The aging process and health: what middle-aged people think of the issue

Objective: To understand the perception of middle-aged adults regarding health and the aging process. Method: A qualitative study involving 30 adults aged 45 to 59 years old, 15 of whom were female and 15 of whom were male, who answered open questions about their perception of health and aging. Data was analyzed using the thematic content analysis technique. Results: Almost half of the respondents had not finished elementary school and only three had a university degree. A total of 27 were married, five were retired and 25 worked in the service provider sector, 26 were Caucasian, and 27 belonged Palavras-chave: Saúde; Envelhecimento; Meia Idade. http://dx.doi.org/10.1590/1809-9823.2016.14122


INTRODUCTION
The repercussions of the aging process on our society are considerable, particularly in the health sector.With increasing longevity, people now want to live longer with better health and a better quality of life.This demonstrates the importance of developing public policies that promote independence and a healthy lifestlye. 1,2st countries worldwide are now dealing with an aging population.The aging process does not begin during adulthood.It is a life-long process, although the characteristics of the process only become evident when a person reaches approximately 60 years of age. 3,4udies of perceptions of aging are important in the planning of public policies, given that people's behavior has been correlated with these perceptions and the value they are given. 5ople's perceptions about their health have a signigficant impact on health and the aging process, while also representing a lifestyle predictor.Selfperception is multi-dimensional and is affected by the capacity of an individual to respond to the demands of daily life. 6lf-perceptions about health are understood to be an individual's interpretation of acquired knowledge and life experiences.This is an important index when assessing an individual's health status, since it deals with physical and emotional dimensions and affects their functional capacity. 7It can also be a mortality predictor. 6 assessment of an individual's health perceptions involves both subjective and objective aspects, with the former related to how the individual feels and judges their own life. 8,9A negative perception of one's own health can be caused by pain, discomfort or malaise and has been correlated with social, cultural, psychological and environmental factors.Previous studies 10,11 of health perceptions have indicated that women, the elderly, uneducated people and black people are more likely to refer to their health in a negative manner.Due to the importance of research into self-perceptions, the aim of the present study was to determine the perceptions of middle-aged adults on the aging process and health.

METHODS
This qualitative, descriptive study involved 30 people (15 male and 15 female) aged between 45 and 59 years.The participants were initially selected by a researcher in restaurants, schools and a gym.Thus, the sample was classified as nonprobabilistic.The interviewees were selected based on the indications of people who knew somebody in the relevant age group that fulfilled the inclusion criteria (aged between 45 and 59 years and living in the municipality of Caxias do Sul, Rio Grande do Sul, Brazil).
Caxias do Sul is located in the state of Rio Grande do Sul (RS) in the south of Brazil.It has a total area of 1,643,913 km 2 and a population of approximately 716,421.The population of middleaged residents in the municipality is 80,674 (38,403  men and 42,271 women).In the state of RS, there are 982,739 men and 1,067,672 women, while in Brazil, these totals are 14,429,352 (men) and 15,820,620 (women). 12e first contact with the interviewees was made by telephone.If the individual agreed to do the interview, a date and location was scheduled.Data was collected between May and June of 2013.
A self-administered instrument containing the variables age, gender, skin color (self-perception), education and economic classification was used.The latter was classified as A, B, C, D or E, based on the Associação Brasileira de Empresas de Pesquisa (Brazilian Association of Research Companies) (ABEP) classification. 13The qualitative data was collected using the following open questions: "What does health mean to you?"; "What does a person's health depend on?"; "What do you do to stay healthy?"; "How do you feel about getting old?; Have you noticed signs of aging in your life?"; "What have you done to combat this?"; and "Have you noticed any difficulty in performing your activities due to health reasons?".
The analysis of thematic content method proposed by Minayo 14 was used to analyze the qualitative data.Since the responses to these questions were very similar, they were divided into three goups: health perceptions; the aging process; and self-protection actions.The interviewees were given fictitious names in the presentation of the data.

Characterization of the interviewees
The study sample was composed of 30 adults (15 men and 15 women), aged between 45 and 59 years.Almost half of the interviewees (12) had not completed primary education, whereas three had completed higher level education.Almost all of the participants were married (27), considered themselves white (26) and were classified as socioeconomic class B (27), according to the ABEP economic classification. 13Concerning their careers, five were retired, although of these five, three had begun working again by the time of the interview.The professions of those who worked were varied, although most of them were somehow connected to the provision of services.

