Conhecimento produzido sobre a saúde das idosas de baixa renda : revisão integrativa Knowledge produced on the health of low-income older women : an integrative review

Objective: to identify the knowledge produced on the health of low-income older women. Method: an integrative review was conducted in February 2016 on the SCOPUS, CINAHL, MEDLINE, LILACS, EMBASE, WEB OF SCIENCE databases, and in the SciELO journals directory. After the application of inclusion and exclusion criteria, 24 articles were selected. Results: the knowledge produced comprises two main themes: “health in face of economic adversities” and “reciprocity in social support between low-income older women and their social network”. Final considerations: health professionals, especially nurses, should be attentive to aspects related to social determinants and the health of low-income older women, highlighting the fact that they are not always the recipients of care. Descriptors: Poverty; Elderly; Social Support; Women’s Health; Public Health Nursing. RESUMEN Objetivo: identifi car el conocimiento producido sobre la salud de las mujeres ancianas de bajos ingresos. Método: revisión integrativa realizada en febrero de 2016, en las bases de datos SCOPUS, CINAHL, MEDLINE, LILACS, EMBASE, WEB OF SCIENCE y en el directorio de revistas SciELO. Una vez aplicados los criterios de inclusión y exclusión, fueron seleccionados 24 artículos. Resultados: el conocimiento producido incluye dos temáticas principales: “la salud frente a las adversidades económicas” y “reciprocidad en el apoyo social entre las mujeres ancianas de bajos ingresos y su red social”. Consideraciones fi nales: los profesionales de salud, en particular el enfermero, deben brindar atención a aspectos relacionados a los determinantes sociales y de salud de mujeres ancianas de bajos ingresos, destacándose que las mismas no son siempre receptoras de cuidado. Descriptores: Pobreza; Anciano; Apoyo Social; Salud de la Mujer; Enfermería en Salud Pública. Conhecimento produzido sobre a saúde das idosas de baixa renda: revisão integrativa Knowledge produced on the health of low-income older women: an integrative review Conocimiento producido sobre la salud de las ancianas de bajos ingresos: revisión integrativa REVISÃO Renata Evangelista Tavares E-mail: renata_tavares@usp.br AUTOR CORRESPONDENTE


INTRODUCTION
Population aging is a reality.The elderly represent 12% of the world population, and this figures is expected to double by 2050 (1) and triple by 2100 (2) .The high number of elderly people is the result of a demographic transition, resulting from the reduction of fertility and mortality rates in different age groups (2) .In this context, the importance of public policies that help people achieve advanced ages with better health is highlighted (3) .
Both in the national and international scope, the current public policies that are more relevant to the older women's health are highlighted.In 2002, in Madrid, the Second World Meeting on Aging was the basis for the International Plan of Aging that consisted of three principles, among which the active participation of the elderly in society and the eradication of poverty stand out (3) .Thus, to elaborate regional strategies aiming at the implementation of objectives and goals agreed in Madrid, in 2003, the Intergovernmental Conference on Aging in Latin America and Caribbean was held in Chile.Also in the context of adequation to the guidelines agreed in Madrid, Law no.10.741/2003 that provides for the Statute of the Elderly has passed in Brazil (3) .In 2006, Ordinance No. 2528 was approved, which provides for the National Policy on the Elderly's Health (3) , incorporating the recommendations agreed in Madrid and addressing although superficially, the issue of gender in aging (3) .
The question of gender in aging is significant, since women correspond to the majority of the Brazilian elderly population (55.7%) (4) .There is evidence that older women in the world are more prone to poverty compared to older men (2,5) .However, it is recognized that few countries have robust data on poverty levels that relate age and gender (5) .
In Brazil, mainly two strategies for economic classification are adopted: the Brazilian Institute of Geography and Statistics (IBGE) and the Brazilian Association of Population Studies (ABEP), which is the criterion of economic classification in Brazil, also known as Critério Brazil.
IBGE uses the minimum wage as a criterion for the evaluation of the economic class (4) , with the individual who belongs to classes D or E being considered of low income, that is, the one presenting an income of two to three minimum wages and up to two wages, respectively.The criterion for the evaluation of economic classes -Critério Brazil -considers those of classes D or E as having low income, using an instrument that evaluates the number of household appliances, household employees, level of education of the head of the household, and access to public services (6) .
Poverty, low economic and educational status, and poor housing are some of the main factors that generate social and health inequities, and social vulnerability (7) .Coping with social vulnerability can be effective with the improvement and application of the public policies that ensure the defense of rights and access to goods and services (8) .
Social and health inequities are an adversity in all countries, to a greater or lesser extent, generated by economic disparities that produce differences in opportunities given to individuals, considering factors such as ethnicity, race, social class, gender, educational level, disabilities, sexual orientation, and geographical location (7) .This makes the gathering of national and international scientific evidence pointing to low-income elderly women and their singularities in the social context relevant.
The objective of this integrative literature review was to identify the knowledge produced on the health of low-income elderly women.The elaborated scientific production can lead to the reflection and improvement of care directed to this population.

