Investigation of the emotional and psychological factors of elderly persons frequenting ballroom dancing clubs

1 Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Pós-Graduação Stricto Sensu em Gerontologia. Campinas, SP, Brasil. 2 Faculdade Metropolitana de Maringá, Departamento de Educação física. Maringá, PR, Brasil. 3 Universidade Estadual de Maringá. Departamento de Pós-Graduação Stricto Sensu em Educação física. Maringá, PR, Brasil. 4 Centro Universitário de Maringá. Departamento de Pós-Graduação Stricto Sensu em Promoção da saúde. Maringá, PR, Brasil. 5 Universidade Federal do Vale do São Francisco. Departamento de Educação física. Petrolina, PE, Brasil.


INTRODUCTION
The psychosocial and emotional changes that occur during aging 1 include a decrease in selfesteem 2 and psychological and subjective well-being 3 and an increase in anxiety 4 , which can lead to the development of depression and in the long term may influence decline in functional and cognitive capacity and subsequent impairment in the quality of life of this population 5 .
For the elderly, self-esteem is related to the admiration, appreciation and importance that is attributed to them, as well as their positive relationship with society and their family and friends 6 .Anxiety, meanwhile, is a factor that may be related to other comorbidities in this population.Symptoms of anxiety can predict limitations in the activities of daily living of elderly persons 7,8 .Moreover, anxiety in the elderly is also related to major depressive disorders 9 .
The subjective well-being of the individual throughout aging is an important indicator of quality of life.Experiences and adaptations that have and still occur in life, and which provide feelings of happiness, positive pleasure and affection, as well as the absence of negative affect, are essential for satisfaction with life, especially among the elderly 10 .An individual with low indicators of subjective well-being will also exhibit a concomitant increase in their perception of stress as a consequence of a series of factors that follow the decline in their subjective well-being.Such processes of stress can influence the emergence of diseases and difficulties in performing activities of daily living (ADLS) 11 .The careful observation of depressive symptoms is also of paramount importance, as such symptoms reflect both positive and negative emotions and feelings, and provide highly relevant information for the mental health care of the elderly 12 .
As a consequence of the aging process and the physical, psychological and emotional changes it causes, the elderly population is highly sensitive to changes in quality of life 13 .Quality of life, in addition to encompassing basic aspects of the overall health of the individual, is also a reflection of their understanding and position in life within their cultural context, and includes their goals, expectations, patterns, and concerns about themselves 14 .It is therefore emphasized that quality of life is closely linked to life habits, such as physical exercise and socialization, potential promoters of physical and mental health 15 .
When performing physical activity, the elderly can maintain an active level of physical, cognitive, social and psychological functioning 16 .Among the existing modalities of physical exercise, dancing is popular among this population, as it provides an environment of relaxation and fun, where the elderly can identify with individuals with similar cultural characteristics and interact socially with others, as well as expressing their emotions and relive feelings of the past.Dancing can therefore benefit the quality of life of these individuals, who set aside many problems, such as shyness, anxiety and depression, and therefore contributes to a better quality of life 17 .
The objective of the present study was therefore to investigate the psychological factors of elderly people attending ballroom dancing clubs, aiming to clarify the relationship between these factors and their impact on life satisfaction.

