Technologies that promote health education for the community elderly: integrative review

Objective to identify in the scientific literature the technologies developed to promote health education for the community elderly. Method integrative review that included original articles indexed by Latin American and Caribbean Literature in Health Sciences, Medical Literature Analysis and Retrieval System Online, Cumulative Index to Nursing and Allied Health Literature, Scopus, Web of Science, Science Direct, and Cochrane databases, without restriction of time and language. Results were analyzed descriptively, in five analytical categories. Results Fifteen articles published on national and international journals were selected, with predominance of experimental studies that tested the effects of such technologies. The types of educational technology developed were printed materials, software and video, as well as mock-up and telephone support. Falls in the elderly were the most discussed theme. The studies have shown that the types of technology found are feasible to promote health education for the community elderly. Conclusion The technologies developed to promote health education for the elderly were multiple and proved effective for use in community interventions.


Introduction
The increase in the number of elderly people observed worldwide is a milestone in the longevity transformation process and emerges from changes in the behavior of fertility and mortality rates. Globally, this demographic segment represents 12.3% of the population, with a growth rate of 3% per year. Global In this scenario, the demands of health services also increase, especially when considering life multiple dimensions and the heterogeneity of the elderly living in the community (2) . Thus, implementing actions that consider integrality and promote active aging is an important challenge for the elderly health. Therefore, health professionals should optimize health promotion strategies that enhance the social participation of the elderly and respect their autonomy (3)(4) .
For this purpose, health education is a necessary tool to promote the elderly health, since it provides knowledge for the prevention and reduction of diseases, makes the person active in the life transformation, and encourages self-care and search for autonomy. With regard to Gerontological Nursing, health education is an integral part of nurses' clinical practice and allows for creativity and multiplicity of choices. However, it is essential to consider the elderly singularity so that to stimulate changes in individual behavior (5)(6) .
In this context, the technical-scientific advance enabled the emergence of educational technologies.
They are result of concrete processes, based on daily experiences, and aimed at the methodical development of knowledge and knowing to be used for specific practical purposes. Therefore, use of educational technologies is seen as improvement to care orientation for the community elderly (7)(8) .
Due to this reality, educational technologies in the tactile and auditory, expository and dialogical, printed and audiovisual modalities are considered methodological strategies to promote health education for the elderly (9) . Thus, introducing such technologies contributes to the construction of the elderly's selfcare knowledge and empowerment.
However, it should be noted that no review studies that presented the technologies already developed to promote health education for the community elderly were found in a wide search in the national and international literature. In this perspective, this study arises from the need for filling this knowledge gap.
For this reason, the intention is to contribute to the Evidence-Based Practice (PBE) in order to potentate the process of acquiring knowledge and decision making of health professionals, especially nurses, in order for them to choose the best level of evidence to make the educative elderly care operational.
In view of the exposed above, this study was aimed at identifying in the scientific literature the technologies developed to promote health education for the community elderly.

Method
It is an integrative review, structured in six distinct     There was identification of 6,750 publications, and 15 articles were selected for the review sample after inclusion and exclusion criteria application. No other studies were included after the manual search process.

Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) (14) were followed, as presented in Figure 2.  Critical analysis and qualitative synthesis of the selected studies were performed descriptively in five analytical categories according to the types of educational technologies identified: "software"; "video"; "printed material"; "mock-up"; and "telephone support."

INCLUSION
Since it was an integrative review, the research was not submitted to the Research Ethics Committee, but the ideas of the authors of the publications used in the development of this study were maintained.

Results
In

Category (Educational technology) Year/Country Objective Outcome
Software 1988/ EUA (15) To investigate the efficiency of computer software instructions for the elderly in reducing nonadherence to drug treatment.
Non-adherence to drug treatment was significantly reduced. Memory was favored. Low-cost and self-sufficient training.
Software and printed material (handout)* 2002/ EUA (16) To evaluate the effectiveness of interactive multimedia software in the elderly's knowledge of drug interaction due to self-medication and in reducing such practice.
Resulted in efficacy to avoid drug interactions with alcohol. Reduction of adverse behavior scores for self-medication was identified.

Software 2003/The
Netherlands (17) To investigate the effect of multimedia training on the subjective cognitive load of young and older adults.
There were slightly elevated levels of cognitive load in the elderly during software training. The elderly needed more training time.
Software 2012/ Malaysia (18) To develop a digital nutrition education package and evaluate its acceptance among the elderly in Malaysia.
It showed good acceptance by the elderly and ease of use.