METHOD Ethical aspects
Since this is a review of published studies, the project was not submitted to a research ethics committee.It should be noted, however, that the original ideas of the researchers were retained when the content was synthesized.

Type of study
This is an integrative literature review, which is a relevant method for the field of health, because it enables to capture, critically appraise and synthesize knowledge on the theme investigated (9) .This method helps to identify results that contribute to professional decision making, as well as to the development of future research (9) .

Data collection and organization
This integrative review was structured in six stages: selection of the research question; establishment of criteria for inclusion and exclusion of studies (sample selection); definition of the information to be extracted from the selected articles (categorization of studies); analysis of information; interpretation of results and presentation of the review (knowledge synthesis) (9) .
The research question was: What was the knowledge produced in the literature on the health of low-income elderly women?The scientific research survey was conducted in February 2016 by the main researcher in the main health databases: Scopus Info Site (SCOPUS), Cumulative Index to Nursing & Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin American and Caribbean Literature in Health Sciences (LILACS), EMBASE, WEB OF SCIENCE, and in the journals directory Scientific Electronic Library Online (SciELO).
The survey of the productions in the databases and in the SciELO journals directory was performed using the descriptors obtained after consultation in the Descriptors in Health Sciences (DECS) and in the Medical Subject Headings (MESH), keywords, CINAHL terms, and Emtree terms.It is noteworthy that the use of the CINAHL and Emtree terms is recommended, because they are thesauri created specifically for searching on the CINAHL and EMBASE databases, respectively.The search strategy is presented in Chart 1.

Inclusion and exclusion criteria
The inclusion criteria used to compose the sample were: scientific outputs published from 1994 to 2015 (the initial period was established in view of the publication of Law No. 8842 of January 4, 1994, which provides for the National Policy on Elderly) (3) , in Portuguese, English or Spanish, available electronically in full; original articles that address low-income women aged 60 or over at the Latin American databases and 65 years or older at other databases.Duplicates in more than one database were excluded.

Data analysis
Based on the sample composition, a database was prepared in Microsoft Office Excel 2010.This allowed organizing and compiling the following information from the selected studies: article title, first author's profession, year of publication, country, database, journal, nationality of study participants, design, intervention and outcome.The data obtained were grouped in instrumental tables and in thematic categories, by content similarity.The results were interpreted based on the literature related to the study theme.

RESULTS
Inclusion and exclusion criteria were applied, and allowed the selection of 24 articles to form the study sample, according to Figure 1.
As to the content of the articles, it was evident that the knowledge produced brings together two main themes: "health in the face of economic adversities" and "reciprocity in social support between low-income elderly women and their social network." Chart 2 shows the synopsis of the articles selected for the integrative review.Correlates of self-care behaviors among low-income elderly women with hypertension in South Korea (10) 2014 South Korea Quantitative, descriptive correlational n= 234