METHOD
The study included 93 elderly persons of both genders who regularly performed activities in ballroom dancing clubs in the city of Maringá, Paraná, Brazil.The sample was selected in a nonprobabilistic and intentional manner for convenience.The inclusion criterion where that the elderly should have participated in their respective groups for at least three months.Elderly people with perceptible auditory and cognitive deficits, in addition to those with neurological diseases that made them incapable of carrying out the questionnaires, were excluded.
To characterize the sociodemographic and health profile of the sample, a semi-structured questionnaire developed by the authors was applied, with questions relating to gender (male and female), chronological age (the values of which were grouped into ranges of 60 to 69, 70 to 79, and 80 years and over), monthly income in 2016 (grouped into bands of up to one minimum wage, one to two minimum wages, and over two minimum wages), schooling (data grouped into categories 0 years of study, one to four years of study, up to eight years of study and more than eight years of study), occupational status (active or inactive), race (white, black, Asian-Brazilian), retirement (yes or no), smoking (never smoked, smoked or currently smoked); time frequented ballroom dancing club (up to 5 years, more than 5 years), weekly attendance at ballroom dancing clubs (twice a week, 3 times a week, 4 times or more) and history of falls in the last six months (yes or no).
To evaluate stress levels, the Perceived Stress Scale 18 , which consists of 14 questions about the feelings and thoughts of the elderly persons over the previous month, was used.This instrument is answered on a five-point Likert scale (zero = never, one = almost never, two = sometimes, three = almost always, and four = always).Questions 4, 5, 6, 7, 9, 10, 13 are positive in relation to the individual, and are thus scored in an inverted manner.The other questions, with a negative character, have an immediate summation.The final score is a result of the sum of the scores of the 14 questions, ranging from 0 to 56 points, with a higher score indicating a greater perception of stress.
The Geriatric Anxiety Inventory, validated for the Brazilian context by Martiny et al. 19 , was applied to evaluate the anxiety levels of the sample group.This instrument consists of 20 questions, answered yes or no, with each yes answer adding one point to the final score of the individual.Scores equal to or greater than ten identify the elderly person as suspected of suffering from generalized anxiety.
In order to identify depressive symptoms, the Geriatric Depression Scale 20 , which consists of 15 dichotomous items, was used.Scores greater than five indicate depression.
To evaluate self-esteem, the Rosenberg Self-Esteem Scale, validated for Brazil by Hutz and Zanon 21 , was used.This instrument consists of ten questions, answered on a four-point Likert scale ranging from 1 (totally disagree) to 4 (totally agree).The final result is obtained from the sum of the scores of the questions, ranging from 10 to 40 points.Higher values indicate greater self-esteem.
Subjective well-being was evaluated through the Satisfaction with Life Scale, validated for Brazil 22 .This scale is one-dimensional in nature and is composed of five questions answered on a scale of 07 points.The higher the value, the greater the satisfaction with life and vice versa.
Quality of life was assessed using the Short-Form Health questionnaire (SF12v2) in its validated Portuguese version 23 .This instrument assesses the individual's perception of their own physical and mental health through 12 questions answered on a Likert-type scale of five points (with the exception of question 02, which is answered via a three point scale).From the answers, the general scores of Total Quality of Life, Physical Health and Mental Health can be calculated, as well as the specific dimensions of functional capacity, limitation by physical aspects, pain, general health, vitality, social aspects and emotional aspects.For the present study, the general dimensions of results were used.
The survey was conducted from November 2016 to March 2017.Initially, contact was made with the managers of ballroom dancing clubs in the municipality of Maringá, Paraná.After the necessary clarifications, and the authorization of such managers, the collection of data began at the clubs at pre-scheduled times.The elderly persons were approached by the researcher responsible, who explained the objectives and nature of the research.The elderly who voluntarily agreed to participate in the study signed a Free and Informed Consent Form (FICF).
The interviews were individual and used only pencil and paper.They were performed by the researchers and lasted from 10 to 25 minutes per elderly person.
For the analysis of the categorical variables, the descriptive frequency and percentage statistics were used.For the numerical variables, the normality of the data was verified through the Kolmogorov-Smirnov test.As the data did not present normal distribution, Median (Md) and Quartiles (Q1;Q3) were used as descriptive measures.For the comparison of the psychological and emotional variables according to gender, monthly income and health perception, the Mann-Whitney U test was used.To compare the psychological and emotional variables according to the age group, the Kruskal-Wallis test followed by the Mann-Whitney U test was used to evaluate the pairs of groups.In order to verify the correlations between the study variables, the Spearman Correlation Coefficient (p <0.05) was applied.
A Multivariate Linear Regression model was then constructed using the variables which had a significant correlation with satisfaction with life as predictors.The existence of outliers was evaluated by the squared Mahalanobis distance (D 2 ) and the univariate normality of the variables was evaluated by the uni-and multivariate coefficients of asymmetry (ISkI<3) and kurtosis (IKuI <10).As the data did not present normal distribution, the Bollen-Stine Bootstrap technique was used to correct the value of the coefficients estimated by the Maximum Likelihood method implemented in the AMOS software package version 18.0.There were no DM 2 values indicating the existence of outliers, nor sufficiently strong correlations among variables to indicate problems with multicollinearity (Variance Inflation Factors <5.0).The regression coefficients were based on the following coefficients: low effect for coefficients <0.20, medium effect for coefficients up to 0.49 and strong effect for coefficients >0.50 ( p<0.05).The present study was approved by the Ethics Research Committee of the Centro Universitário de Maringá, under approval number 2.091.893/2017,CAAE 67067517.6.0000.5539.