Video 2005/The
Netherlands (19) To describe the development and effectiveness of a deaf elderly education program about communication strategies.

Effective in increasing communication techniques.
No differences were identified in the emotional response of the elderly in the six-month period.
Video 2009/ Australia (20) To verify the video efficacy for promoting health education for community elders hospitalized about the prevention of falls in the hospital.
Effective in improving the fall risk self-perception and levels of confidence and motivation to engage in self-protection strategies.
(the Figure 3  and had their effects evaluated after a two-week followup (15)(16) .In turn, a primary study compared the effects of technology on the elderly and young adults (17) . The process of software development and evaluation by the elderly was described in only one primary study (18) .
The results of the studies included in this category The second category deals with the use of video in individual interventions (19)(20)(21)(22) . Among the studies, three have used this technology in different ways, namely: a series of short films (19) , as part of an educational program (21) or associated with a motivational strategy (22) . Regarding the device used for storage, only two presented this information: one study used videotape (19) , and in another, the device used was DVD (20) . With the exception of one study (20) , the other studies verified the effects of video application in different follow-up periods: two evaluated the outcome from one month of intervention (21)(22) , and another from six months of intervention (19) .
The results showed that this type of educational technology was effective in improving the learning of different subjects by the community elders.
Regarding the third category, printed material, the seven studies included developed and/or applied educational technology as booklet, primer and guide, which transmit information through written text and pictures (16,21,(23)(24)(25)(26)(27) . Among these, three primary investigations were carried out with the objective of constructing and validating the technology (24,(26)(27) . The It presented effectiveness in more autonomous decision making and in changing the preferences of life support treatment.
Video 2011/ EUA (22) To compare the effectiveness of multimedia interventions in the elderly's knowledge of fall risks and in changing behaviors for prevention.
Effective in identifying and reducing fall risks and in the knowledge and effort to prevent fall risk behaviors.

2004/The
Netherlands (23) To determine the effects of educational intervention for the elderly in the self-management of health issues and decision making in seeking medical care.
It did not change the elderly's health behavior.
There was no change in the frequency of demand for medical care.
Printed material (primer) 2012/Brazil (24) To present the educational primer as a gerontotechnological product useful for care of the elderly with ostomy in the light of complexity.
It consisted of an instrument for health promotion, which facilitated the educational process, enabling participation of the elderly with ostomy in their care.
Printed material (booklet) 2015/Korea (25) To verify the effects of the education program for the elderly in preventing falls at home, and intentions to change the domestic environment.
Greater knowledge of fall prevention and greater willingness to make changes in the domestic environment were identified.
Printed material (guide) 2017/ Portugal (26) To develop a guide for fall prevention. It has been validated by the elderly and can be used as an educational strategy.
Printed material (primer) 2017/Brazil (27) To describe the process of construction and validation of an educational primer for HIV/AIDS † prevention in the elderly.
Effective in preserving the privacy of the elderly, clarifying doubts and providing knowledge.
Mock-up 2015/Japan (28) To evaluate the effects of an educational program for the elderly in reducing falls at home and knowledge of fall prevention.
Effective in improving knowledge of fall prevention and home modification.
Telephone support 2017/Brazil (29) To evaluate the effectiveness of educational intervention by telephone support in the metabolic control of elderly patients with diabetes mellitus.
It favored the reduction of fasting blood glucose. It was considered an effective educational strategy for the elderly with diabetes mellitus.

Of the four intervention studies included in this
category, only one showed greater effectiveness in the individual use of the printed material. It should be noted that this intervention consisted of the use of the booklet by the elderly, with weekly reinforcement before outcome evaluation (25) .
In the fourth category, the mock-up was presented as a small scale representation of a given structure.
Only one intervention study used this technology, which was employed in group educational activity at just one moment. The individual effects were evaluated at 12 and 52 weeks after mock-up presentation. The researchers identified that there was a progressive improvement of the outcome studied (28) .
The fifth category included telephone support, used in research that carried out the monitoring of the elderly health through 16 telephone calls, with educational content, for four months. The results indicated an improvement in the outcomes studied after this period (29) .  health problem that has a direct impact on the health sector (33) . In Spain, 13.9% of the elderly who suffered a fall had to seek health care (34) ; in Canada, this prevalence was 5.8% (35) , and in Brazil, 7.8% (36) . All studies included in this review used at least one type of educational technology as an instrument for the educational care process with community elders in order to contribute to meaningful health education.

