Factors associated with the functional independence of elderly women in the city of Cuiabá

1 Faculdade de Ciências Sociais Aplicadas de Tangará da Serra (FACISA/TS) – UNIC Tangará Sul, Departamento de Enfermagem. Tangará da Serra, Mato Grosso, Brasil. 2 Universidade Federal de Mato Grosso (UFMT), Faculdade de Enfermagem (FAEN). Cuiabá, Mato Grosso, Brasil. 3 Universidade Federal de Mato Grosso (UFMT), Instituto de Saúde Coletiva (ISC). Cuiabá, Mato Grosso, Brasil. 4 Secretaria de Estado e Saúde (SES), Auditoria Geral do SUS. Cuiabá, Mato Grosso, Brasil. 5 Hospital Universitário Júlio Müller (HUJM), Assistência de enfermagem. Cuiabá, Mato Grosso, Brasil.


INTRODUCTION
The 60 years or older age group is the fastest growing population segment in the world when compared proportionally with other age groups.Globally, the number of elderly women is significantly higher (a difference of 70 million) than the number of elderly men. 1 In Brazil, 55.8% of all individuals aged 60 years or more are female. 2This phenomenon has been called the "feminization of the elderly" and is caused by the greater longevity of women when compared to men. 3 This increase in the number of elderly individuals has led to global concerns about the need to implement new public policies that favor the maintenance of the functional independence of this segment of the population throughout the aging process.In accordance with a proposal by the World Health Organization, 4 the Ministry of Health has used its care network and certain public policies to develop strategies for the recovery, maintenance and promotion of independence among the elderly. 5It is therefore hoped that this group of people will retain their ability to perform activities of daily living for as long as possible, without requiring assistance, as well as their autonomy, freedom of action and decision making skills. 6,7number of tools have been created to assess the degree of care (from third parties) required by the patient in order to complete motor and cognitive tasks.One such tool is the Functional Independence Measure (FIM). 8However, these assessments are difficult to apply to community-dwelling elderly individuals and are usually conducted with institutionalized or hospitalized patients.
The independence scale for basic activities of daily living (ADLs) was originally created to assess the results of treatment protocols for elderly patients, the prognosis of which provides a brief description of the ability of patients with chronic illnesses to take care of themselves and perform daily functions.This instrument is used to measure the functional capacity of community-dwelling and institutionalized elderly individuals. 9Instrumental activities of daily living (IADLs) are considered more complex and are related to the capacity of the elderly individual to live in the community. 10veral authors have reported that the prevalence of dependence is higher among women than men. 11,12Since they tend to live longer, women become more susceptible to a reduction in their functional capacity, as well as in their ability to perform activities of daily living or communitybased activities, even when certain morbidities are involved. 13,14However, reports in literature do not always agree on the functional capacity of elderly women. 15,16 this context, it is important to understand the conditions that favor the independence of these elderly women and the complex interrelationships between all the factors involved in the aging process.
It is common knowledge that the main healthcare models for the elderly in Brazil are highly medicalized, inefficient and expensive, due to the use of highly-complex services.The identification of factors associated with functional independence can guide health promotion and disease prevention practices in other sections of the population, thereby decreasing the intense use of more complex health care services among the elderly.
The monitoring of health conditions and its determinants can favor the development of more effective health and social policies.Therefore, the aim of the present study was to analyze the prevalence (and associated factors) of functional independence among elderly community-dwelling women.

