How do old men take care of their own health in Primary Care ?

Objective: To understand the care of elderly men with their own health. Method: A qualitative study with the participation of ten elderly men, through responses to the semi-structured interview guided by the “Tell me about your experiences of care with your health”, carried out in a basic health unit, during the period of October-December 2014. The speeches, after being transcribed were submitted to content analysis. Results: The ten interviewees were retired and had an average age of 67.3 years. From the analysis of the data, two categories have emerged: Elderly health care ways and health service as a supporter in the care (less) of the elderly, which revealed the restriction of health care to the triad: medicines, consultation to professionals and exams. Final considerations: Institutional and sociocultural barriers that need to be overcome so that the male population can be consolidated, guaranteeing care of their peculiarities, encouraging active behaviors for self-care. Descriptors: Elderly; Men’s Health; Primary Health Care; Health Services for the Elderly; Self-Care. RESUMO Objetivo: Compreender os cuidados de homens idosos com a própria saúde. Método: Estudo qualitativo com participação de dez homens idosos, por meio de respostas à entrevista semiestruturada norteada pela questão “Conte-me suas experiências de cuidados com sua saúde”, realizada em unidade básica de saúde, no período de outubro-dezembro de 2014. As falas, depois de transcritas, foram submetidas à análise de conteúdo. Resultados: Os dez entrevistados eram aposentados e tinham em média 67,3 anos de idade. A partir da análise dos dados, emergiram duas categorias: Formas de cuidados à saúde pelo homem idoso e serviço de saúde como apoiador no (des) cuidado do homem idoso, que revelaram a restrição dos cuidados com a própria saúde à tríade: medicamentos, consulta a profi ssionais e exames. Considerações fi nais: Barreiras institucionais e socioculturais que necessitam ser superadas para que se possa consolidar acolhimento à população masculina, garantindo atendimento de suas peculiaridades, com estímulo de comportamentos ativos para o autocuidado. Descritores: Idoso; Saúde do Homem; Atenção Primária à Saúde; Serviços de Saúde para Idosos; Autocuidado. RESUMEN Objetivo: Comprender el cuidado de los ancianos con la propia salud. Método: Estudio cualitativo con participación de diez hombres ancianos, por medio de respuestas a la entrevista semiestructurada orientada por la cuestión “Cuéntame sus experiencias de cuidados con su salud”, realizada en unidad básica de salud, en el período de octubre-diciembre de 2014. Las palabras, después de transcritas, fueron sometidas al análisis de contenido. Resultados: Los diez entrevistados eran jubilados y tenían en promedio 67,3 años de edad. A partir del análisis de los datos, surgieron dos categorías: Formas de atención a la salud por el hombre mayor y el servicio de salud como apoyador en el cuidado del hombre mayor, que revelaron la restricción de los cuidados con la propia salud a la tríada: medicamentos, consulta a profesionales y exámenes. Consideraciones fi nales: Barreras institucionales y socioculturales que necesitan ser superadas para que se pueda consolidar acogida a la población masculina, garantizando atención de sus peculiaridades, con estímulo de comportamientos activos para el autocuidado. Descriptores: Ancianos; Salud del hombre; Atención Primaria a la Salud; Servicios de Salud para Ancianos; Autocuidado. CORRESPONDING AUTHOR Walterlânia Silva Santos E-mail: walterlania@unb.br