Health perceptions
When asked about how they conceptualized health, the interviewees linked health to eating well (21); physical exercise (13); having some type of occupation (10); physical, mental and spiritual wellbeing (9); taking care of oneself (7); family and social life (5); medical care (5); personal hygiene (1); and keeping mentally active (1).Living life to the fullest was also mentioned, as well as the importance of sleeping well (5), leisure time (4) and maintaining contact with nature (2).For the vast majority of the interviewees, health was considered the most important factor for a high quality of life.
When discussing nourishment, Maria explained that "[...] you need to eat healthy things, with less pesticides".She also stated that it is important to drink less soft drinks and more natural fruit juice.Ana stated that if a person eats carefully, they don't need to go to the doctor so much.Rosa said that health is associated with "[...] the things that make up our routine, being careful about what you eat and doing some exercise".Exercise was classified as fundamental by many of the interviewees.Changing one's habits and customs requires patience and care, particularly when these habits are linked to a person's lifestyle.Nutrition and nourishment are factors that affect the quality of life of an individual and provide them with greater longevity. 15,16Physical exercise helps adults to perform better in their jobs and protects them from chronic diseases such as diabetes, obesity, high blood pressure and osteoporosis.Among the middle-aged and elderly, exercise has been strongly correlated with wellbeing, since the body and mind need activity in order to avoid stagnation in these phases of life. 17,18Regular physical activity maintains the function of the muscles, bones and joints.It also maintains blood and hormonal levels within the adequate parameters and stimulates intestinal and immunological equilibrium.People that exercise throughout their lives usually sleep better and are more disposed to perform their daily activities.They are also less likely to suffer from diseases due to a healthier aging process, with better balance, mobility, flexibility and self-esteem. 19,20eling good about oneself is one of the reasons why middle-aged people try to maintain some form of physical activity, which provides them with obvious health benefits and results in an improvement in body satisfaction. 21,22Cultural factors affect people's understanding of the aging process and the development of lifestyles. 23They also influence how society views the elderly population and the aging process. 24ccording to the World Health Organization (WHO), quality of life is defined by people's perceptions of their own lives in terms of culture and the values associated with their goals, standards and worries.This concept has been correlated with environmental, physical and psychological factors, as well as the individual's level of independence, their social relationships and personal beliefs. 25uality of life can be promoted through public health policies.
Concerning medical care, five of the interviewees mentioned the importance of preventive action and continuous self-assessments of their health.João spoke of the need to "[...] look after yourself.We are getting older, so we need to go to the doctor.I have a checkup once a year.If you want good health, you need good medical care".For this participant, it was also importtant to take care of "[...] what we eat and drink".Olívia stated that she was trying to stop using controlled medications for depression and rheumatism.She has tried to replace them with walks, which she never did before.Ana said that in order to have a healthy body, you need a healthy mind, thereby highlighting the significance of the relationship between the mind and body.Physical and emotional wellbeing were considered important health factors.According to José, a healthy mind, with positive thoughts, helps a person to obtain a better quality of life.
Having some sort of occupation (10), whether paid or not, was also deemed necessary for emotional health, given that it improves the individual's disposition.Marta stated that walking, working and keeping the mind and body busy are necessary if you want to stay healthy.
The results of the present study are in agreement with those reported in a qualitative study 26 of 4060 adults and 4003 elderly residents in regions containing 240 basic health units in the south and north-east of Brazil (2005).According to the adults assessed, the most important factors for health were healthy nourishment (33.8%), physical exercise (21.4%) and a healthy lifestyle, in particular, not smoking (13.9%).According to the elderly individuals, the most important factors were healthy nourishment (36.7%), not smoking (17.7%) and regular visits to a doctor (14.2%).This study 26 confirmed that most adults and elderly individuals recognize and recommend careful eating as an essential component of a healthy lifestlye.
In the present study, 56.6% of the middle-aged adults also mentioned careful eating, whereas 46.6% cited physical exercise and 6.6% mentioned not smoking.All of these factors were considered significant to an individual's health.

