Resilience among the elderly cared for by the Primary Healthcare Network in a city of Northeast Brazil

Abstracts

Objetiva-se avaliar a capacidade de resiliência, a auto-estima e o apoio social em idosos através de um estudo exploratório com uma amostra por conveniência constituída por idosos usuários da rede pública de saúde do município de Natal-RN, Brasil, os quais responderam ao questionário e às Escalas de Resiliência, Auto-estima e Apoio Social. Participaram 65 idosos com idade média de 71 anos, sendo 81% do sexo feminino, com baixas condições sócio-econômicas. Identificou-se que os idosos apresentam características resilientes, auto-estima positiva e apoio social percebido como satisfatório, mesmo diante das perdas e declínios vivenciados na velhice. Além disso, verificaram-se correlações moderadas e positivas entre resiliência e auto-estima, já que na medida em que uma aumenta, a outra também se eleva. Assim, o ato de viver bem esse período crítico parece ser favorecido pela resiliência enquanto recurso propiciador do desenvolvimento e pelos fatores de proteção, importantes indicadores de saúde.

Idoso; Envelhecimento; Resiliência psicológica; Saúde do idoso

ARTIGO ORIGINAL

Resilience among the elderly cared for by the Primary Healthcare Network in a city of Northeast Brazil^*

Resiliencia en ancianos atendidos en la Red de Atención Básica de Salud en municipio del nordeste brasileño

Camomila Lira Ferreira^I; Lúcia Maria Oliveira Santos^II; Eulália Maria Chaves Maia^III

^IPsychologist. Master student of the Graduate Program in Health Sciences, Federal University of Rio Grande do Norte. Specialization in Health Psychology, Development, and Hospitalization. Volunteer Research of the Psychology and Health Study Group, Psychology Department, Federal University of Rio Grande do Norte. Rio Grande do Norte, RN, Brazil. [e-mail]

^IIPsychology undergraduate, Federal University of Rio Grande do Norte. Fellow of the Scientific Initiation Program with the Psychology and Health Study Group. Natal, RN, Brazil [e-mail]

^IIIPsychologist. Ph.D. Professor of the Psychology Department and the Graduate Program, Federal University of Rio Grande do Norte. Coordinator of the Psychology and Health Study Group. Natal, RN, Brazil. [e-mail]

^{Correspondence addressed}

ABSTRACT

The objective of this study is to evaluate the capacity of resilience, self-esteem and social support among the elderly by means of an exploratory study. The convenience sample consisted of elderly users of the public healthcare network in Natal-RN, Brazil, who answered the questionnaire and the Resilience, Self-Esteem and Social Support Scales. Participants were 65 seniors, with a mean age of 71 years, 81% female, with poor socio-economic conditions. It was found that the elderly participants have resilient characteristics, positive self-esteem and social support perceived as satisfactory, despite their losses and decline due to aging. Furthermore, moderate and positive correlations were observed between resilience and self-esteem, because as one increased, the other also increased. Therefore, it appears that resilience, considered a resource that assists development, favors staying well through this critical period, as well as the protective factors, which are important health indicators.

Descriptors: Aged; Aging; Resilience, psychological; Health of the elderly

RESUMEN

Se objetiva evaluar la capacidad de resiliencia, autoestima y apoyo social en ancianos mediante estudio exploratorio con muestra por conveniencia constituida por ancianos, pacientes de la red pública de salud del municipio de Natal/RN-Brasil, los cuales respondieron al cuestionario y a las Escalas de Resiliencia, Autoestima y Apoyo Social. Participaron 65 ancianos, edad promedio 71 años, 81% de sexo femenino, con baja condición socioeconómica. Se identificó que los ancianos presentan características resilientes, autoestima positiva y apoyo social percibido como satisfactorio, aún ante las pérdidas y declinaciones experimentadas en la vejez. Además de eso, se verificaron correlaciones moderadas y positivas entre resiliencia y autoestima, ya que en la medida en que una aumenta, la otra también se eleva. De este modo, vivir bien dicho período crítico parece ser favorecido por la resiliencia como recurso favorecedor del desarrollo y por los factores de protección, importantes indicadores de salud.