INTRODUCTION
The concept of health guides the care practices of each individual and connects to socioeconomic-political-cultural events, with consequent differences during time (1) .Therefore, the importance of understanding the thoughts of specific populations that guide the care of their own health.In this study, we sought the look of elderly men, mainly because the number of elderly people in Brazil is increasing, as well as they are examples for young people and, therefore, they guide actions of other members of the family.
People in this age group, that is, 60 years old or more (2) corresponded to 13.4% of the Brazilian population in 2014 and with an estimated reach of 33.7% in 2060 (3) .As a consequence, chronic-degenerative conditions have become the main causes of morbidity and mortality (4) .Although the number of elderly women with chronic conditions and degenerative disabilities is greater than the elderly men, these have a lower life expectancy (5) .
It is worth mentioning that there are fewer men with diagnoses of health impairment compared to women, and it does not mean that they suffer less, but may be related to greater resistance to attending health services, with less participation in health promotion and prevention actions (6) , a characteristic that pervades the gender issue.
Thus, the male population does not prioritize the search for health services, with an impact on the knowledge of general and specific guidelines that favor their quality of life.The health care of the man as a public health problem is a relatively new topic, because although the elderly have been covered by the Brazilian National Health Policy for Elderly Persons (PNS-PI-in Portuguese) (7) since 2006, which proposes the targeting of collective and individual measures of health, man has peculiarities that need to be highlighted.Through this context, we reinforce the importance of understanding the specificities of this population group to better serve them in health services since, in addition to the issues pointed out, the exclusionary cultural aspect of society is summed up when the man moves away from work, most often reflecting their health (8) .
In view of this, the singularities of the elderly men, including by gender, that emerge in childhood and that are perpetuated in the life cycle of these individuals are aspects that highlight the importance of investigations on this topic.
For this purpose, there was identification of a study (9) in which elderly men refused to participate in the study, as well as identification of research with participants of both genders, in which women predominated (10)(11)(12) .When the research participants are exclusively elderly men, the aspects investigated were body perceptions (13)(14) , health (8) , quality of life (15) , health groups (16) .
Thus, with a gap in the literature consulted on the view of autonomous elderly men, that is, those who do not have limitations to develop care with their own health.Thus, it can contribute to the development of projects and interventions in public health for the elderly men, especially in Primary Care (PC), so that this knowledge can subsidize health professionals to act more assertively.

OBJECTIVE
To understand the care of elderly men with their own health.

Ethical aspects
The project was approved by the Ethics and Research Committee of the Foundation for Teaching and Research in Health Science (FEPECS), according to Resolution No. 466/2012 of the National Health Council (17) .And in order to maintain the anonymity of the participants, we identify the speeches by means of the denomination "H" followed by the Arabic numbers (1, 2, ... 10).

Type of study
It is a qualitative study, based on strategic social research, which aims to approach the universe of these individuals, knowing their singularities, their yearnings and their perceptions.

Methodological procedures
The researchers took the time to get closer to the data collection scenario and observed the demand for service to the men in the reception area of the users and waiting room, when they presented themselves to the possible participants who were informed about the objectives, procedures and the possible risks and benefits of the research.Later, the elderly men were invited to participate in the research.Those who agreed to participate signed the Free and Clarified Consent Term (FCCT) in two ways.The document made explicit the secrecy of the information obtained individually and that the participants could refuse or give up the research at any time without any harm to it.
After the legal aspects, the individual was invited to a reserved place of the Basic Health Unit (UBS) to interview questions about the sociodemographic profile (age, marital status, family income, education level), and their care with their own health, being guided by the question: "Tell me about your experiences of care with your health".The average time for the interviews was 30 minutes, being reduced or prolonged according to the availability and receptivity of the participants.

Study scenario
Study carried out in UBS of Health Region of the Federal District that, in 2013, had a population of 449,592 inhabitants.Of these, 48.22% are male, and 14.45% are elderly. (18).

Data source
The participants of this research were men, aged 60 years and older, and preserved global functionality, that is, performing basic daily life activities independently (without supervision, guidance or personal assistance), sought health care during the period of data collection, and, therefore, sample for convenience.None of the elderly approached was excluded, since they all had the ability to express their thoughts, verbally.
The number of individuals followed the saturation criterion of interviews, in this study, with ten interviewees.

Collection and data organization
Data collection took place from October to December 2014.The interview was digitally recorded in order to optimize data analysis, the interviewee being informed of the recording, as well as that the information obtained would be used for academic purposes.
How do old men take care of their own health in Primary Care?Queiroz TS, Rehem TCMSB, Stival MM, Funghetto SS, Lima LR, Cardoso BG, et al.

Data analysis
Socio-demographic data were analyzed by simple frequency.And the recorded interviews were transcribed by the researchers, and then, submitted to content analysis, in the thematic modality (19) .This way of analysis allows articulating the analyzed texts with the factors that determine their characteristics, whether psychosocial, cultural or contextual, and the process of message production (19) .