RESULTS
In the present study, the sample consisted of 93 elderly persons, with 19 men and 74 women (79.6%), a mean age of 70.4 (±7.1), aged between 60 and 69 years (53.8%),unmarried (single, widowed, divorced and separated (92.5%), white (66.7%), retired (83.7%), with a monthly income of one to two minimum wages (84.9%) and inactive (82.8%).The majority of the elderly had an incomplete primary education (52.7%) and 9.7% had no formal schooling (0 years of study).The majority (71.0%) had attended ballroom dancing groups for at least five years and at least twice a week (58.1%).The majority of the elderly were perceived to be in good health (69.9%), and had no history of falls in the last six months (86.0%).
Regarding psychological and emotional aspects, it was found that the majority of the elderly persons were not suspected of suffering from anxiety (64.5%) or depression (84.9%).Figure 1 shows that the elderly had moderate to high levels of Life Satisfaction (Md=27.0)and Self-Esteem (Md=31.0);low levels of Anxiety (Md=6.0),moderate levels of perceived stress (Md=20.0)and low signs of depression (Md=3.0).Moderate values were found for perception of physical (Md=59.4)and there were high perceptions of mental health perception (Md=71.9).When comparing the psychological variables of the elderly attending ballroom dancing clubs based on gender, age group and monthly income, no significant differences were found ( p>0.05).In comparisons based on perception of health (Table 1), there was a significant difference ( p<0.05) in all the variables except for quality of life.Higher life satisfaction, better self-esteem and lower levels of anxiety and stress characterized elderly persons with a good perception of health, while those with a poor/ fair perception of health exhibited more anxiety and stress and profiles that were more indicative of depression, as well as lower self-esteem and satisfaction with life.
When correlating the psychological and emotional variables (Table 2), it was found that life satisfaction was negatively related to anxiety (r=-0.41),stress (r=-0.30)and being indicative of depression (r=-0.30),and positively related to self-esteem (r=0.21).In addition, it was observed that self-esteem was inversely related to negative psychological factors (anxiety, being indicative of depression and stress), whereas these correlated positively among each other.
A multivariate regression model was constructed to verify the impact of the psychological variables measured on the life satisfaction of the elderly people (Figure 2).It is observed that anxiety, stress, self-esteem and depression predicted 21% of the variability of the life satisfaction of these elderly people (Figure 2).Regarding the individual trajectories of the model, it was verified that only anxiety (β=-0.32)and depression (β=-0.15)had a significant impact on life satisfaction.It is noteworthy that the increase of one standard deviation in the anxiety and depression units causes a reduction of 0.32 and 0.15 standard deviations, respectively, in the life satisfaction unit.Stress and self-esteem did not exhibit significant regression coefficients ( p>0.05).