METHOD
A cross-sectional study was conducted with elderly women who lived in the urban zone of the municipality of Cuiabá, in the state of Mato Grosso.The women were selected based on a previous study by Cardoso et al., 17 who assessed the health condition and associated factors of elderly individuals in the urban zone of Cuiabá.In this earlier study, the sample was determined using a calculation for finite populations, with a confidence interval of 95% and a sampling error of 5%.Sampling by conglomerates was used to determine visitation in 11 census sectors.In order to determine the quantity of elderly individuals to be interviewed in the urban districts of Cuiabá, the total number of elderly residents in each district was stratified by gender, giving a total of 573 elderly individuals.Of this total, 319 were women aged 60 years or more.These women were selected for participation in the present study.
The following exclusion criteria were applied: the presence of cognitive decline; or when present, the absence of a caregiver to help the elderly individual with the interview responses.Cognitive decline was assessed using the mini mental state examination (MMSE), applying the education score established by the Ministry of Health. 6e following situations were classified as cognitive decline: illiterate elderly women with a total MMSE score of less than 19; elderly women with one to three years of education and a score of less than 23; elderly women who studied for between four and seven years and scored less than 24 points; and elderly women who studied for more than seven years and scored less than 28 points. 6ata was collected between March 30 and May 30 of 2014 in the home of the participant, after they had read and signed a free and informed consent form.The data was collected through semistructured interviews using a previously-tested questionnaire containing the following sociodemographic information: age was categorized as between 60 and 79 years or 80 years or more; marital status was dichotomized as married versus separated/widow/single; living conditions were classified as living alone or living with somebody; education was classified as illiterate, 1 to 3 years, four to seven years, or more than seven years (this was later reclassified as illiterate or up to three or four years of study or more); retired (yes or no); occupation (active/inactive); and income of up to or more than the minimum wage (MW).The health condition of the participants was classified as follows: self-perception of health (very good/good versus normal/poor/very poor); hospitalization in the previous six months (yes/no); health issues (yes/no), which were obtained from a list of health issues that are common in the elderly population; how many health issues (one and two or more); regular use of medication (yes/no); how many different drugs used (up to two or three or more); reported falls after reaching 60 years of age (yes/ no); suffering injuries or fractures after reaching 60 years of age (yes/no); immobility after 60 years of age (yes/no), which meant be unable to move, be bedridden or use a wheelchair, irrespective of the cause.Social relationships were classified as follows: visits friends or relatives (yes/no); receives visitors (yes/no); attends a social group (yes/no); performed physical exercise at least once a week in the previous month (yes/no).
Functional independence was determined using the Katz index, 9 which assesses the capacity of elderly individuals to perform six ADLs (take a shower/bath, dress themselves, go to the toilet, get around, continence and nourishment), and the Lawton and Brody scale, 10 which determines the capacity to perform nine IADL activities (using the telephone, travelling a long distance using some form of transport, going shopping, making their own meals, cleaning the house, performing manual domestic tasks, washing clothes, taking medication and looking after their finances).Both of these scales have been validated and adapted for use in Brazil and are recommended by the Ministry of Health. 6om a hierarchical perspective, functional losses occur in the IADL>ADL direction.Following this principle, the elderly women were classified a priori as independent if they scored 27 points on the Lawton and Brody scale and did not require assistance to perform the Katz index tasks.Participants who scored between 10 and 26 points were classified as partially dependent, while those who scored up to nine points for IADLs and required complete assistance in all ADLs were considered to be completely dependent.
Thus, we began with the notion that if the participant was able to perform all of the IADLs without assistance, they would obviously be able to perform ADLs.Notably, none of the participants scored nine points or less for the IADLs and thus, none of the participants were completely dependent.
The data was codified and digitalized, with bivariate analysis conducted using EPI-INFO 7.0 software.The variables were described using absolute (n) and relative (%) frequencies.Bivariate analysis identified associations between the variable response (functional independence) and the other variables of exposure.The chi-squared test ( p≤0.05) and the Mantel-Haenszel method (CI 95%) were used to calculate the statistical significance of the associations.
Multiple analysis was conducted using the Poisson regression model and the Statistical Package for Social Sciences 22.0 (SPSS).All variables with a p-value of ≤0.20 in the crude analysis were included, using a method that enabled the insertion of blocks of variables.Sociodemographic data was inserted first, followed by health conditions and social relationships.Associations that lost their statistical significance ( p>0.05) in each block were excluded using the progressive withdrawal method (stepwise backward).At the end of the analysis, variables with a p-value of ≤0.05 were considered as having a statistically significant association.