RESULTS
The interviewees had an average age of 67.3 years, with a minimum of 61 and a maximum of 77 years.With the exception of one who reported being divorced, the others were married.They reported having an average family income of 1.8 minimum wages, approximately R$ 1,300.00.All are retired and three also carry out paid activities.Eight of the ten interviewees are either illiterate or functionally illiterate.
From the analysis of the data, we obtained two categories: 1) Ways of health care for the elderly, with two subcategories: "the other takes care of me" and "I take care of myself"; 2) Health service as a supporter in the care (less) of the elderly man.

Ways of health care for the elderly man
The elderly men participating in this investigation pointed out care actions in order to have a healthy life.These men, for the most part, have reported that such actions are more effective when they are performed by other people, whether family members or health professionals.Therefore, this category unfolds into two subcategories: "the other takes care of me" and "I take care of myself".
"The other take care of me" translates the statements of the interviewees who demonstrated the need for caregiver as responsible for their health, including the control of medication administration, even when they could launch strategy of memorizing them.In this context, the interviewees opted to attend to the request of family member who coordinates the routine of health care, with reminders about health actions, as well as being accompanied to UBS, despite having independence for bathing, dressing, using the bathroom, transferring to the bed/chair by their own, food, controlling urination and evacuation.They also explained the need for a greater incentive to human health so that they feel more motivated to attend such space, since there are other attractions instead of going to health services, such as socializing with friends.

Come [to UBS] ... me and her. She motivates me to look for and reminds me to take the medicines [the UBS]. (H2)
Here in the case only if the person looks for it, because there isn't a specific program to say like this: no, let's do at least once a year, make the specific X test to the man, right.Because for women, for women people say ... Look, let's do a campaign of the thing of breast, thing of cervix.Man, people don't do that.It's not talking like that ..

. let's take a month to, because people say they have a month of the prostate thing, but the people don't do that campaign. (H5)
There is not a [staff] table for a meeting, so I can encourage a man to do it.Like a woman, we are going to do the gynecological exam for prevention, and this and that, in the man's, he hardly sees speak.[...] And I didn't feel anything, so what for?I didn't think I had to take a routine exam, I didn't need anything of that.(H10) The second subcategory "I take care of myself" was more discreet, since some of the interviewees were concerned with the care of their own health, but still restricted to the performance of general laboratory tests or related to sexual and reproductive health; and pointed out the importance of caring to signify being alive.Others sought care only when they had an acute illness.Some interviewees pointed out that men are less likely to seek health care compared to women, as they do not often need such care, pointing out that women are sicker than men or that they are privileged in this context.
And the woman has more time, there are of them that don't work right.And already have to come to the doctor with the child and gets hers too, right?The man has to earn the money, right.And as I told you the binge, the drink that business, there chooses right.Then he chooses, right, so it says: I want business with [...] a doctor, I don't know what, let it go right [...].Women always seek health more than men.The man doesn't seek much health, only when he suffers.When he is in the hospital we see a person coming sick, bored, beaten, broken his head, his leg, then he will see that it has to be treated right.Then he will see that life is good.He's going to drink rum, smoke and fight with others, and then he'll let it go.I don't want to visit doctors, and so on.(H4) The amount of woman you see here.It is a despair, man!!!.The man consults in fact, but it is not so much as the woman like that [...] In a consultation because I think they don't have disease to live so much in the hospital consulting or else they don't need it.(H6)

In the case I do a PSA [prostate specific antigen test] complete every year, to check everything [...] Why do you say you don't feel anything, but suddenly something appears, right? I myself take very good care of my penis which is still good. (H7)
Man is slower, I know that men are very careless and don't take care of their health, right?There's a lot he doesn't want, he only goes the day he sees that the situation is getting worse, that he goes, right?To take care of himself.(H8) Health service as a supporter in the care (less) of the elderly man This category presents the relations established by the participants between the realization or not of care with their own health and the performance of health professionals/organization of the UBS.
How do old men take care of their own health in Primary Care?Queiroz TS, Rehem TCMSB, Stival MM, Funghetto SS, Lima LR, Cardoso BG, et al.
With regard to UBS, the interviewees emphasized the proximity of this health service with their residences as a positive point, but highlighted the difficulty of access to medicines.As for health professionals in UBS, some pointed out disqualified care, yet others described as satisfactory, but were unanimous about the exaggerated waiting in line for this consultation.According to participants, these aspects also weaken health care.
Here is close to home, but you have to face the line, sometimes it doesn '