DISCUSSION
The present study sought to investigate the emotional and psychological factors of elderly people attending ballroom dancing clubs.It was observed that the majority of these elderly persons exhibited indicators of a profile of satisfactory quality of life, as they perceived themselves to have good general health, had good levels of self-esteem and life satisfaction and a good perception of physical and mental health, as well as low anxiety, stress and few indicators of depression.It can be inferred that the individuals evaluated in this sample of elderly persons who attended ballroom dancing clubs have a relatively high emotional and psychological profile, reinforcing the importance of physical activities for this population.
There was a predominance of desirable aspects of quality of life and health, which suggests a distancing from the problems typically faced by this population, such as social isolation, depression and accidents (falls).Such results may or may not be linked to the regular practice of ballroom dancing, which develops important physical abilities for the prevention falls and increases the autonomy of the elderly in activities of daily living, in addition to providing an environment rich in social interactions 25 .It was observed that most of the sample attended ballroom dancing clubs for more than five years, with the hypothesis that frequency in attending such groups may have been an influence factor for the profile found in the sample.
Sedentary behavior in the elderly population has been related to cognitive deficits, which may in turn impair the well-being and quality of life of such individuals, while physical exercise plays an important role in mitigating or even protecting against such deleterious effects of aging 26,27 .Evidence shows that sedentary elderly persons have a worse quality of life than active individuals 28 .
There is a consensus about the benefits of performing physical activities and exercises among the elderly population.It has been found that physical exercises are potential promoters of the performance and well-being of the elderly, from sedentary individuals to elite athletes 15 .A systematic review 16,18 evaluated controlled and randomized clinical trials investigating the self-esteem, symptoms of depression and the quality of life of the elderly aged over 65 and concluded that exercise programs for this group effectively improve such variables.
On the other hand, there is also evidence that physical exercise is not directly related to improvements in the psychological well-being of the elderly 29 , although an analysis of literature suggests that such divergence may be related to the type of physical activity practiced.It is observed that, when dealing specifically with dancing, there is a consensus regarding the favorable results for the emotional and psychological health of the elderly.Studies conducted in Hong Kong 30 , Greece 31 and Turkey 25 have shown the effectiveness of dance in reducing levels of stress and anxiety, improved the subjective perception of quality of life and well-being, and produced physical benefits favorable to the autonomy of the elderly.
Regarding the impact of psychological and emotional factors on life satisfaction as evaluated by the regression model, it was observed that, for this sample, anxiety levels and symptoms of depression appear to be intervening factors in the satisfaction of the elderly persons with their lives.Curiously, self-esteem and stress did not present significant trajectories, despite their significance in the correlation test.However, no studies were found that evaluated the direct relationships between these variables, making it impossible to discuss their effect further.What is known is that despite the individual contribution of each variable, literature seems to agree that the practice of physical activities will bring generalized benefits to the quality of life, life satisfaction and general well-being of the elderly.
The physical activity of ballroom dancing is a potential promoter of this profile, exposing its practitioners to a context rich in social interactions and positive experiences, as well as benefiting aspects of physical health that promote the quality of life of these individuals and being an attractive environment for practitioners that motivates them to remain engaged in this long-term activity.
Thus, professionals working with the elderly should seek to develop and/ or encourage more frequent attendance of facilities that offer ballroom dancing sessions and other physical exercises, as a form of promoting the physical and mental health of the elderly.
It is important to mention the size and geographical restrictions of the sample of the present study which do not allow the generalization of the results obtained for the wider Brazilian elderly population.

CONCLUSION
The elderly participants of the ballroom dancing clubs that participated in the present study presented a psychological and emotional profile that was favorable to their well-being, life satisfaction and quality of life.Anxiety and depression can be considered detrimental variables to the life satisfaction of the elderly person.

Figure 2 .
Figure 2. Impact of psychological and emotional variables on the life satisfaction of elderly ballroom dancing club members.Maringá, Paraná, 2017.

Table 1 .
Comparison of the psychological variables of elderly people attending ballroom dancing clubs based on self-perception of health.Maringá, Paraná, 2017.

Table 2 .
Correlation between the psychological and emotional variables of elderly people attending ballroom dancing clubs.Maringá, Paraná, 2017.