Secondary data analysis of a community-based intervention study for hypertension control
The youngest elderly women had better control of hypertension, were self-effective and more prone to report better behaviors of self-care.
"My legs affect me a lot… I can no longer walk to the forest to fetch firewood": challenges related to health and the performance of daily tasks for older women in a high HIV context (11) 2014 South Africa

Qualitative, narrative analysis n=30
Open interviews about daily activities The elderly women took care of their homes and families, made grass carpets or sold traditional beer, [...] took care of ill people.They were responsible for many of their grandchildren.
Future talk in later life (12) 2014 Portugal

Qualitative, ethnomethodological n=7
Workshop named "Selfawareness about the future" performed in three sessions The older women expressed negative perceptions of their future and negative connotations on aging.
Aspects of quality of life associated with self-rated health: a study of elderly women from a physical activity program in low-income neighborhoods in Curitiba in the state of Paraná, Brazil (13) 2013 Brazil

Quantitative, cross-sectional n=450
Instrument Whoqol-Bref and Likert scale to classify health perception The Physical and Environmental domains had the greatest associations with negative health perception.Eight in each ten older women had a negative health perception.
Older women associating obesity with a negative perception of their health: a study in low-income neighborhoods in Curitiba, southern Brazil (14) 2012 Brazil

Quantitative, correlational, cross-sectional n=449
Questionnaire application, measurement of body weight (kg) and height (m) Obese older women had 2.09 more chance of having a negative health perception.
Factors associated to risk of malnutrition amongst elderly women in low-income communities (15) 2012 Brazil

Quantitative, cross-sectional n=222
Questionnaire application, measurement of body weight (kg) and height (m), arm and calf circumference (cm) The older women had a prevalence of 33.8% with risk of malnutrition, or were undernourished, and 64% were classified as overweight or obese.

Quantitative, cross-sectional n=222
Questionnaire application, measurement of body weight (kg) and height (m), arm and calf circumference (cm) The prevalence of functional disability was 46.8%.
Informal support networks of lowincome senior women living alone: evidence from Fort St. John, BC (17) 2011 Canada

Qualitative n=62
Questionnaire, via mail, to identify the support networks Older women who lived alone depended more on their families and friends (informal support).
Factors associated with depressive symptoms in low-income, older Korean women with hypertension (18) 2011 South Korea Quantitative, cross-sectional n=107 Geriatric Depression Scale, Katz Index of Independence in Activities of Daily Living, and The Lubben Social Network Scale 64.5% of the older women showed social isolation or were in high risk of isolation.
Examining mindfulness-based stress reduction: perceptions from minority older adults residing in a low-income housing facility (19) 2011 USA

Qualitative n=13
Focus groups in the Eldershine Program Benefits such as stress management and possibility of social support were found.
Social support among elderly women in a low income area in the municipality of Rio de Janeiro (20) 2010 Brazil

Quantitative, cross-sectional n=442
Application of questionnaire to measure social support The flow of exchange relations was greater from the older women to their families than the opposite.
Concurrent validity of self-reported weight and height for diagnosing elderly women's nutritional status (21) 2010 Brazil

Quantitative, cross-sectional n=181
Questionnaire application, measurement of body weight (kg) and height (m) 62% of older women were classified as overweight or obese.
Effects of exercise program on physical fitness, depression, and self-efficacy of low-income elderly women in South Korea (22) 2009 South Korea

Quantitative, experimental n=48
Exercise program consisting of four weeks of education and eight weeks of physical exercise.
Significant improvements were noted in relation to depression, self-efficacy and all measures of physical fitness, except for heart rate and flexibility (experimental group).
To be continued

Title
Year/ Country

Design/ Number of participants Intervention Outcome
Factors associated with physical inactivity amongst elderly women in low-income communities (23) 2009 Factors associated to functional limitations in elderly of low income (24) 2008 Brazil Quantitative, cross-sectional n=208 Questionnaire application and Fulleton Physical tests 56% of the older women had moderate or severe functional limitations.There was a significant association with the age group over 80 years, widowhood conditions, presence of arterial hypertension and physical inactivity in leisure time.
Testing and developing the health promotion model in low-income, Korean elderly women (25) 2008 South Korea
Psychological factors were perceived as the most important component of health promoting behaviors.
Socio-demographic profile and selfreported health status of elderly women in a low-income community (26) 2008 Brazil