Self-protection for healthy living
When questioned about what they did to stay healthy, only two of the interviewees claimed to do nothing.Margarete had been advised to perform physical exercise to minimize rheumatic pain, although she said it was very difficult to stay active.Bolivar claimed to be aware of the importance of physical exercise, but was not able to find the time to do any.Olívia stated that she did not worry about aging, preferring not to think about it and to concentrate on her work: "[...] so the years pass and you barely notice that you are getting older".It is notable from these comments that, despite the fact that the respondents recognized that physical exercise is a health protector, this knowledge alone was not enough.It must be put into action, which often requires discipline and courage. 27couraging people to adopt a healthy lifestyle is not always easy, since it involves changing the way they live their lives. 28Promoting a healthy lifestyle is essential as it teaches these people that they can make healthy life choices and do what is required to attain a better quality of life.Thus, it is important that each individual identifies their needs and takes responsibility for their own care. 29,30th the increasing prevalence of nontransmittable chronic diseases that are linked to lifestyle choices and a lack of physical exercise, the Brazilian government has created a number of projects that promote healthy norishment, a healthy lifestyle and physical exercise. 31,32Concerning healthy aging, the WHO has recommended the expansion of access to health services and social services, with a focus on health promotion, the adoption of healthy habits (nourishment and exercise), the avoidance of tobacco and alcohol, and care when self-medicating.It is also necessary to provide a physical environment that prevents accidents and the abuse of elderly individuals, while appreciating their work in informal business, the home and the communities in which they live. 33In order to ensure these determinants, it is important to involve several sectors of society, including those responsible for quality transport, jobs, social justice, housing and safety, among others. 34herefore, there is a need for inter-sector actions, in which health promotion is used as a strategy to overcome the health problems of the population.These projects should involve technical knowhow, traditional knowledge and the mobilization of both public and private resources. 35,36ong the interviewees who actively tried to stay healthy, the vast majority performed physical exercise (gym, swimming and walking) and ate carefully, avoiding overeating, fried foods, sugars and white flour.Serafina stated that as her work routine is quite rigorous and consequently, she has no time to go to a gym.In order to supplement her lack of regular physical exercise, she walks up and down the stairs at home for a period of time.She explained that "[...] it makes me feel better, since I need strong legs in my job".This comment demonstrated her perception of the importance of keeping active for her health and quality of life.
The interviewees mentioned several strategies that could improve their health and quality of life.Antônio said he tried to go to bed early and get up early, believing that this provided him with more vitality.Marcos said that he did not perform physical exercise but he did go to bed early and walk to work.João said that he eats carefully and goes to the doctor regularly to control his health.He also rarely consumes alcohol and when he does, the quantities are small.Carlos claimed to eat carefully, work and try to live life to the fullest, by going out with friends to restaurants and the cinema.He believes that being healthy means feeling good and these activities help increase his wellbeing.
These results are similar to those reported in an earlier study 37 containing 67 people, divided into young adults, middle-aged adults and elderly individuals.The interviewees were found to exhibit the following determinants of illness: a poor diet; alcohol and drug consuption; a lack of concern about their general health; a lack of exercise; not sleeping enough; exposure to the sun or cold temperatures; working too much and social isolation.Another study 38 of middle-aged individuals confirmed that there needs to be some sort of threat to their health for them to adhere to physical exercise programs as a regular part of life.Nevertheless, the interviewees were aware of the benefits these programs would provide.Other studies [39][40][41] have stated that if a person starts to do physical exercise and eat a healthy diet at an earlier age, they will have a greater chance of aging healthily, given that the activities of a healthy lifestyle are already incoprorated into their life.These results confirm the importance of staying active and being able to enjoy the health benefits that this activity provides.

