The coexistence center for elderly people and its importance in the support to the family and the Health Care Network

Objective: To know the perception of relatives of elderly people about the coexistence center and its importance in supporting the Health Care Network. Methodology: A qualitative study carried out with 14 relatives of elderly people participating in a coexistence center. Data collection took place in January 2016 through individual interviews, which were recorded, transcribed and submitted to content analysis. The results were discussed in the light of the theoretical referential of health promotion. Results: The elderly's participation in the coexistence center was an alternative to support care and institutionalization, provided time for self-care and to maintain or engage in the formal labor market and positively influenced the family relationships. Conclusion: The coexistence center was set up as a health promotion institution, being jointly responsible for the care of the elderly with the Health Care Network and the families.


INTRODUCTION
The demographic aging represents opportunities and challenges, at the same time.While some of the elderly continue to carry out daily, social and work activities, despite their particularities, others represent great demands on social and health services due to the chronic-degenerative diseases and their consequences in the maintenance of autonomy and independence. 1,2n the context of greater fragility, more costs and less financial and social resources demand the search for a specifically structured care provision to the elderly, 3 since the provision of care by the family has become increasingly difficult in view of the major changes in the structure of homes.The new conformations of family groups, the internal and external migrations of young generations and the entry of women into the labor market, who in many cultures are responsible for the care of older people, have reduced the family's ability to provide full-time informal care to the elderly. 1 Relatives, sometimes without an alternative due to the few options of services that provide care to the elderly, become caregivers and with the demands of daily life, change their lifestyle and stop performing formal, daily and leisure activities. 4The complexity of this situation highlights the need to reduce health risks related to its determinants and constraints.In order to do so, actions are required that guarantee people the opportunity to make health-promoting choices, extrapolating the performance of a single sector, and imposing as necessary the intersectoral actions, whose purpose is the co-responsibility for the promotion of the health of individuals and populations. 5rom this perspective, a study that proposes a Brazilian model of integrated care for the elderly and describes the coexistence center as a care level directed, mainly, to the health promotion of the elderly. 3This service is linked to the Social Protection Network and is intended for the daytime stay of people aged 60 or over, developing for this group physical, work, recreational, cultural and education activities for citizenship. 6he coexistence center is an alternative to support care and acts in a way to reduce the overload of the elderly's family, 7 but little is known about the repercussions of the service in the scope of health promotion for this group and the support to the Health Care Network (HCN).Publications on the influence of social care services on the elderly and their families are incipient in developing countries, 8 with inconsistent current knowledge and, therefore, in need of expansion. 9,10iven this context and considering that day care services for the elderly are a strategic action in relation to the strengthening of the network of services to support the families that have elderly in their homes, 6 it is asked: What repercussions occur in the life of the relatives after the elderly joins the community center?The objective of the study was to know the perception of the elderly people's family about the importance of the coexistence center on family support and on the Health Care Network (HCN).