RESULT
The final sample contained 247 elderly women, after the following exclusions: one individual was excluded due to a diagnosis of cognitive decline; 33 participants were excluded due to a change of address or interrupted monitoring (after three visits had been completed); 28 individuals had died since the completion of the previous study; and 10 elderly women refused to participate in the research.Of the 247 individuals who did participate, 40.4% were aged between 70 and 79 years, and the mean age was 73 years (SD±7.9).There was a predominance of widows (44.5%) with four to seven years of education (29.5%), who were retired (54.7%) and received an income of up to the minimum wage (55.1%).These values are not contained in the tables.
Concerning the distribution of the elderly women in accordance with functional capacity, the prevalence recorded for independence was 63.2% (CI: 57.0-68.9) of the population assessed, while the remaining 36.8% (CI: 31.1-43.0)were classified as partially dependent.None of the subjects was classified as completely dependent.
In the bivariate analysis, statistically significant correlations were recorded for the following variables: aged between 60 and 79 years; five or more years of education; marital status of married; living with a partner or family member; working; and earning more than the minimum wage (Table 1).
Concerning health conditions, the following variables correlated with independence among the elderly women: no more than one health problem; taking no more than two drugs concomitantly; and no hospitalizations in the previous six months.Statistically significant associations were maintained for participants who had suffered no falls, immobility, injuries or fractures after reaching 60 years of age (Table 2).
In the analysis of social relationships, statistically significant associations were recorded for the following variables: visiting friends or relatives; attending a social group; and performing physical exercise (Table 3).In the Poisson multiple regression analysis, the following variables remained associated with functional independence: an age of between 60 and 79 years; having an income of more than the minimum wage; no hospitalizations in the previous six months; using no more than two types of medicine on a regular basis; the absence of immobilization after 60 years of age; visiting friends or relatives; attending social groups and performing some form of physical exercise (Table 4).