Quantitative, cross-sectional n=369
Questionnaire application based on Brazil Old Age Schedule 62.3% of the older women had a monthly income of up to one minimum wage, and 22% reported having no income.The higher the income, the better the perception of the elderly regarding their current state of health.
Living vigilant lives with chronic illness: stories from older lowincome minority women (27) 2008 USA

Qualitative, descriptive n=13
Focus groups on experiences on dealing with chronic diseases.
Speaking for themselves something positive, having strong spiritual faith and not letting themselves lose the meaning of life were strategies used by the older women.
Medicalization of elderly females and interaction with consumption of tranquilizers (28) 2008 Brazil Qualitative, descriptive n=18

Questionnaire application on use of tranquilizing drugs
Older women with experience in attending health services, including psychiatric ones, were able to incorporate knowledge and experiences on the use of tranquilizers, promoting their diffusion in the social environment.
Nursing Diagnoses of Pauper Elderly Women of a Family Health Program (FHP) (29) 2008 Brazil

Qualitative n=69
Questionnaire application, Geriatric Depression Scale and Behavior Scale Among the most frequent diagnoses, the following stood out: "Impaired physical mobility", "Chronic pain" and "Impaired home maintenance".
Nutrient intakes and serum lipid profiles are improved in elderly Korean women with home food delivery (30) 2007 South Korea

Quantitative, experimental n=27
Delivery of food at home to be consumed for one week Significantly improved intakes of vegetables, protein, fat, iron and vitamin A, and reduced depression significantly in the group receiving food at home.
Elderly women show neither a shortage of strategies nor an overreliance on drugs in handling aging and in dealing with minor health problems (31) 2005 Canada

Qualitative n=49
Semi-structured interviews about how to age healthily Medication was not seen as panacea nor as source of youth by the older women.
Breast cancer knowledge, beliefs, and Screening behaviors among low-income, Elderly black women (32) 2003 USA

Quantitative, cross-sectional n=214
Focus groups on Breast Cancer Knowledge, Beliefs and Screening The younger group (65-74) was twice as likely to recognize risk factors for breast cancer compared to the older (≥85 years).
Elderly Mexican women's perceptions of exercise and conflicting role responsibilities (33) 2001 Mexico Quantitative, crosssectional n=50

Questionnaire application and instrument Stages of Change-Exercise
Obstacles for participation in physical activities: caring for the husband and grandchildren, housework, church appointments and childcare at home.

