labor force". Active aging aims to extend healthy life expectancy and quality of life regardless of age 16 .
These three approaches are interrelated and implicitly or explicitly view participation as a form of empowerment 15 and fundamental condition for people to achieve their fullest health potential. The interdependence between these approaches has led some authors to suggest that PHE is a component of health promotion 17 , whereas others see it as a health promotion strategy 18,19 . Nonetheless, both contribute to active aging, which in turn can facilitate both approaches, since people of all ages can contribute to the implementation of PHE and health promotion ac-tions, resulting in a virtuous circle for individual and collective well-being.
Key factors influencing active aging include functional capacity, degree of independence, and autonomy. Policies, programs and projects aimed at promoting well-being in older people should therefore seek to enhance, maintain, or recuperate these aspects. These are priorities set out in the Older Persons Statute 6 and health policies aimed at older people 7,8 , which stress that older people should be seen as, and have the opportunity to be, active participants in society, particularly in relation to matters that concern them. However, despite the participatory discourse and official documents embodying the principles of participation, achieving public participation in practice is no easy task because it implies a sharing of power.
It is important to highlight that habits, attitudes and behaviors adopted during childhood can influence quality of life in older age. Healthy practices and public participation should therefore be encouraged throughout the life course to ensure they are perpetuated into old age. Older people should be aware of the power they have, given that this segment of the population is becoming increasingly important to different kinds of interests and has the potential to be a political force.
Thus, considering the pace of population ageing in Brazil, risks of health problems, the need to develop emancipatory practices, and the importance of the latter for making aging a pleasant and active phase of life, the present study sought to identify education and health promotion actions aimed at promoting active aging.

Method
The method used in the present study was an integrative literature review, which synthesizes and critically evaluates theoretical and empirical literature on a topic of study. Integrative reviews therefore have the potential to provide a comprehensive understanding of the current state of knowledge about a particular phenomenon or healthcare problem, identify effective health care interventions and cost reductions, build health knowledge, and enhance health policy and practice 20,21 . We followed the recommended steps for this type of review 20  The following combinations of descriptors were used: "health education" "aged" and health promotion. We also used the keywords "active aging" and "popular health education", which are not found in the DeCS (Health Sciences Descriptors). The descriptors and keywords were used in Portuguese, English and Spanish together with the Boolean operator "AND", as shown in Figure 1.
Relevant articles were initially selected by reading the titles and abstracts. We included only full versions of articles in Portuguese, Spanish, and English on the theme of education with an emphasis on PHE and those related to health promotion aimed at promoting active aging. Literature reviews, theses, and duplicate articles were excluded. The selected articles were then read in their entirety using the following inclusion criteria: articles that explicitly or implicitly addressed the promotion of active aging and articles involving popular health education and health promotion actions that followed underlying principles such as active participation geared towards participant empowerment, intersectorality, and promotion of the autonomy, independence, and functional capacity of participants.

results and discussion
The literature search resulted in 2,069 articles, of which 33 met the inclusion criteria ( Figure 1).
A synthesis of the results is shown in Chart 1. The analysis showed that the studies were carried out predominantly in primary healthcare settings 30,31,33,36,38,41,42,[45][46][47][48]50,53 and universities 22,24,[26][27][28]32,35,37,39,44,51,52,54 . This is to be expected in the case of primary healthcare settings, given that health promotion is one of the priorities of the National Primary Healthcare Policy 55 , health centers are closer to the community, and these kinds of actions tend to be restricted to the health system in Brazil. The review also shows that uni-versities are increasingly developing actions with older people, be it through open universities of the third age or extension projects, indicating an awakening of interest in issues related to aging in these institutions and bringing them closer to the community, which could in turn facilitate other similar interventions and influence other sectors. Community involvement in the development of the actions appeared to be limited. Nonetheless, some of the studies mentioned the importance of community participation for promoting more far-reaching results. Studies that reported the in-  To present the methodology of the "Health Circle" and highlight some assessment data from the activities records.
Educational "afternoon tea" groups aimed at encouraging reflection and collective production regarding topics related to health and quality of life. Mazo  To evaluate the relevance and effectiveness of the "story telling" method as an active aging strategy.
Story telling activities aimed at older people. Active aging: an interventionresearch report.
To examine the effects of activities such as language activities on autonomy and public participation among older people.
Evaluation of the effects of life story language activities on autonomy and public participation. To develop a board game to be used as a gerotechnology for the promotion of active aging.
Interviews, participant observation, and group discussions, resulting in the development of a board game for older persons.