Discussion
Among these, it is observed that software-type technology contributes to health education because, through visual, tactile and auditory stimuli, it exercises memory and helps retention of information (38) . However, memorization and construction of specific skills (40) .
All the studies included in this review, using this type of technology, indicated its effectiveness in the intervention (19)(20)(21)(22) . Among these, it was also noticed its use associated with other teaching strategies (21) . Other studies have found positive effects in teaching different subjects to other populations mediated by video (41)(42)(43) .
Thus, the adequacy of this type of educational technology as a health education strategy isolated or associated with other technologies is verified.
Despite understanding the advantages of video for health education, it is noted that few studies have developed this material for the elderly. Therefore, investments of gerontology researchers in the construction, validation and evaluation of the effects of educational videos for the elderly are paramount.
The printed material was presented as the type of educational technology most developed for the community elderly. In addition, it was observed that the same study may have been classified in more than one analytical category, since two studies, included in the other categories, compared the effectiveness of those technologies with a printed material (handout) (16,21) . However, among those which tested the effects of this type of technology alone, only one study that used the booklet in an educational strategy with weekly reinforcement, achieved the results expected (25) .
It was also noticed that three studies presented the construction and validation of primers and guide (24,(26)(27) .
It is therefore recognized that it is important to make this type of material available for use in health services. However, the need for testing the effect of the self-management in health (44) .
In Brazil, a study that evaluated the FHL conditions of diabetic elderly found that 73.7% had low FHL, and this was associated with schooling (45) . It is understood, therefore, that educational printed materials for the elderly should be used with caution and take into account the simple and objective language, which favors the correct understanding of the information.
Another technology found in the primary studies was the mock-up, which was effective in guiding a realistic understanding of the changes in home fall risk factors in a Japanese population. In addition, it was Sá GGM, Sila FL, Santos AMR, Nolêto JS, Gouveia MTO, Nogueira LT.
observed that there was retention of knowledge after different follow-up periods (28) .
With regard to health education, the use of the Results of an integrative review of the literature indicated positive effects on adult population teaching after the use of telephone support (47) . Therefore, positive value should be added to professional telephone counseling for the community elderly, as it favors a therapeutic and trust relationship between the professional and the service user.
It is also added that telephone follow-up is a nursing intervention established by Nursing Interventions Classifications (NIC) (48)  For this purpose, one should consider cross-cultural care and popular education, since the elderly's way of thinking and acting comes from the context in which they live (49) . This promotes greater interest in the use of educational technology and involvement in the health education process.
It was found that among the experimental studies included in this review, the effectiveness of the technologies was tested in different contexts and time intervals between the intervention and outcome evaluation. In this way, new studies can be developed with application and measurement of the effects of the use of these materials at different moments and outcomes.
Regarding the approach used by the study researchers to evaluate the effects of the technology application, the individual presentation of the materials stood out, to the detriment of the group intervention, found only in one study (28) . It is thus identified that the use of such technologies in elderly groups should be tested in new studies, since it is the main approach used in educational actions in public health, and that it enhances autonomy and empowerment through closer therapeutic ties and knowledge exchange among the actors involved in this approach (50) .
It should be emphasized that each technology has its importance within the context of health education and it is up to the nursing professional, in partnership with patients and others involved in the care process, to choose the ones that best fit the social reality of the community elderly. In addition, the use of educational technology should not reduce assistance procedures to simple techniques, but rather strengthen relationships, facilitate dialogue, humanize care and effectively promote health.
As a limitation of this review, the inclusion of only studies that have developed educational technologies for the community elderly is indicated, thus not considering technologies for institutionalized elderly, which restricts the results for the use of such technologies in this public.

Conclusion
It was identified, in this integrative review, that there were several technologies developed for the community elderly health education. Printed materials, software and videos prevailed, but there was also identification of mock-up and telephone support.
Fall prevention was the topic most addressed by the studies, whose majority performed an experiment and verified the effectiveness in the individual use of the educational technologies to promote health education for community elderly.