METHOD
A qualitative study developed with 14 relatives of elderly people who participate in a coexistence center in a city in the interior of the state of Paraná, Brazil.
The institution is a service of the Social Protection Network, of philanthropic character, maintained through donations of the community and resources derived from charitable actions carried out by it.It has capacity for the care of 20 individuals.Admission to the service can be done by request of the family, social care or by judicial means.For that to happen, a screening is done, consisting of a home visit by the Social Worker of the service to the elderly's residence, in which the financial situation, family relations, housing conditions and the ability of the elderly to perform basic activities of daily living are analyzed.Elderly people who are more socially vulnerable and independent to perform basic activities of daily living are the target audience for the service.
Although the elderly assisted by the service are not dependent on the basic activities of daily living (bathing, dressing, going to the toilet, transfering, continence and feeding), most of them are dependent on instrumental activities (cleaning the house, taking care of clothes, making food, using household equipment, shopping, using private or public transportation, controlling medication and finances) and mild to moderate cognitive impairment.
The data collection took place through semi-structured interviews in January 2016.The subjects were selected for convenience and the inclusion criteria were: being the relative of an elderly who attends the coexistence center for at least three months and who lived with the elderly for at least six months.
The interviews were conducted by two master degree student nurses with experience in qualitative research and members of a research group on aging, linked to a university in Paraná.Initially, telephone contact was established and the previous invitations to participate in the study were made, and after the verbal acceptance, the interview was scheduled at a place and date of preference of the relatives.There was no refusal to participate in the research.
At the scheduled encounter, the participants were given explanations about the research and its objectives, its voluntary nature, and the need to record the interviews.Four interviews took place at the participants' residences and the others at the coexistence center.These were recorded in digital media and had an average duration of 20 minutes, with each family member being interviewed only once.
The guiding question was: "Tell me what has changed in your life after the elderly person joined the coexistence center".The search for new informants was concluded when the collected material allowed reaching the objective of the study, according to the evaluation of the researchers.
The interviews were transcribed in full and then revised in relation to the spelling, without the essence being modified.After that, the information was submitted to the content analysis technique in the thematic modality, which consists of the steps of Coexistence center for the elderly people's family Derhun FM, Scolari GAS, Castro VC, Salci MA, Baldissera VDA, Carreira L pre-analysis, material exploration, data processing and inference of the results. 11n the pre-analysis the floating reading of the printed interviews was carried out, highlighting the points of interest, followed by the exploration of the material with the thorough and exhaustive reading of all the content.Afterwards, the coding of the messages was performed, through which the meaning nuclei were apprehended and grouped, leading to the thematic categories.After the categorization was completed, the inference was made from the data obtained. 11n order to better understand the repercussions on the life of the family member resulting from the elderly's participation in the coexistence center, the findings of this study were discussed in the light of the Health Promotion referential. 5This is based on the concept that health promotion is a set of strategies and ways of producing health through the intersectoral articulation between the care networks.
The study was developed in accordance with the current ethical legislation and the research project approved by the Ethics Committee of the State University of Maringá -PR, under opinion No. 1,349,694/2015.Everyone was clarified about the research and signed the Free and Informed Consent Term (FICT) in two copies.The subjects were identified with the letter "F", referring to the term "Family Member", followed by Arabic numerals, according to the order of the interviews.

RESULTS
The participants of the study were 14 relatives of elderly people attending the coexistence center.The characterization of these, as to the sex, age, relationship with the elderly, occupation and income, as well as the time that the elderly person is attending the service, is listed in Table 1.
From the participants' answers, it was possible to know the repercussions in the life of the family coming from the participation of the elderly in the coexistence center of and the importance of this service in the support to the HCN.These have been grouped into three categories: 'The coexistence center as an alternative to support care and institutionalization', 'A time for yourself: the elderly's relative and self-care' and 'Positive influences on the family relationship'.

The coexistence center as an alternative to support care and institutionalization
The professionals of the different care points of the HCN, with knowledge of the importance of the action of other sectors to provide care to the health of the people, in identifying the situation of vulnerability of the families, indicated and/or referred the elderly to the coexistence center.

The health clinic referred me here. I called and explained the situation (financial difficulty) that was happening because of the need to stay home with him. They scheduled an interview at home and then called him to an adaptation time (F-5).
The neurologist suggested that we should look for a place to leave him, for our peace of mind and his safety (F-6).
The insertion of the elderly in the coexistence center brought greater integration between the HCN and the Social Protection Network, with an exchange of information about the care provided to the elderly and, sometimes, their family.In addition, the partnership between the different sectors and care points made them both co-responsible for the health of the elderly and their families.
Prior to meeting the coexistence center, the relatives linked its role to the Long-term Care for the Elderly Institution (ILPI -"Instituição de Longa Permanência para Idosos", in Portuguese) activities, and for this reason, initially, the majority was afraid to enroll the elderly in this institution.The contact with the service allowed the assigned meanings to be modified new conceptions to be constructed.It was understood that the coexistence center offers physical, recreational and cultural activities, among others, and is intended for the daytime stay of the elderly.