DISCUSSION
The prevalence of functional independence (FI) in the present study was 63.2%, which is quite similar to the results of a study conducted in Norway, in which 74.3% of the women monitored were classified as independent. 15Similarly, a study of 1339 elderly women in Uberaba, in the state of Minas Gerais (Brazil) reported a FI prevalence of 69.2%. 18However, other studies have shown lower levels of independence among elderly women. 19e of the possible explanations for this result is the fact that most of the participants have lived at a time when, historically, women have more rights and opportunities. 20The oldest women exhibited the greatest growth in relation to their inclusion in the workforce 21 and their involvement in family decisions.These modern benefits have made them more financially independent. 22,23In addition, they have found new meaning in their lives, broadening their horizons, seeking more information, incorporating new knowledge and expanding their interpersonal relationships. 24number of studies have shown that many elderly women are more physically resistant, maintaining their health and autonomy. 23,25owadays, they take care of themselves and participate in social activities that preserve their physical and cognitive condition through activities such as dancing, travelling and crafts workshops.22,25,26   The association found in the present study between the age group of younger elderly women and FI is not surprising.Studies have shown that women aged under 80 years are more independent. 18,27,28This is due to the aging process itself, in which physiological decline and pathological risks progress over time, leading to the onset of disabilities at more advanced ages. 3 Similarly, elderly women who did not exhibit immobility after 60 years of age, had not been hospitalized recently and performed some form of physical exercise were associated with FI, thereby confirming that the maintenance of an active and healthy body is directly related to the preservation of FI. 13 Variable PR The reduction of disabilities comes from the conservation of physical mobility and the prevention and control of chronic illnesses and biopsychosocial equilibrium. 29Women tend to perform less physical exercise than men, 30 which leads to organic-functional benefits, as well as other benefits related to sociability, beauty and esthetics. 31In addition, active aging reduces the demand for health services, thereby reducing the cost of treating illnesses and hospitalizaitons. 13e association found between elderly women with a higher income and FI in the present study was also reported by Ribeiro and Neri. 30These authors assessed 1538 elderly individuals aged 65 years or more in six Brazilian cities and determined the influence of socioeconomic factors on aging.A higher salary improves the level of self-care of an individual (in terms of their health), ensuring that incapacitating processes are delayed and the autonomy of the individual is maintained. 25,30A higher family and per capita income favors more socializing among elderly individuals, thereby improving their ability to perform daily activities and interact with different social groups.Consequently, a higher income "socially modifies the idea that aging is linked to reclusion, passivity and rest". 23e association between the non-use or low consumption of drugs and FI is significant.Polypharmacy occurs when an elderly individual exhibits several chronic illnesses concomitantly, which usually involves greater functional dependence. 32However, knowledge about the adequate and safe use of drugs can prevent illnesses and functional decline. 13e social interactions involved in visiting friends or relatives were important to the FI of the elderly women, corroborating the findings of other studies. 7,30,33These activities prevent the individual from developing a sedentary lifestyle, thereby delaying the onset of disabilities and the loss of autonomy. 7,34Domestic tasks that make up the daily life of women can also prolong their independence.Furthermore, the maintenance of social relationships and recreation/leisure activities can assist the physical and psychological wellbeing of elderly women.Prevention measures that delay the evolution of illnesses reduce the complexity of the care required and improve the social and family life of individuals, while also increasing their desire to perform physical exercise. 35nce this was a cross-sectional study in which the exposure factors and the outcome were determined simultaneously, caution should be used when interpreting associations between factors related to the functional independence of the participants.
It is not possible to rule out the occurrence of information bias or memory bias, given the fact that this study assessed the recollections of elderly women.Functional dependence may be related to cognitive decline or a lack of awareness of the previous situation of the patient (on behalf of the person who helped them to complete the questionnaire).However, the participation of the main researcher in the interviews may have minimized the possibility of this occurrence.
In cross-sectional studies such as this, the use of the prevalence ratio as an effect measurement in both the bivariate analysis and the Poisson multiple model favors a satisfactory adjustment of the effect measurements and prevents the overestimation of association measurements.
The significance of the present study lies in the fact that it focused on the identification of factors associated with the functional independence (FI) of elderly women, thereby ensuring that such data could identify predictor variables for healthy aging, specifically among women.

CONCLUSION
The prevalence of functional independence among the elderly women was 63.2%.Strong associations were recorded between FI and age group, an income of more than one minimum wage, no hospitalizations in the previous six months, using a maximum of two medications on a regular basis, mobility after reaching 60 years of age, visits to friends/parents, attending social groups and performing some form of physical exercise.
The results of the present study showed the diversity of factors that are directly correlated with FI and confirmed that different aspects of daily activities and the physiological aging process can affect an individual's ability to perform ADLs or IADLs.
It is believed that the present study could stimulate new subsidies for the implementation of policies focusing on this segment of the population.Health professionals need to invest in the health education of these women before they become chronologically elderly in order to promote active aging and effective participation in society and in family environments.
1R1: prevalence ratio; CI 2 95%: confidence interval for the proportion of 95%; P 3 : level of significance considering the distribution of the chisquared test ( p<0.05); Active 4 : income from work only or from work and other sources; Inactive 5 : income from non-work sources (retirement funds, pensions, health assistance, donations, others); MW 6 : minimum wage at the time (R$724.00).

Table 2 .
Distribution of elderly women, according to the health condition variables.Cuiabá, Mato Grosso, 2014.

Table 3 .
Distribution of the elderly women, according to social relationships.Cuiabá, Mato Grosso, 2014.

Table 4 .
Poisson multiple regression model of the variables associated with the functional independence of elderly women.Cuiabá, Mato Grosso, 2014.