DISCUSSION
Brazil is recognized worldwide as a country with high and persistent income inequality (34) .The analysis of the Brazilian Gross Domestic Product (GDP) indicated the stagnation of economic growth in 2014, and decrease in 2015 (34) , revealing that there is no expectation of resolution of this political-social problem in the short term.South Korea has invested in research and economic policies aimed at reducing income inequality among the elderly population, because more than half of them live in poverty (35) , which explains the largest number of publications on low-income elderly women in both countries.
The knowledge produced on low-income older women was discussed starting with the following themes.
Theme I -Health in the face of economic adversities Low-income older women have a high prevalence of functional disability (16) .The impairment in functional capacity "causes social seclusion, a trend towards sedentarism, and loss of self-esteem" (36) .Thus, maintenance of functional capacity should be encouraged by the health team, because it allows for well-being at old age and healthy aging (37) .
An attentive look at long-lived older women (80 years and over) is necessary, considering that they are more likely to show moderate to severe dependency when performing instrumental activities of daily living, dissatisfaction with body overweight (23) , physical inactivity in leisure and hypertension (24) .
Low-income older women have difficulties performing regular physical exercises (33) .The barriers reported for not carrying out these activities regularly were: caring for the husband and grandchildren, housework, church appointments, and child care at home.These findings are corroborated by a long-term study on long-lived women that revealed physical limitations due to illness, long-lived person's lifestyle, family role (overprotection and lack of encouragement), and influence of the environment (inadequate means of transportation and lack of safety) for the development of physical activities (38) .
It is understood that the barriers for low-income older women to perform physical exercises are related to commitments made with their social network, while the barriers reported by long-lived women are individual, and related to the social environment.Therefore, the professionals have to recognize the barriers to practicing regular physical exercise, to evaluate them and to encourage this practice that significantly improves depression and self-efficacy (22) .
In addition to questions related to functional capacity and physical exercise, the scientific production on low-income older women indicates that chronic noncommunicable diseases (CNCDs), especially hypertension, are challenges faced in the daily life of this population group.
In order to confront CNCDs, they use the following strategies: speaking something positive for themselves, having strong spiritual faith, and not losing the meaning of life (27) .In agreement with this result, a study with Brazilian elderly people with CNCDs emphasized that the "meaning of life" or "sense of existence" for them is related to the importance of the presence of relatives in the social context (39) .It is therefore crucial that health care of older women with CNCDs goes beyond the medication and inherent issues of lifestyle changes, also considering subjectivity and culture.
In assisting older women with CNCDs, it is also necessary to qualify the care with knowledge on the health problems presented, contributing to self-care, autonomy and independence.Also, to involve the family and/or social network people to support in health care.In this perspective, it is important to intensify the attention to long-lived low-income women, because two studies pointed out the disadvantages experienced by them, involving lack of knowledge regarding CNCDs (10,32) .One study found that long-lived women are less likely to recognize risk factors for breast cancer (32) , and the other showed that they have less control of hypertension, selfefficacy, and are less likely to report better health behaviors (10) .
Older women's health is also influenced, positively or negatively, by the use of medications.A study on low-income Brazilian older women attending an outpatient mental health service indicated that they used benzodiazepines to treat disagreements with family members, suffering from illnesses, deaths, and economic distress (28) .In addition to using these medications, they encouraged family and friends to use them as well (28) .
The use of benzodiazepines is associated with the risk of dependence, cognitive deficits, falls that result in fractures and traumas, accidents with motor vehicles and global mortality (40) .Therefore, professionals who prescribe this type of medication need to pay attention and carefully evaluate the real need for this therapy, prioritizing pharmacological and non-pharmacological measures that are alternative to their use (41) .
Unlike the elderly women who use medications to confront family conflicts, illness and economic problems, Canadian older women considered to be low-income women are careful when using medications (31) .In this case, it should be noted that these women, even though they are classified as low-income by the authors, have higher income than those in the Brazilian study.Therefore, it can be inferred that they have better living conditions, high level of education, and quality of access to health services and, therefore, use medications in a prudent way.
Regarding quality of life, low-income older women with negative health perception had lower scores in the areas of quality of life: Physical and Environmental (13) .This finding is similar to that of a study carried out with elderly Brazilians residing in cities of the Triangle of the State of Minas Gerais, in which they also presented lower scores in the Environment domain (42) .In the latter study, most elderly people lived with an income of one to three minimum wages and presented low level of education (42) .
The Environment domain deserves attention, because the place where one lives can contribute to dependence, lack of autonomy and social isolation (42) .A survey carried out with Polish elders found that in order to have a high quality of life, it is necessary to have good education and sufficient income to live (43) .Therefore, it is important to consider that, in health care for elderly women, social determinants, such as income and level of education, contribute to quality of life and consequently to a positive perception of health.
Negative health perception was identified in low-income elderly women (12)(13)26) . Studes that involved the evaluation of body mass index (BMI) recognized the prevalence of overweight and obesity in the low-income elderly women (14)(15)21) .To corroborate these findings, a study developed with Brazilian older people living in the city of Porto Alegre, in the state of Rio Grande do Sul, showed that, in addition to the prevalence of overweight and obesity, dyslipidemia was also more prevalent in elderly women (44) .
According to IBGE data, the prevalence of overweight in Brazilian elderly is higher among older women (41.9%) compared to men (31.6%), and the Brazilian regions with the highest prevalence are the South (45.1%) and Southeast (38.3%) (45) .Thus, obesity is a relevant issue for the health care of low-income elderly women.
Nurses were the professionals who published the most on the subject researched.However, only the publication on nursing diagnoses brought a discussion focused on nursing care to low-income elderly women.Diagnoses of "impaired physical mobility", "chronic pain" and "poor home maintenance" were the most frequent (29) .It should be emphasized that health care of older women needs to be based on the health needs of this population, because only then it is possible to predict and take action in health care when facing economic adversities of this vulnerable population.
Theme II -Reciprocity in social support between lowincome older women and their social network Social support may be formal or informal.Formal support consists of institutions and government agencies, and informal support consists of family members, friends and neighbors (46) .When elderly people receive social support, they are less likely to get sick, which contributes to the improvement of their quality of life (46) .
A study on low-income Brazilian women living in a community in the city of Rio de Janeiro found that they supported families more than the opposite (20) .This support was of a financial nature, because their retirement money contributed to the family income.In addition, they indirectly supported their families, because they cared for the grandchildren so their children could work.
South African women living in villages also supported the family more than they received support (11) .They supported through their work, making grass carpets or selling traditional beer (11) , in addition to cooking, cleaning, collecting water and firewood, plowing the land, hitting corn, and caring for grandchildren and sick relatives (11) .Taking care of the grandchildren for the older women participants of the study in South Africa, most of the time, implied being responsible for them due to the loss of the "intermediate generation" that emerged as a consequence of the morbidity and mortality generated by the virus epidemic and immunodeficiency syndrome (11) .On the other hand, the study on low-income Canadian older women living alone identified that they depended significantly on informal support (family and friends) (17) .
The size of the friends network is positively associated with happiness, and the relationship of closeness with relatives is related to high levels of satisfaction with life (47) .Thus, relying on the social network generates benefits related to the health and well-being of low-income older women, and it is important to encourage activities that increase social support (19) .On the other hand, according to the studies analyzed, these women showed to be great supporters of the family.This result evidences older women as citizens who still contribute to society, family and friends.