Descriptores: Anciano; Envejecimiento; Resiliencia psicológica; Salud del anciano

INTRODUCTION

Based on the understanding of resilience as the human capacity to adapt and change situations of risk and vulnerability into strengths, the objective of this article is to evince the importance of understanding how some aged individuals, in spite of all the disadvantages of old age, are able to access and live well in the stage of development, minimizing the effects from the pain and losses that are accumulated through life.

In this perspective, the study sought to evaluate the capacity to resilience, self-esteem and social support among the elderly subjects, and verify the effects of these protection factors in their process of aging.

LITERATURE REVIEW

Resilience is a concept with growing reference in both national and international scientific literature. It is understood as the human capacity to deal with adversities, permitting the individual to be changed by these potentially stressing factors, thus adjusting or overcoming these traumatic/stressing experiences. Resilience is discussed not only as an innate or acquired attribute, but as an interactive and multifactorial process that involves personal aspects, the environment, the number and quality of life events, and the presence of protection factors⁽¹⁾.

Protection factors consist of characteristics with the potential to promote resilience, as they can minimize the eventual negative or dysfunctional effects in the presence of risk, besides being able to modify, improve, or change one's response in view of any given danger. Therefore, protection factors do not, necessarily, eliminate risks; rather, they encourage individuals to overcome those risks, working as mediators and protectors against adversity^(1-2).

When resilience is considered to be a capacity to develop normally under difficult or risk situations, and that everybody, at a higher or lower degree, will eventually face some of these conditions in life, resilience and the interaction between risk and protection factors may be integrated throughout life, in adulthood and old age⁽²⁾.

The study of this construct among the elderly gained relevance with the growing concern with population aging. This occurs due to the increased life expectations, which, according to the World Health Organization (WHO) will be of 73 years in 2025. The same will occur in Brazil, where the life expectation will increase from 67 to 74 years in 2025, i.e. causing a two-fold increase in the number of aged individuals in the country, which today corresponds to 18 million people⁽³⁾.

Regarding aging, uncountable definitions exist to characterize this process of human development. Most concepts refer to the multiple determination of this process, marked by changes to one's physical, social, biological, and psychological aspects, as well as to their political, cultural, and economical dimensions. In this setting, old age is considered a stage in life often seen as a period of stagnation and end of life, one of decline and losses, despair, and fear of death, without any possibility of development, participation and involvement in the many contexts of life⁽⁴⁾.

Human aging, therefore, is a process of the evolutional cycle that can pose risks to one's psychological wellness and quality of life, as it involves significant losses for the individual who is aging. All the changes that the elderly experience can result in negative feelings, such as abandonment, uselessness, lack of autonomy, and loss of control over the environment and one's self⁽⁴⁾. However, as many biological, social, psychological, cultural and economical factors affect the process of human aging, it should be observed that different aspects work in the life of the elderly with the purpose to protect them from risk situations and/or adverse conditions, and mobilize them towards adapting and/or overcoming these experiences, and teaching them new things and compensate for possible losses⁽¹⁾.

It is realized that, despite the existence of threats and risks inherent to old age, some elderly individuals can develop normally and avoid the occurrence of several pathologies, without any complications or sequels that could hinder their independence and autonomy. Therefore, after overcoming a risk situation, the elderly assume an active role in their treatment and become involved in preventing chronic situations and their symptoms. This becomes possible by reverting the losses associated to age. To do this, this population use resources such as the capacity to resilience, self-esteem, support and care from the family, health teams and community institutions⁽⁵⁾. Therefore, through these resources, the elderly have the possibility to cope with the adversities that mark this phase of development, achieving successful outcomes throughout the process of aging.

METHOD

This exploratory study was performed with the objective to evaluate resilience in aging in a convenience sample consisting of 65 elderly users of the Primary Healthcare Network in the East Health District of Natal/RN, Brazil.