DISCUSSION
Participants in this study reinforced gender issues such as being a man supports them to take less care of their own health.However, because they are elderly with diagnosed morbidities, as opposed to when they were young, they emphasized the search, even if irregular, of health services, but believe that this care needs to be performed by another sphere, whether it is an element (diagnostic tests, medicines), family (usually female) or health professionals.That is, they did not point out actions in which they can perform, such as performing physical activities or other healthy habits.
Participants characterized the, being a man, as "rested, sloppy or absent-minded" and who prioritized fun rather than caring for one's health.Again, the subliminal discourse of these participants points out how much need to be remembered and cared for by the "other," invigorating the gender issue.That is, it means that they do not see themselves as protagonists of their own care and therefore do not give the proper value to actions that could contribute to that goal, for example, decrease the salt intake and calories in the diet.
Even when they described changes in behavior over the years, that is, of non-health service attendants to become present in consultations with UBS professionals, they revealed thoughts that these punctual actions are enough to take care of their own health.This movement refers to the culture that man needs to be taken care of (20) , and not taken care of themselves.In this way, the interviewees of this research pointed out the access to the triad (medicines, exams, professionals) as synonymous with health.
However, this triad pointed out as the focus to take care of themselves can be the target of interruptions, caused by the paralysis of the professionals' activities, problems with the supply of medicines or of the input to perform examinations, defects in equipment.These events can generate discontent, since they have deposited in the triad the solution of their health problems, or even the way to avoid diseases.Although the elderly men did not give the proper value to clinical examination, they sought to consult professionals when they felt discomforts that were not resolved with home recipes.In their opinions, they pointed out negative aspects of PC for the purchase of medications for chronic condition (antihypertensive, for example).
Self-management with their health was evident in acute aggravation or exacerbation of the chronic condition.One man revealed that his participation in health education activity was associated with a medical appointment scheduling guarantee, or one he shared who performed periodic examinations to investigate sexually transmitted disease, rather than being prevented during sexual intercourse with use of the condom.
The behavior of not seeking health services, frequently, highlighted by the elderly of this research as typical male, was related to the cultural imaginary about what it is to be a man; the fear of discovering that they are sick and the shame in exposing their body (16) .This aspect also converges with other studies (6,(21)(22) in which this resistance reflects the culture of our society and is based on the fact that man is considered to be an invulnerable being and holder of health, being immune to diseases and expendable care.
This aspect only reinforces that there is no need for more programs, in addition to existing programs.Indicating what needs to be guaranteed is the access to PC, as proposed by the national policy of primary care, and thus, populations resistant to developing health promotion and disease prevention behaviors, such as men over 60, can be appropriate information that would make them the protagonists of their care, that is, participation of health education actions, because as we identified additional demands, these could be incorporated into our culture of care.
The speeches of the participants of this investigation converged with those of another study (5) on the need for incentives to users by health professionals.However, they concluded that, after an educational intervention for elderly men, there were no changes in behavior to deal with the health-disease process.It is worth emphasizing that the work of promoting health with men depends on demographic, personal and cultural factors, so the importance of intensifying intervention activities.
Moreover, another reason that may justify men's low demand for health services (23) is the mismatch of the structure of care and assistance to the specific demands of the male population, which may increase their difficulties in the search for health care, as well as to contribute to their lesser commitment to maintaining healthy habits and adherence to treatments in situations of greater vulnerability.
In the structural aspect, there is little investment in the organization of the service from a gender perspective, reinforcing the common sense that men are not primary care users, so they repressed their health needs and presented difficulties expressing them, looking for less (22) , this aspect was highlighted by the participants of this research, pointing out the need to adapt the spaces for this population's inhabitants, since they referred to the identification of early diagnosis directed only to women, and therefore, the approach to health services.Some of the interviewed elderly men sought UBS only when they presented a health problem and sought immediate solution; an aspect that corroborates the fact that man undergoes a cultural process, in which it is imposed on them that this kind does not need health monitoring.Men have difficulty recognizing their needs, cultivating magical thinking that they do not get sick (22) .
According to the participants of this study, women become more sick, reinforcing the, being man, as healthy, but these thoughts expose how much society imposes to man a posture of not showing its fragilities (22) .Being that the demand resistance of health service for treatment or prevention of diseases reflects conceptions of this androcentric society (22) .
In old age, men are led to confront their own vulnerability, especially since at this stage in the life cycle, many men were led to seek health services in the face of irreversible illness, because they did not use injuries (24) .
In view of this situation, the elderly men interviewed pointed out strategies to establish a link between elderly men and UBS, such as the provision specific incentives and care directed to men, so that they feel included in care, in the same way that they identified care for women.They suggested care due to gender separation, even when monitoring for chronic conditions, such as systemic arterial hypertension.
This attendance requested by the participants may at first look discriminatory, that is, separate by gender, but this indication reflects opinions of men interviewed, and of course, our culture, as well as the desire of these men to meet with other men in the service environment health, and thus share similar problems (25) .