Chart 1.
Publications on popular education and health promotion directed at active aging by author, year of publication, place of study, title, objectives, and type of action developed. tegration of various sectors in the development of actions were also scarce. This is partly due to the common notion that health is influenced by purely biological factors. The role social determinants of health play, and therefore the need for joint action across various sectors, is not well understood and therefore often overlooked. This remains one of the major challenges in implementing effective health promotion actions 56 .
Workshops and the formation of groups were the most commonly used techniques, with groups being made up of between eight and 20 individuals and predominantly female. A number of reasons may explain the predominance of women in these types of actions, including: men are more resistant to adopting healthy practices and participating in activities for older adults; the proportion of women is higher in the older population; and many older men still work to complement their income 20 . According to the authors, the discussions involved topics of interest to the participants. This approach played an important role in making the actions attractive, ensuring they had a positive impact, and promoting the exchange of professional and popular knowledge, one the aims of popular education [11][12][13] . The principles of popular education underpinned the majority of activities addressing various themes, ranging from sharing of life stories to practical issues related to healthy eating, physical activity, and the discussion of chronic diseases. Only one action involved older people and teenagers, seeking to promote intergenerational sharing of life stories 34 . This finding supports the observation that education and health promotion activities for older people are still limited almost exclusively to this group, which may unconsciously promote age segregation. This may be due to the following: difficulties in bringing together various age groups in the same activity; the prevailing idea that actions with older people should be restricted to this group; or unconsciously preconceived ideas that both older and young people prefer to be with their peers, which has been demystified by previous studies 9, 34 .
Only 11 of the 33 interventions were evaluated 22,23,25,34,37,40,45,48,51,52,54 , suggesting that evaluation is not very common practice in education and health promotion activities. According to the authors, results and benefits depend on the type of intervention. However, all studies involved the promotion of the autonomy, independence, and participation of older people, characterizing them as actions that promote active aging 16,17 . In most of the actions older persons had the freedom to express opinions and participate freely, often conducting the workshops and activities themselves, with few examples of lectures or activities where participation was more passive. All articles made some kind of reference to education, health promotion, or active aging, illustrating the interdependence and interrelation between PHE and health promotion highlighted by Reis 17 and highlighting the difficulty in defining whether they are a single methodology, as proposed by Vasconcelos 18 , or whether PHE is a health promotion strategy, as suggested by Pedrosa 19 . The findings of the present study seem to indicate that PHE is a means of achieving health promotion, which in turn fosters active aging. However, there are no boundaries defining where one begins and the other ends; the three form a virtuous circle of mutual influences and dependencies.
According to the authors of the articles, older people perceived an improvement in their memory and self-esteem and there was a reduction in anxiety levels and improved awareness of the importance of self-care among older people, thus promoting well-being, interest in life, knowledge gains, and the adoption of healthy lifestyle habits. The authors also reported that the actions helped prevent future complications related to chronic disease and led to significant improvements in functional capacity, the performance of activities of daily living, engagement in physical activity, and mental health. However, more in-depth, long-term studies are required to confirm these findings.
With regard to social benefits, in general, the findings show an increase in the autonomy and active participation of older people in the actions, the promotion of social interaction between the individuals and professionals involved, sharing of experiences, strengthening of affective bonds, building of new relationships, and expansion of social support networks. These findings illustrate the importance of popular education and health promotion, which take a holistic approach to the question of health that goes beyond physiological needs.
Considering that empowerment is a key factor in health promotion actions 15 , all of the actions analyzed in this review appear to be in alignment with this principle, which suggests that they transform the environment and ways of dealing with daily challenges.
The findings also demonstrate the diversity of actions aimed at promoting active aging and the numerous benefits they provide to older people. Although research on this approach is scarce, we found studies that made a contribution to the knowledge and understanding of active aging and its multiple benefits for health and well-being. However, there was little discussion of intersectorality and community participation in the planning of actions in the studies analyzed by this review.
The findings indicate that it is possible to replicate the actions analyzed by this review in other services and locations, which is one of the aims of integrative reviews 20,21 . However, it is also clear that actions could have an even greater impact if they increased the involvement of the community, schools, universities and other sectors in health services at all levels, as envisaged by popular education and health promotion 9-13 , thereby enabling people and groups to take control over their lives and health and be actors in their own destiny.
One of the main limitations of our review is that it only considered articles available in the full version, which may have limited the number of publications, particularly those in English and Spanish.

Final considerations
The present study achieved the proposed objective of identifying education and health promotion actions aimed at promoting active aging. The promotion of active aging should be encouraged in Brazil given the current scenario for life expectancy. It is therefore essential to develop health actions aimed at promoting greater autonomy, well-being, and participatory culture, and new research in this area.
The idea of active aging proposed by the WHO is opportune and should be understood from a life course perspective so that people can develop the habit of engagement and critical capacity to enable them to become actors in their own health and life and drive lasting social change.
This integrative review facilitated reflection on replicable practical activities and research, allowing for the reflective observation of what has been published for this purpose. It also draws attention to existing gaps, such as the need for evaluation to demonstrate effectiveness, and to the fact that old age can be a productive, desirable, and pleasant phase of life.
Governments and health managers in general therefore need to understand the value of health education and promotion for all ages and the importance of tackling social injustices. This in turn could help promote the active participation of older people in society, consequently reducing their demand for social resources and unlocking their potential power, thus enabling them to demand the effective implementation of policies aimed at them.