Perceptions about the aging process
The importance of healthy aging was highlighted by six of the interviewees in the present study.The reason this number was so low may have been because the majority of the participants had not yet noticed signs of aging in their lives.However, for people such as Lídia, "[...] if you are going to get old, it has to be with your health.It is good to get old like that.As the years go by, we gain experience".Rita stated that she was very much afraid of aging, getting sick, requiring care and being unable to continue living alone: "[...] I am afraid of being a burden to others".Maria added that "[...] the old become a worry for everybody, dont they?Everybody wants to grow old, but nobody wants to die [...], everybody wants to be able to walk and remain lucid in their old age.If not, they become a burden for their family".
A number of the interviewees said that it was terrible to grow old and realize that you didn't do things that you should have done.They said that it is not good to regret the things that you never did.Sometimes, they worked too hard and became stressed, which affected their sleeping and eating habits.This also affected their health and quality of life.
An earlier study 42 of adults and elderly individuals confirmed that the aging process was noticed by almost all of the interviewees over the course of their lives, which is similar to the results of the present study.The elderly individuals claimed to notice greater physical limitations, whereas adults were more concerned with esthetics and their social lives, although they still confirmed a fear of growing old.The middleaged participants in the present study preferred the strategy of simply not thinking about aging.Some of them worried about esthetic issues, such as spots on their skin and grey hair.Work was considered a great way of staying in touch with other people.However, it is essential that people confront the reality of the aging process so that they can take the required action to achieve healthy aging.Longevity is a common concern in society and is often associated with physical capacity.Improvements in living conditions can increase the elderly population.Although these people want to live longer, they are often in denial about the aging process. 43nce the aging process occurs throughout our lives, its signs are self-perceivable, depending on the age of the individual, and become more obvious with increasing age. 44Aging is dependent on factors such as a person's history and their individual understanding of this process.Often, culture and self-perceptions affect how aging is perceived.Understanding and accepting this process is of great importance if an individual is to experience healthy and independent aging. 45ncerning this denial of aging, Adão (age: 57 years) claimed not to have noticed any changes in his life and did not feel that he was aging.He had worked up until the age of 55 and was currently very active, "[...] like a young boy, I go dancing all night, I go to the gym and I run for 45 minutes".Olívia also claimed not to have noticed any signs of aging and said that she lived her life normally.
However, perceptions about aging are exhibited in different ways.Some people see this period as empty and meaningless, without an occupation or value.Forgetfulness, loss of muscle mass, increased vulnerability and the increased probability of death appear throughout our lives, particularly after 40 or 50 years of age, and were all mentioned by the interviewees.As a result, it is important that people are able to look at themselves and notice the changes that are happening, in order to adapt to this new phase of life. 46,47ing aware of the passing of time is essential to our wellbeing.When we begin to perceive the aging process, issues such as death and finiteness arise more frequently.9][50] Most people do not like to talk or think about the fact that it will all (good and bad) end one day.If a person becomes upset at the thought of the finite nature of life, they are more likely to develop emotional illnesses and consequently, are less lilely to age healthily.Annoyance at the finite nature of life does not decrease an individual's strength or relieve their pain.On the contrary, it amplifies their pain and turns it into suffering.Accepting that everything has a beginning, a middle and an end allows people to enjoy their lives and live them to the fullest. 51e vast majority of people hope to grow old with health, independence and satisfactory living conditions (housing, nourishment, education and work), among others. 52Historical, social, genetic and environmental factors can have positive or negative effects on how we age, as can the manner in which we deal with stress and our level of expoisure to certain pathologies. 53,54A previous study 55 of individuals aged between 18 and 65 years confirmed that the causes of disease among middle-aged people are correlated with a poor diet and inadequate personal care.Despite noticing signs of aging, such as slowness during daily tasks, tiredness, muscle pains, rheumatism, difficulty in losing wight, grey hair, worsening vision and hearing, movement issues, spots on their skin and forgetfulness, many of the participants were not able to adapt and live a healthier lifestyle.
Mario stated that his work was starting to wear him out and he felt that people tended to get slower.According to Marta, it is important to keep the mind occupied to avoid depression.Hibiscos noticed that his sight had worsened over time and he believed that it was because he had worked with a computer for a long time.Lídia highlighted pains in her arms and legs that hindered the performance of certain tasks, which she had previously done automatically.
Aging occurs differently for everybody and is affected by an individual's lifestyle and genetic factors.Factors such as a decrease in fuctional capacity and suscepticibility to chronic diseases (acquired with age) can be reduced by adopting a healthier lifestyle.It is important that people pay more attention to themselves if they are to notice the signs of aging. 56ny of the interviewees in the present study said that they did not want to think about getting old.This avoidance can be transformed into suffering and leave people unprepared for the limitations that are inherent to this stage of life.They need to develop a positive view of their life so that they can work in accordance with their psychological well-being and consequently, their health. 56e results of the present study could help the planning of actions that will positively affect perceptions about the aging process.Most of the interviewees had not completed primary education, which could be seen as a limitation of this study.People with a more complete education did not agree to participate.Another limitation is the fact that, since this is a qualitative study, it is not possible to generalize the results.Therefore, further studies are suggested, with a qualitative approach and a larger sample, in order to extapolate the data for the general population and guide the planning of public policies.On a positive note, the participants were genuinely interested in talking about this issue and reflecting on the questions asked during the interview.

CONCLUSION
Most of the interviewees recognized that physcial activity and a healthy diet are associated with physical and emotional wellbeing and can lead to a better quality of life.Although every person ages differently, the manner in which they perceive these changes in their body determines how much care they will dedicate to this process.Many of the participants preferred not to think about this subject, despite the fact that they could feel these changes occuring in their lives.Denial leads to illness, given that a person can only improve their physical and emotional health by paying attention to these aspects of life.To do so, people must choose to reflect on old age and prepare for this stage of life, thereby achieving their goals and living a fuller life.
Understanding how middle-aged people perceive their own health, as well as how they feel about the aging process and what they do to stay healthy, could help the planning of public policies that promote a healthy lifestyle among middle-aged and elderly populations.Active aging programs that encourage people to live a healthy lifestyle and take responsibility for their own selfcare could contribute to a better quality of life in these populations.Based on the results of the present study, these programs are important as many people are not capable of modifying their lifestyle, despite knowing how important it is to do so.If public policies stimulated and facilitated healthy practices, it is possible that more people would adhere to these activities.This is a challenge that faces all those who deal with middle-aged and elderly populations.