Healthy aging from the perspective of the elderly : an integrative review

1 Universidade de São Paulo, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem. São Paulo, SP, Brasil. 2 Universidade Federal de Juiz de Fora, Faculdade de Enfermagem, Departamento de Enfermagem Básica. Juiz de Fora, MG, Brasil. 3 Secretaria Municipal de Saúde de Astolfo Dutra. Astolfo Dutra, MG, Brasil. 4 Universidade Federal do Estado do Rio de Janeiro, Escola de Enfermagem Alfredo Pinto, Departamento de Enfermagem em Saúde Pública. Rio de Janeiro, RJ, Brasil. 5 Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Materno-Infantil e Psiquiátrica. São Paulo, SP, Brasil.


INTRODUCTION
The elderly represent 12% of the world's population, and this figure is expected to double by 2050 1 and triple by 2100 2 .Greater longevity can be considered a success story for mankind 3 , and these extra years of life allow people to plan their future in a different manner to previous generations, depending on one central element: health 4 .
With this understanding, public policies have emphasized the positive meaning of aging and the contribution the elderly can make to society with their wealth of knowledge, skills and experiences in everyday life and work 3,5 .For this positive sense of aging, different terms are used: successful aging, active aging and, more recently, the resumption of the term healthy aging, proposed by the World Health Organization (WHO) 3 .
The WHO defines healthy aging as the "process of development and maintenance of functional capacity that allows well-being at an advanced age" 3,4 .Functional capacity, in turn, can be understood as the combination of the intrinsic capacity of the individual, the relevant environmental characteristics and the interactions between the individual and these characteristics 3 .Intrinsic capacity is the articulation of physical and mental abilities (including psychosocial) 3 .Environmental characteristics are the context of life, including social relations.Well-being is unique and permeated with subjective aspirations, including feelings of fulfillment, satisfaction and happiness 3 .Thus, the understanding of healthy aging, as defined by the WHO, is comprehensive and relevant for all elderly people, even for those living with chronic diseases.It is also not centered on the absence of aggravations, nor is it restricted to the functionality of the elderly.Instead, it is based on a process that will allow the construction of skills that will enable elderly individuals to experience aging in the best possible way 4 .
In addition to the comprehensive WHO understanding of healthy aging, it is also worth exploring the collected scientific evidence on the perspective of the elderly on this issue, as they are the main actors in this context.This knowledge may provide additional information to support interventions and care for this group, and contribute to one of the guidelines of the Global Strategy and Plan of Action for Aging and Health 2016-2020, which encourages the construction and synthesis of evidence on healthy aging 6 .In this context, the present study aimed to identify the perspective of the elderly on healthy aging as described in scientific productions.

METHOD
An integrative literature review was performed, allowing the identification of themes or problems relevant to the field of health and public policy, through the gathering, critical appreciation and synthesis of knowledge about the subject under investigation 7 .Such a method contributes to Evidence-Based Practice, following a standard of excellence regarding methodological rigor 8 .This integrative review was performed in five stages 7 : in the first stage, the research question was formulated: what knowledge has been produced about healthy aging from the perspective of the elderly?The second stage involved the literature search through a survey of the scientific productions carried out in February 2017 in the main databases of the area of health: Scopus Info Site (SCOPUS), Cumulative Index to Nursing & Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Literature of Latin America and the Caribbean (LILACS), EMBASE, WEB OF SCIENCE and in the journal directory of the Scientific Electronic Library Online (SciELO).The period from 2005 to 2016 was used as a temporal cut-off point, with the start date based on the publication of the document Active aging: a WHO health policy 9 .
The search was carried out based on the key-word "Healthy aging" and the descriptor "Aged", obtained from the Health Sciences Descriptors (DECS) and the synonyms "elderly", "senior" and "older people".It was decided to use terms in English and the Bolean operators AND and OR, as shown in Chart 1.
To compose the sample, the following inclusion criteria were used: original articles published in the period from 2005 to 2016, electronically available in full in the English language, which addressed the perspective of the elderly on healthy aging.Literature reviews, annals of scientific events, experiment reports, dissertations and theses were excluded.
The inclusion and exclusion criteria were applied and allowed the selection of 11 articles to make up the study sample, as shown in Figure 1.
Chart 1. Search strategy and articles found in databases and in the search directory.São Paulo, 2017.