To do this, a structured questionnaire was used, which contained sociodemographic questions, as well as a Resilience Scale⁽⁶⁾, adapted for the Portuguese Language⁽¹⁾. This scale is one of the few instruments used to measure levels of positive psychological adaptation in view of important life events⁽¹⁾, considering it comprises the main characteristics of resilience, is easy to administer and understand, regardless of the age and education level. It includes 25 items described in a positive way, with likert answers ranging from 1 (not at all characteristic) to 7 (totally characteristic). Scale scores range between 25 to 175 points, with high values indicating high resilience.

The Social Support Scale adapted to the Portuguese language⁽⁷⁾ was used as an aide to investigate the protection factors. This scale permit to investigate social support and its associations with outcomes related to the health of a population group in Brazil, by evaluating five social support dimensions: material (supply of practical resources and material aides); emotional (support that involves trust, listening, sharing concerns/fears and understanding one's problems), information (receiving suggestions, good advice, information, and desired counseling), affective (demonstrations of love and affection, hugging and loving) and positive social interaction (having fun together, relaxing, doing pleasant things and unwinding)⁽⁷⁾. In this scale, high scores are associated with a satisfactory social support.

Another protection factor was studied with the Self-Esteem Scale⁽⁸⁾, adapted for the Portuguese language⁽⁹⁾. The referred scale comprises 10 items designed for a global evaluation of one's positive and negative attitude towards oneself. In this scale, high scores are associated to high self-esteem.

The participants were individuals with 60 years of age or older, with preserved mental functions, oriented in time and space, besides being able to express themselves orally, and agreeing to answer the research protocols. Those whose mental state was compromised or who did not agree with the proposed procedures were not included or were later excluded from the study. The evaluation of the subjects' time and space orientation was performed using the Mini Mental State Test⁽¹⁰⁾. The study was reviewed and approved by the Research Ethics Committee at Federal University of Rio Grande do Norte (CEP-UFRN), under protocol number 022/06, and all ethical recommendations established by the National Health Council Resolution 196/96 were followed. All elderly subjects answered the protocols though individual structured interviews, in one single meeting.

Considering the importance to complement the obtained information, the scales were corrected according to their specific instructions and scores, together with the data from the questionnaire, and were organized and analyzed using Statistical Package for the Social Sciences (SPSS) 12.0. Data analysis was performed using descriptive analysis and Pearson's correlation test, which measures the degree of correlation (and the direction of that correlation – whether it is positive or negative) among two variables from the metric scale (intervals or ratios). In addition, in order to determine the reliability of the results obtained in the scale, we chose to verify the Cronbach's Alpha Coefficient, according to the proposal of George and Mallery⁽¹¹⁾, which has the following heuristic rule to validate the alpha coefficient: α > 0.9 is excellent, α > 0.8 is good, α > 0.7 is acceptable, α > 0.6 is questionable, α > 0.5 is poor, α < 0.5 is unacceptable.

RESULTS

It was observed that 83% (N=54) are female, with an average age of 71 years (SD=7). In the sample, 40% (N=26) are widowed and 66% (N=43) have up to five years of education (Table 1). Regarding the family income, 80% (N=52) receive between one and three minimum salaries, from their retirement or pensions, which supports an average of 3.8 people (SD=2.1) living in their homes (Table 1).

Regarding the activities performed by the elderly participants, 83% (N=54) performed domestic activities on a daily basis, 57% (N=37) have a leisure activity, 91% (N=59) enjoy entertainment activities such as watching TV and listening to the radio, 83% (N=54) attend religious activities, 83% (N=54) do not participate in educational activities and 51% (N=33) do not practice sports. Regarding to how the elderly participants evaluate their relationships, most reported having good interpersonal relationships (Table 2).

By correcting the resilience scale, it was verified that the average score indicated a high resilience score (Figure 1). Regarding the results obtained with the self-esteem scale, the average score also indicated a high score (Figure 2).

Regarding the social support scale applied in this study, the results are presented by dimensions, and each is evaluated by final scores ranging between 0 and 100. Therefore, in the perceived social support material dimension, the average score was 90.85±14.65; while in the affective dimension, the average score was 93.95±13.18; the average score in the emotional dimension was 80.62±20.00; in the information dimension, 79.85±21.97; and in positive social interaction, 82.62±20.00.