Study limitations
When addressing the issue of "low-income elderly women", we included older women classified as such according to their country of origin.This means that there is no possibility of ensuring that they all have the same economic condition, level of education, and the same disadvantages regarding access to health and social services.

Contributions to the areas of nursing, health and public policies
The relevance of this review is the presentation of the synthesis of primary studies that discuss social and health issues of low-income older women in the last 15 years, bringing evidence that can guide public policies and professional actions directed at these women.
The need for counseling to prevent overweight and obesity, to encourage regular physical exercise, and to monitor the use of benzodiazepines evidenced in the study should be valued in public policies aimed at low-income elderly women, as well as by the health and nursing team in care practices.A professional training that values the physical and social environment, lifestyle and the knowledge of these women about the CNCDs can contribute to improve health care of these people.
It should be pointed out that, in this review, no articles were identified that would broaden the discussion about aging connected to gender and income, and also about the health needs of these elderly women.Therefore, the development of further research, mainly at a national level, to contemplate these themes and contribute in a concrete way to the health care of low-income older women is considered necessary.

FINAL CONSIDERATIONS
The knowledge produced in the literature on low-income older women showed the need to pay attention to overweight and obesity, quality of life, functional capacity, practice of regular physical exercises, and knowledge related to chronic noncommunicable diseases, with special attention to those who are classified as long-lived.It was emphasized that older women who are economically disadvantaged use benzodiazepines to deal with family conflicts, illness and economic problems, and encourage the use of this drug among the people in their social network.
There is reciprocity in social support among the low-income older women and their social network.They contribute financially, directly to the family income, with their pension, or indirectly when they take care of the grandchildren so that the children can work.
The results of this study indicate the need for health professionals, especially nurses, to pay attention to aspects related to the social and health determinants of low-income older women, emphasizing that they are not always only care recipients.

Figure 1 -Chart 2 -
Figure 1 -Diagram of the result of the application of the study's inclusion and exclusion criteria, 2016