At first, we thought it would not be appropriate to put the father in such a place (nursing home). So we came to see it (F-9).
The performance of the coexistence center offered support to the family in the care of the elderly during the period in which they remained in the service.It was allowed to maintain the affectionate and relational bonds coming from the familiar coexistence, since at the end of the day the elderly returns to their residence.For some family members, especially those who were of productive age, the insertion of the elderly in the coexistence center was an alternative to the institutionalization in long-stay services, since the day's stay in the institution reduced the care overload.

My family said that when I could no longer take care of my uncle I should put him in a nursing home. But while he is here (coexistence center) we can handle [...]. In the nursing home, the contact with the family is lost and it is bad for him and for us. Here he comes in the morning and comes back in the afternoon and is not alone, without a company (F-5).
The coexistence center, while meeting the basic needs of the elderly during the day, provided support to the family in the care of their beloved one, including sharing responsibilities, which Coexistence center for the elderly people's family Derhun FM, Scolari GAS, Castro VC, Salci MA, Baldissera VDA, Carreira L motivated them to continue the care at home.In addition, the service provided support to the HCN so that, integrated, they could meet the needs of the elderly and their families.

A time for yourself: the elderly's relative and selfcare
The fact that the elderly were included in a day care service reduced the overload and generated greater availability of time for caregivers.For the retired relatives, especially the spouses, the participation of the elderly in the coexistence center provided and/or increased the rest time.

It is the only time I have, it is the time he is in the coexistence center. It is the time that I have to rest [...]. For me, the overload was reduced, it was very good, because it is not the whole day that he has to spend with me (F-6).
With the participation of the elderly in the service, the family members were able to devote more time to their personal needs and to carry out pleasant activities, such as social, intellectual and leisure activities.They could also focus on domestic, health and financial issues.With this, they were able to exercise greater control over their own lives and chose trajectories appropriate to their socioeconomic cultural condition to modify their behaviors and to see health improvement.

Now it is good, when I need to go to the grocery shop or pay the bills, I do not have to worry about him, I do not go out worried and I do not have to leave so fast (F-3). Now I have more time for my things and I even walk (F-6).
In the face of the needs of the elderly, the person responsible for the care provision had difficulty maintaining an occupation due to the need to remain with their beloved ones.The care provided by the coexistence center was an opportunity for family members of productive age to start or continue to engage in paid work.

He was staying with my kids and me, I was already agonized, because I wanted to get my life out there and work, but at the same time I could not leave him alone (F-5).
We would consider that someone from home should stop working to take care of him, but we cannot afford it.The thing is, we have to work, it is not an option.The coexistence center was a real blessing (F-7).
Family members who, due to financial needs, were divided between work and informal care for the elderly perceived positive influences in their routine.Often, faced with the need to maintain Coexistence center for the elderly people's family Derhun FM, Scolari GAS, Castro VC, Salci MA, Baldissera VDA, Carreira L a paid occupation, the family member, with little or no alternative, would let the elderly alone at home, which would bring insecurities and the frequent need to move away from work to remain with their beloved one.This would bring labor conflicts, which were minimized with the insertion of the elderly in the service.
Currently we can work because we know he is safe.Before we went to work without peace, worried about what could happen, with him alone inside the house, with the news that we could be receiving.So, it brought peace, peace in our daily life (F-10).

I have more motivation at work now. When he was at home it was bad for me, because I would be worried and did not know if I should work or stay with him. I would get messed up with my service and now that he does not have to be alone with me during the day, things are better (F-12).
Prior to the joining of the elderly to the coexistence center, the family members had reduced opportunities to perform various activities, such as work, domestic, physical, social, intellectual and leisure activities.The inclusion of the elderly in the service has modified this context by reducing the overload of care and by allowing them to use the time available to improve their lifestyle and to enter and/or maintain a formal employment.

Stress reduction and positive influences on family relationships
The family member was often involved in formal and domestic work activities and the responsibility of caring for their beloved ones.This situation generated overload and added to the negative attitudes of the one being cared for, causing wear and friction in the relationship between caregiver and elderly.