Database
Search strategy Articles found SCOPUS "Healthy aging" AND ("aged" OR "elderly" OR "senior" OR "older people") 77 CINAHL "Healthy aging" AND ("aged" OR "elderly" OR "senior" OR "older people") 14 MEDLINE "Healthy aging" AND ("aged" OR "elderly" OR "senior" OR "older people") 24 LILACS "Healthy aging" AND ("aged" OR "elderly" OR "senior" OR "older people") 2 EMBASE Emtree terms: "Healthy aging" AND "aged" 6 WEB OF SCIENCE "Healthy aging" AND ("aged" OR "elderly" OR "senior" OR "older people") 43 SciELO Keywords: "Healthy aging" AND "elderly" 11 Total 177   In the third stage a critical evaluation of the scientific productions that met the established criteria was carried out.The identified articles were evaluated for rigor, credibility, and relevance through the Critical Appraisal Skills Programme checklist (CASP).This instrument classifies the studies into two categories: A and B. Those classified as Category A present a small risk of bias, as they meet at least nine of the ten topics: 1) clear and justified objective; 2) methodological design appropriate for the objectives; 3) methodological procedures presented and discussed; 4) intentional sample selection; 5) data collection, instruments and saturation process described; 6) relationship between researcher and researched; 7) ethical aspects; 8) dense and substantiated analysis; 9) results presented and discussed, pointing out the credibility and use of triangulation; 10) description of the contributions, implications of the knowledge generated and its limitations 10 .Category B included those with a moderate risk of bias, that is, those that meet at least five of the ten topics 10 .
The CASP checklist was applied independently by three of the authors in order to guarantee the reliability of the present study.After CASP classification, a database was elaborated that made it possible to organize and compile the following information from the selected studies: article title, profession of the first author, year of publication, country, journal title, method and results (perspectives of the elderly about healthy aging).
In the fourth stage, the perspectives of the elderly on healthy aging were grouped by similarity of content (Table 2).The results were interpreted based on the literature related to the study theme.Finally, the fifth stage included the presentation of the synthesis of knowledge, contained in the discussion and final considerations section.

RESULTS
The highest proportion of articles (27.3%) was published in 2014.The countries that published the most articles were Brazil (36.3%),Canada (18.1%) and Thailand (18.1%).The professional area which published the most studies were psychologists (54.5%), followed by nurses (27.2%).Most of the journals (63.6%) were not specific to geriatrics or gerontology.
All the sampled articles were classified as Category A according to the CASP checklist 10 .In terms of content, the selected studies found that the perspective of the elderly on healthy aging covered the biological, psychological, spiritual and social dimensions. .

2014/ Canada
Qualitative/ n=40.Age: 65 to 85 years/ Explore the meanings, experiences and perceptions of healthy aging among rural elderly persons.
Interact socially, stay active, independent, optimistic and maintain cognitive health.
Boratti KLP, Soriano FS/ The perception of elderly persons about beliefs on self-efficacy and healthy aging 17 .

2013/ Brazil
Qualitative/ n=6.Age: 60 to 80 years/ To verify the perception of the elderly about the beliefs of selfefficacy and healthy aging.
Perform routine activities, contribute, accept life as it is, have positive thoughts, believe in God and have health.

DISCUSSION
The sample of articles analyzed was diverse, with studies from each continent: America (Canada, USA, Brazil), Oceania (New Zealand), Europe (Germany, Hungary, Latvia, Sweden, United Kingdom), Africa (Ethiopia) and Asia (Thailand).It has been found that, as addressed in the scientific literature, healthy aging is a global concern 3 .
In terms of the participants, individuals under 60 years of age were considered in two studies.An Ethiopian article included Ethiopians over 50 years of age due to the expectation of life in this country being 54 15 .And in New Zealand, New Zealanders aged 55 and over were considered elderly 11.The knowledge produced about the perception of elderly people about healthy aging was discussed through the biological, psychological, spiritual and social dimensions.
The set of habits and behaviors described by the elderly is a priority theme in the National Health Promotion Policy (NHPP) in Brazil 23 , and is expected to form part of Primary Health Care (PHC) through advice provided in educational groups on health, medical and nursing consultations and home visits, among other opportunities 22 .
Thus, the efforts of professionals to prevent or control CNCDs focus heavily on the lifestyle of the individual.Such action contributes to the elderly assuming, in an isolated manner, the selfresponsibility of acquiring a healthy lifestyle.From this perspective, scientific literature encompasses two distinct approaches, which involve either stimulating this posture or encouraging it with caution.
An American study 24 which stimulated selfresponsibility in acquiring a healthy lifestyle considered a model described as a possible basis for enhancing PHC actions among the elderly with chronic conditions.This model consists of four pillars: "centered on the perspective of the elderly"the elderly population considered as a heterogeneous group that requires individualized attention; "goaloriented approach" -setting individualized, specific and achievable goals to be shared with the elderly; "individualized 'training' strategy for behavior change in health" -focused on the elderly and based on instrumentalization with knowledge that allows the awareness that triggers behavioral change to be achieved; and the "context in which healthy behavior occurs" -a network of meaningful relationships for the elderly that contribute to achieving their goals.
In contrast, another American study advocated cautiously encouraging actions aimed at selfresponsibility in the adoption of a healthy lifestyle.It presented in a broad manner the discussion about the poor efficacy of actions directed at an individual lifestyle, emphasizing the need to tackle the deeper causes of CNCDs.It recognizes that the economic and social environment is capable of restricting or increasing opportunities as it interferes in the behavior of the population 25 .As a result, not everyone is able to eat healthily, exercise properly, lose weight and avoid using tobacco, alcohol and other drugs 25 .