The correlation between resilience and the studied protection factors showed, through Pearson's correlation, a moderate, positive correlation between the self-esteem and resilience scores (r=0.410). No significant correlation was found resilience and social support variables. However, between the social support dimensions, moderate positive correlations were found between the information and the emotional social support dimensions (r=0.640), between the affective social support and positive social interaction dimensions (r=0.595), and between the positive social interaction and emotional social support dimensions (r=0.546).

Through Cronbach's Alpha Coefficient of Variation, it was observed that the Resilience Scale presented α = 0.7360, considering that the in the Social Support Scale α = 0.7930 and in the Self-Esteem Scale, α = 0.7416. These coefficients indicate that the reliability of the obtained results is considered acceptable.

DISCUSSION

The present study sample was comprised mainly by women, which confirms the tendency reported in other Brazilian studies^(12-13). This predominance reflects the greater longevity of women compared to men – a phenomenon that has been attributed to a smaller exposure to certain risk factors, a smaller prevalence of tobacco and alcohol use, differences regarding personal attitudes towards diseases and incapacities, and a more extensive coverage by obstetrics-gynecology care⁽¹³⁾.

The average age found in the present study is somewhat above the age group most commonly observed in Brazilian studies⁽¹²⁾, although it is an average that characterized the elderly referred to as younger, that is, those younger than 80 years. These so-called younger elderly present a high plasticity of what does not happen with the elderly referred to as very old, that is, those of ages between 80-85 years or more, whose capacity of adapting is gradually reduced⁽¹³⁾.

In terms of the low education level found in the present study, it is justified by the restriction of Education exclusively for the small Brazilian elite. Education is considered a protection factor associated with psychological well-being, considering that more years of study mean more competencies to achieve satisfaction in life and a balance of emotions ⁽¹⁴⁾. The few years of study among the elderly also affect the low socio-economical level found in the present study, considering the income of the elderly are mostly from pensions, retirements, of government benefits, which is in agreement with other studies^(13,15).

Almost all present study subjects live in multi-generation homes, characteristic of the outskirt areas in Latin America, of all regions in Brazil⁽¹³⁾ and of the studied health district, which is a region with a low family income. These authors believe that living with two or more generations may represent a necessary survival arrangement for the children and grandchildren of these aged individuals. Furthermore, the more people living in the same house, the more affectivity and help these elderly receive⁽¹⁷⁾.

It is observed that the elderly evaluate their relationships with their children, grandchildren, and friends as positive. Therefore, it is evidenced that the elderly do not isolate from people. In fact, they comprise a positive and diversified network of relationships strongly associated with positive outcomes for the elderly, such as certain health measures and the coping with changes due to the process of aging⁽¹⁷⁾.

It appears that the elderly make good use of their time by engaging in several activities, with special emphasis on entertainment activities, that help them fill up the free time, as well as in domestic activities, most common among women, and religious activities as a refuge from losses and health problems. The presence of younger elderly in the sample probably favors this involvement in varied and social activities, just as the women's involvement in domestic activities appears to have been influenced by what the local culture defines as more appropriate and acceptable⁽¹⁵⁾. The small involvement in leisure activities can be related to the lower education and socio-economical levels of the sample, which accessibility to the current social interactions for leisure more difficult⁽¹⁷⁾. The involvement with religiosity at an old age often corresponds to an effective coping strategy and the Church emerges, in this context, as a strong element in the social support network for the elderly, either by promoting the faith or by offering a chance to building new positive relationships with the other users of this Institution.

By evaluating the resilience in this population, it was found that these individuals are facing old age with resilience, which is in agreement with the idea that the elderly have a great capacity for resilience, and, in view of their losses, they tend to organize their environment in a way that maximizes the positive and minimizes the negative effects. Considering the possibilities of development at old age, resilience can make the elderly assume a positive attitude when facing a difficult situation, challenges and demands inherent to the process of aging⁽¹⁸⁾.

It appears that self-esteem has improved this potential referred to as resilience in the elderly, considering that is appeared as favoring the present study results and may have worked as a useful psychological process of the elderly. In this sense, a satisfactory self-esteem corresponds to a protective factor that helps cope with the adaptive challenges at old age, and is also strongly related to health, well being, and happiness, which helps to reduce the negative effects of stress and increase longevity⁽¹⁹⁾.