It is worth mentioning that data collection also took place in November at UBS, which developed activities of the campaign named "Blue November" (campaign to promote preventive measures for cancer of the prostate), with a proposal to care for men (adults and the elderly).When questioned directly about the campaign, they were unable to identify any specific action for men.This aspect, although not the subject of this study, is something that needs to be investigated, as it may be related to the way the campaign is publicized, or even to the adequacy of the language.
In this context, the health team needs to plan actions for this population, adapting to the environments frequented by men to initiate the process of changing the vision of this population and care for their own health.Education level is also a reason not to understand some aspects of the campaigns, as well as to prefer to be accompanied by the wife to attend the health service.
Another aspect that was pointed out by the participants is the change of care in hospitals.With the implementation of risk classification, cases that are not urgent/emerging are referred to UBS (10) .This movement has been happening as a form of organization of the health care network (HCN), as recommended by the Ministry of Health, in which PC occupies a prominent position as the coordinator and coordinator of care (25) , therefore, the initial monitoring should be in PC and be referred to another point in HCN, if there is a need for specialized and/or hospital care.The positive aspect also reflects this organization, since in the UBS seeks to privilege the proximity to the user of the affiliated region of the health service.Thus, geographical access was a facilitator to go to the health service.
According to most of the interviewees, this geographical issue did not make health care difficult, since UBS is close to or at a reasonable distance from their homes, and because they were elderly, they did not mind using public transport, since they did not need to spend amounts for fee payment (26)(27)(28) .
Most reported that they went to the service, mainly to get drugs provided monthly, but they often came across the lack of them and described the frustration feeling as a complicating factor for the continuity of health care.Thus, organizational access, reported both on professional care as well as service offerings, was also highlighted as an aspect that extenuates care with one's own health, being discouraged, especially since they described the financial difficulty to obtain such inputs through their own means.
Regarding the professionals, the participants pointed out predictors of satisfactory care of the UBS professionals, that is, the explanation of how their needs will be met.In this way, they reported commitments with the returns for the examinations, consultations, acquisition of medicines and immediate access to acute aggravations.However, they felt disadvantaged when faced with the lack of medicines and when they are not well served, affecting adherence to treatment and continuity of care.In addition, these obstacles generated the search to meet these needs in other UBS.Faced with this reality, the elderly need to overcome their physical limitations (despite performing basic daily activities) and socioeconomic, to acquire medication and continue treatment.However, they restricted care to these actions, omitting other actions of self-care.
Although the participants in this study were retired, some remained active in the labor market, that is, with limited time to dedicate themselves to health care.A previous study (28) found the lack of time as a justification for the low participation of men with PC, including specific campaigns for them, as in the case of screening for prostate cancer.
Considering this point is important for the planning of health actions, since the UBS generally work during the day, coinciding with the working hours of these individuals (28) .This aspect could also be related to the lack of knowledge of the majority of participants about the "Blue November" campaign and reduced coverage of the family health strategy in the Federal District, of 12.5% of the population (29) ; therefore, the minority has domiciliary agents with updated information on health actions.
In a study conducted in the United States, the elderly pointed out that not only the users, but also the health team needs training on health promotion policies (30) , so that they can develop educational activities skills consistent with age groups.
Regarding the lack of help in health care, this was expressed by 5% of men and 3.03% of diabetic women in another study (31) .Although this index is not very representative from the numerical point of view, it expresses important social implications and should be considered by the formal social system (health/social professionals/services).
In addition, as the elderly, people have already appropriated information from different sources from family members to social networks and health professionals, as well as their experiences that have supported decision-making about health care.The elderly may have approached health services at different moments of their lives and these environments were regulated by public policies that evolved, not only in terms of technological equipment, but also in the manner of providing care to the user.These movements can lead to misunderstanding of the organization of health services, and therefore, choose not to use it.
Thus, because of the age range of the interviewees, they have experienced different health service organizations, due to the adopted models of health care in Brazil in the last decades (32) , as National Institute of Medical Assistance of Social Security (IN-AMPS-Instituto Nacional de Assistência Médica da Previdência Social); Unified and Decentralized Health System (SUDS-Sistema Único e Descentralizado de Saúde) and Unified Health System (SUS-Sistema Único de Saúde).In general, the users have approximated these changes only when they made attempts to attend the hospitals/UBS, in this way, the participants of this study expressed dissatisfaction, and the implementation of the HCS, in the eyes of the interviewees, has been a dynamic with greater demand for UBS and waiting time for long-term care.
The results presented reaffirmed the lower participation of men in projects developed at UBS, mainly because they do not feel the need to participate in health education activities, both for the long term and for the language that needs to be appropriate to the male context.Thus, in the imaginary, we constructed the belief of continuous immunity, generating a deficit of selfcare.Consideration should be given to distinguishing between genders in relation to the different patterns of aging (33) .