Psychological Dimension
In the psychological dimension, the perspectives of the elderly on healthy aging were aggregated, with optimism appearing most frequently 11,13,16,18,19 .The older persons revealed that being positive and optimistic is an essential part of healthy aging, with optimism understood as the expectation that something positive will happen 26 .
Optimism in aging may result from the presence of a social support network, quality of life and individual and social activities within the daily lives of the elderly 27 .Based on this understanding, a Brazilian study brought together scientific productions about optimism and health, and found a significant number of international studies with this theme, considering people with CNCDs.According to these individuals, optimism is considered a factor of protection and coping with the consequences of these injuries 28 .
There is no well-defined concept for happiness as it varies according to the cultural and social context of each country 29 .In South Korea, a study of the elderly revealed an association between family and the perception of happiness.These individuals often described the importance of being together with family and living in peace with relatives 29 .It therefore appears that elderly persons with significant contact with family members and people close to them enjoy a broader sense of well-being than those without such contacts 30 .
The welfare of the elderly is a vital component to be considered in public policies.In 2002, in Madrid, the Second World Assembly on Aging established the International Plan of Action on Aging, listing priorities for action which included "well-being in old age" 31 .In 2015, the WHO report on aging and health encompassed well-being in the concept of healthy aging, emphasizing the importance of "promoting health and well-being throughout life" 3 .Accordingly, in this report, the WHO recommends that to achieve healthy aging, public policies, health services and professionals should work from an intersectoral perspective, connecting the elderly, family and society, and develop actions that promote the development and maintenance of functional capacity as a strategy that allows the well-being of the elderly population 3 .

Spiritual dimension
This dimension brings together the perspectives of the elderly on healthy aging in relation to faith and spirituality.According to the studies that composed the analyzed sample, faith and spirituality provide support for dealing with the challenges of living with multiple sclerosis 11 and facing daily difficulties 19 .Most of these studies, however, while recognizing the importance of this theme for healthy aging, did not explore it further 12,15,17,21 , with the exception of the articles on elderly Thai people 18,20 .
For these individuals, food and care of the body are related to spirituality, as well as the practice of healing and worshipping of ancestors.The practice of healing involves taking care of oneself before consulting a doctor (such as body massages with a piece of wood to relieve muscle pain) and worshiping one's ancestors to preserve health, as failing to do so may result in one falling ill 18,20 .
There is evidence that older people tend to be more religious than younger people 32 .Still, the elderly who live with chronic diseases often have a need to feel close to a higher power which gives them the strength to face difficulties 33 .
Religiousness and spirituality can contribute to healthier lifestyles by assigning negative points of view to the consumption of drugs and alcoholic beverages, tobacco use and nonmarital sex, among others 32 .In addition, they can make it possible to deal with stressful life events 30 , contribute to overcoming adversities, such as the loss of loved ones, the loss of physical abilities, and promote meaning in life.Faith can promote virtues such as humility, altruism, compassion, wisdom and gratitude 32 .