My mother was very much at home, doing nothing. She wanted everything ready and could only ask. I was getting annoyed and started talking things I should not, but I was at my limit (F-2).
The coexistence center was an initiative that promoted the mental well-being of family members by generating satisfactory and pleasant living conditions.This has repercussions in the context of the family relationship and the care provided to the elderly at home has become a positive experience and source of well-being.

Even our love for our father increased. Now that he has less time to stay at home, we end up giving him more attention (F-9).
The elderly care was almost always centered on only one family member, who was deprived of labor and leisure activities.This, with the feeling of ambivalence about wanting to remain full-time with the elderly and the impossibility of dedicating themselves fully to this activity, due to the financial condition, among others, would impose the need to share the task with other family members, who did not always have the pretension or time to help.This situation would generate conflicts in the family, which was reduced when the elderly began to attend the coexistence center.

When there was no kindergarten, it was a discussion among the family. No one wanted the responsibility of staying with him all day. My sisters would say: 'I do not have time, I cannot help'. For me it was a big load, a rush and now it has improved on that part (F-12).
It was noticed that the elderly's enrollment into the coexistence center gave the family members several opportunities that reduced the overload and, consequently, the stress.And this positively influenced the relationships between the family and the elderly and the mental health of caregivers.

DISCUSSION
Health promotion actions must take place through intersectoriality so that they can effectively reduce vulnerabilities and health risks arising from social, economic, political and cultural determinants.In addition, the identification of differences in people's conditions and life chances are necessary actions in order to allocate efforts for the equitable distribution of social assets, so that the most disadvantaged ones also have a chance to improve their lives. 5Possibly, from this perspective, the HCN professionals when identify the situation of vulnerability of the families, refer the elderly to the coexistence center.
The health conditions of individuals and collectivities are determined socially and, therefore, cannot be dissociated from their ways, conditions and lifestyles, which are often guaranteed through public policies. 12In this sense, it was noticed that the integration between the HCN and the Social Protection Network promoted the health of the elderly's relatives when acting on the social determinants of health, especially those related to modes and lifestyles.
In addition, the support offered by day care centers for the elderly motivates family caregivers to continue home care, 6 especially due to the perception of these in relation to the sharing of responsibilities and to the improvement of the health status and quality of life of the elderly, as of the enrollment in this type of service. 7This, surely, has an influence on the rates of institutionalization, which are smaller when the family has support for Coexistence center for the elderly people's family Derhun FM, Scolari GAS, Castro VC, Salci MA, Baldissera VDA, Carreira L the care of the elderly. 13,14armony in the family relationship is crucial for the caregiver to perform. 15However, the caregiver's overload and the negative attitudes of the elderly provide a frailty in such a relationship, which makes care an exhausting activity and the person minimizes efforts to achieve it. 15,16When inserting the elderly in a coexistence center that offers physical, cognitive and social activities, among others, that positively impact the behavioral problems of the elderly 10 the repercussions extend to the caregiver in reducing the occurrence of negative affective reactions in relation to the person being cared for 17 and helps the person to have more energy and patience to deal with relational challenges. 6esearch reaffirms the above, suggesting that there is a decrease in stressors related to elderly care when the family member receives support from day care services for the elderly. 18he caregiver's level of stress is influenced by the time that the elderly person remains in the service 10 , having this, significantly lower levels of cortisol in the days in which it is assisted by the care center, when compared to the days that the person remains at home. 18n this study, the interviewees showed that with the inclusion of the elderly in service they had more opportunities to dedicate themselves to their health; however, they were not emphatic regarding the repercussions on physical health.In this sense, the literature shows that family caregivers of older people who had more days of rest, that is, that left the elderly more time in the service, were less likely to have functional health damages compared to those who used the service for a shorter period. 19esearch with 23,815 elderly Brazilians showed that 30% of them have difficulty performing one or more activities of daily living.Among those with functional limitations, 81.2% reported needing help to carry out activities and a majority (81.8%) received only informal help.Of the elderly who reported receiving help, 62% received it from a non-paid family member living in the same household and 35.8% from an unpaid family member living in another household. 20n addition, another study has inferred that in developing countries the need for elderly people to be helped with daily life activities will increase further due to the expansion of morbidities caused by lifestyle-related risk factors. 21These data give the dimension of the challenge to be faced by the Brazilian society to guarantee care for the elderly with functional limitations.Against this background, as a way of guiding which actions can be taken in the different scenarios, the World Aging and Health Report points out that all nations, regardless of the resources they have, should and can implement interventions that promote or maintain the functional capacity of the elderly. 22o that end, the focus should be on developing a system that helps elderly to age, be caring and still maintain ties with their community. 22In this sense, day care centers have shown that they respond to the needs of the population with resolution, cost-effectiveness and results in improving the functionality of the elderly, well-being and quality of life for them and their families. 23ven in Brazil, the high financial and social costs of institutionali-zation services show that they do not compensate, and this has given weight to the care initiatives in which the elderly remain in the community. 24espite this, in Brazil, even with the Federal Constitution, the National Policy on the Elderly and the Statute of the Elderly, describing that it is the responsibility of the family and the State to support the elderly in order to defend their dignity and well--being, is incipient when compared to that of families.These, for the most part, provide care for the elderly alone, which is due to the difficulty of access to services, which are insufficient to care for the population. 24t is important to emphasize that the care responsibility of the elderly left entirely to the family is no longer sustainable.This does not mean that care is the sole responsibility of the State.A relationship must be established in families, communities and the State so that care is shared.Therefore, long-term care expenditures for the elderly should be seen as investments, as they not only benefit the elderly, they also influence caregivers who are informally engaged with them so that they can enter or remain in the formal labor market , increasing the productive workforce of the country 22 and have, in the long-term access, no difficulties in accessing their retirement. 1he Ministry of Health directs that for the implementation of a comprehensive care line for the elderly, there is a need for intersectoral articulation, since the health sector is only one aspect of care.When considering the capillarity and similarity in the organization of the Unified Health System (SUS -"Sistema Único de Saúde", in Portuguese) and the Unified Social Care System (SUAS -"Sistema Único de Assistência Social", in Portuguese) that are in decentralized services in the territories and in particular through the convergence of the Social Care Policy (SUAS) and the National Policy on the Health of the Elderly (SUS), there is possibility for intersectoral articulation, 12 which are resolute and sustainable to produce health not only for the elderly, but also for their families.