Study limitations
The distancing presented earlier made it difficult to perform this investigation, although we managed to saturate the data.And as a limitation, we identified the need to expand to other points of the health care network for older men, and in this way to understand the optics beyond basic care.

Contributions to the area of nursing, health or public policy
In order to attend to this population, the team needs to appropriate tools that can awaken the elderly in their own care, since there is no coherence in the historical-political-economic context, the reinforcement of machismo and assistance.One of the tools we can implement in the care of elderly men is self-care supported, which focuses on health promotion and disease prevention.And in this way, men in this age group can achieve goals to improve their health condition and lead their therapeutic plan.
It is hoped that this research will contribute to the enrichment of debates among the managers and health professionals of UBS, especially the nurse, so that future actions are planned and executed, since they pointed out important aspects for the planning of care for the elderly male population .In this way, the nursing team can emerge with provocations and stimulations to this specific population to appropriate and apply the supported self-care.
In addition, we point out the need for further studies that address the perspectives of older men about health in other services, which can be carried out in community centers, homes to support the elderly, providing indicators for the implementation of actions and programs involving elderly men as protagonists of health care.

FINAL CONSIDERATIONS
From the objective and, at the same time, answering the question of the title, these elderly people have restricted their care with their own health to the triad: having medicines, consulting professionals and performing tests.
We identified barriers for both participants and health services, which need to be overcome in order to consolidate the culture that welcomes the male population in a unique way, ensuring care of their peculiarities; since, for these elderly men, taking care of one's own health is to place some responsibility for such care, such as technologies (equipment and examinations) and caregivers (professional and non-professionals), it is necessary to implement actions that responsibility of the users.
In the course of the study, we noticed that institutional barriers proved to be a limiting factor in the search for healthcare in the interviewees.However, sociocultural barriers were highlighted, since they expected to present acute and unresolved symptoms at home, in order to seek health care.Therefore, the facilitation of access to early care services has proved to be an element that encourages and encourages older men, mainly due to the gender issue.
In this sense, we perceive that the provision of access to men is of fundamental importance for establishing/strengthening links between users and health professionals, so that this movement will require professionals trained and sensitized with the health needs of independent elderly men, so that together they develop synergetic therapeutic design of treatment, prevention of diseases and health promotion.
t work and you have to go home.(H1) [...]You have to change everything.First place, putting the morals on the doctors and the employees to serve well ...Last week I arrived and he answered me badly, saying that it is already over.He doesn't explain things right.(H3) It's good because it serves us well.He serves well, every life that comes to us is attended to.[...] Now about our medicine it's been a month that is missing, two months, three months.Sometimes you come, have one medicine and there is no other, there is no other, there is no other and they tell you to go to the pharmacies that provide medicine, but also there is another problem because they only want the prescription for four months and then there is a problem [...] because the wages [money] cannot afford to buy the medicine too, because it's expensive, right?. (H6) What medical care here [...] is it bad?I cannot deny it, because I've seen it, do you understand?For the poor here [...] business is very difficult.(H9)