Social dimension
The perspective of the elderly on healthy aging is closely related to social relationships.For these individuals, relating socially 11,13,16,21 , with the family 12,15,[19][20][21] , friends 12,14,19 , or with a partner 12 or engaging in collective leisure activities 13 are ingredients for healthy aging.
It was also emphasized that social relations with family members, children and partners or informal relationships with friends, neighbors and colleagues, as well as formal relationships with health and community services, are fundamental to the wellbeing of the elderly 30 and to healthy aging 3 .Yet strong social relationships can increase quality of life, and longevity and promote resilience 3 .
There is ambivalence 3 involved with social relations as both actors involved in the relationship are influenced in a reciprocal and singular way.At the same time, one person may influence or contribute to a greater extent than the other.In this case, when the elderly participant in the social relationship receives support through such an interaction, it can be said that social support is provided 34 .This can alleviate everyday problems and promote physical and mental health 35 .As a support for health actions, social support can also contribute to increasing the sense of joy, self-esteem and self-confidence of an individual 34,35 .
In addition to being supported, the elderly can also provide support.For many, supporting others is more important than receiving support, contributing to a strengthening of their self-esteem and social involvement 30 .This can be seen by their social contributions 17,18 and desire to do good 21 through voluntary work 11,18 .
According to the WHO, voluntary work can positively influence the health of the elderly, favoring self-perception of health, reducing systemic arterial hypertension, increasing physical strength and gait speed and reducing depressive symptoms 3 , especially as it is socially valued and publicly recognized.It is worth mentioning that voluntary work should respect the autonomy of the elderly, or it may influence their mental health in a harmful way instead of bringing benefits 36 .
Autonomy and independence were also perceived by the elderly as components for healthy aging.Autonomy is the ability to act and take decisions 13 while independence is the ability to perform activities without the help of other people.In this sense, the studies reviewed related autonomy to financial security 11,12,14 , which has also been found to be a component of healthy aging 3 .In Brazil, the National Policy for the Health of the Elderly states that income contributes to the health of the elderly, demonstrating that being healthy should include financial independence, physical health, mental health, functional capacity and social support 37 .This policy also stresses that care for the elderly, at all levels, must preserve their autonomy and independence 37 .
Independence for the elderly involves caring for oneself 15,16 and for others 13 , enjoying activities 13,16 and home management 14 .Elderly persons with multiple sclerosis connected the environment with independence when they noted the need to adapt the environment in which they lived to be able to live independently 11 .It is because of this insight that the WHO highlights the importance of considering the environment in the promotion of healthy aging, noting that it can be a resource or a barrier 3 .Unlike Western cultures, studies that focused on Thai seniors discussed interdependence, rather than autonomy and independence.In the Thai culture the elderly are a central part of rituals, their children and grandchildren demonstrate love and respect towards them, they receive support from their families in many ways (respect, love, care, financial, clothing, among others) and they are honored in village festivals 18,20 .This interdependence favors selfesteem, involves companionship, contact, concern and reciprocity in care 18,20 .
One of the limitations of this study was that it featured a small sample of articles, although the survey reflected the perception of the elderly in diversified countries in relation to cultural, political and social aspects, which influence the population's perception of healthy aging directly and indirectly.
The synthesis of knowledge about healthy aging from the perspective of the elderly can support the actions of professionals who work with this population in order to stimulate and value the social determinants involved, leading to guidance directed exclusively towards the adoption of habits and behaviors inherent to lifestyle in order to age in a healthy manner.

CONCLUSION
The study revealed that the perception of healthy aging brings together biological, psychological, spiritual and social dimensions.In the biological dimension, the need to adopt habits and behaviors inherent to lifestyle to age in a healthy way was clear.Such a position encompasses two distinct discussions: stimulating this behavior or encouraging it with caution, recognizing that the economic and social environment can restrict or expand opportunities, and as a consequence interfere in the behavior of the population.
In the psychological dimension, the elderly described optimism and happiness as important for healthy aging.In the spiritual dimension, most of the elderly recognized faith and spirituality as elements for healthy aging, yet the authors of the studies did not explore this dimension further, except for studies involving Thai seniors.
In the social dimension, social relationships with family, friends and partners were highlighted.There is some ambivalence in this dimension, which is evidenced by the need to receive support and simultaneously support and contribute, mainly through voluntary work.
In this context, further studies are recommended to broaden knowledge of the perspective of the elderly on healthy aging in order to contribute to one of the guidelines of the Global Strategy and Plan of Action for Aging and Health 2016-2020, and to strengthen the relationship between social determinants and healthy aging.

Figure 1 .
Figure 1.Diagram of the result of applying the inclusion and exclusion criteria of the study.São Paulo, 2017.

Figure
Figure created by authors based on PRISMA diagram.
Synopsis of articles included in the integrative review.São Paulo, 2017.
to be continued Chart 2. , Chart created by authors.