Another studied variable that facilitates this coping process as well as the adaptive capacity id social support, which, in average terms, the elderly subjects consider adequate in all the studied dimensions. Some authors^(16-17) believe that the elderly who have a more developed social network and with more psychological and social resources use adaptation strategies that are richer and healthier for their development, besides being able to neutralize the effects from the disadvantages of old age and maintain their quality of life, self-conceptions and personal adjustment satisfactory. The studied factors also relate to the social support available for the elderly and perceived in this sample, which include: positive relationship with friends and relatives, participating in groups, multi-generation homes, being married or widowed, and having children⁽¹⁷⁾.

Regarding the resilience and self-esteem, a positive correlation was found between them, considering that, when one increases, the other does too. Therefore, it was realized that, although the elderly from the sample were in a development moment marked by adversities, they appear to be adapting well to all the changes inherent to the aging process. This fact might indicate that a satisfactory development is not related only to age, but to multifactorial aspects, which include coping with and accepting one's life condition^(20-21).

Therefore, self-esteem is an important protective factor for the development of the elderly, as it is related to health and psychological well being, and associated with other elements such as social support, self-efficacy and autonomy, with will affect the way the elderly will experience their old age^(19,22). Thus, although this stage in life involves significant changes, it is also a stage of development, with positive perspectives in the course of the elderly^(18,21-22).

CONCLUSION

Resilience and the protective factors found in the present study promote a healthy experience of this stage of development marked by losses and gains, as it is observed, through the present study results, that the elderly subjects were able to overcome the adversities that emerged in their lives until this moment, because resilience is form of survival related to integrity, adaptability and tenacity, particularly when favored by protective elements such as self-esteem and social support also present in this sample. Therefore, based on the data presented herein, among other aspects, it is observed that resilience does not depend on some variables, which suggests that resilience does not depend on personal traits and dispositions, nor does it appear only for overcoming predetermined risk factors. Resilience, in this sense, corresponds to a normative adaptation process, present in humans and applicable to development in both favorable and adverse environments. This capacity for a healthy and positive development pertains, therefore, to all living beings. In this perspective, it becomes essential to create attitudes that help develop resilience, including strategies that promote self-esteem, considering it is a construct that, in this sense, is associated to resilience and represents an important indicator of mental health and in the social development analyses. This way, it becomes possible to improve social and individual well being, which is highly desired for the elderly in this period of development and adaptation.

Therefore, it is verified there is a need to understand old age as a period of life that deserves attention from health care professionals, policies and services. This way, it is possible to promote the so-called successful aging, which includes the development for programs for the elderly that aim at maintaining their functional capacities, and, thus, improve their self-esteem and, consequently, their quality of life. These programs should have an interdisciplinary character and be founded on the implementation of alternatives for the elderly to participate and live with other generations, offering them the necessary skills to deal with daily demands and favoring mechanisms that promote a healthy development.

One limitation of this study is the fact that it has a cross-sectional design, representing an excerpt of the studied sample, and, eventually it was also not possible to establish other significant relationships, such as between resilience and the sociodemographic variables, and between the latter and self-esteem and social support. However, we expect that the information provided in this study contributes to improve the current knowledge about resilience in human aging, and that the results can serve as a reference for further studies, helping health professionals and the community in terms of care for the elderly.

Acknowledgements

The authors thank the Coordination for the Improvement of Higher Education Personnel (CAPES) for the fellowship (master degree) established with the first author. We also thank the students of the scientific initiation program from the Psychology and Health Study Group of the Psychology Department, Federal University of Rio Grande do Norte.

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Correspondence addressed to:

Eulália Maria Chaves Maia

Rua Seridó, 754 - Apto. 902 – Petrópolis

CEP 59020-010 – Natal, RN, Brasil

*

Extracted from the from the study "Resiliência e velhice: a influência de fatores de risco e de proteção no processo de envelhecimento", Federal University of Rio Grande do Norte, 2008.

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Apr 2012

History

• Received
  18 Feb 2010
• Accepted
  27 Sept 2011