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE
The study allowed knowing the repercussions in the life of the family coming from the participation of the elderly in a coexistence center.The service was set up as a health promotion institution by being jointly responsible for the care of the elderly with the HCN and the families.It provided family caregivers with time to care for themselves and to maintain or engage in the formal labor market and positively influenced family relationships.In particular, it influenced the social determinants of family health related to the opportunity of formal work, income and lifestyle.
This research contributes to the construction of scientific knowledge in the gerontogeriatric area by demonstrating the coexistence center as an option to care for the elderly and that provides positive repercussions in the daily life of the family.For health professionals, especially for Nursing, which works in various sectors and levels of care, whether in assistance, Coexistence center for the elderly people's family Derhun FM, Scolari GAS, Castro VC, Salci MA, Baldissera VDA, Carreira L management, research or teaching, this study contributes to the understanding of the intersectorality between health and social care, as to promote the health of family members who care for the elderly.
The limitations are related to the scope of the study, since it was performed in a single service, of one city, but this does not invalidate the importance of the results found.It should be highlighted the value of this study for management with a view to encouraging the expansion of the 'coexistence center' and include them in care networks to the elderly, when these are consolidated.This study motivates and challenges the elaboration of new researches for the thematic deepening.In addition, it should be investigated the quality of life with different family members that live with elderly people who attend the coexistence center.

Table 1 .
Sociodemographic characteristics of elderly people's relatives who attend a coexistence center and length of stay of the elderly in the service, Brazil, 2016.
* In minimum wages.