The impact of discursive linguistic activities in promoting the health of elderly people in a long-term care institution

Abstracts

The present study aims to analyze the impact of linguistic-discursive activities in health promotion for a group of elderly residents in a long-term care institution for the elderly (ILPI, for its acronym in Portuguese) in Paraná. This is a qualitative case study that was carried out with 10 subjects of 60 years of age, living in an ILPI. Subjects with linguistic or neurological limitations were excluded from the study. The data was analyzed according to the Bakhtinian view of language. It was collected through semi-structured interviews, performed orally and individually with seniors after their participation in 16 focus group meetings. The results showed the importance of group interaction and dialogical activities among the elderly participants, since it promoted experiences of learning, self-knowledge, acceptance and belonging. Such activities also resulted in the active participation of the subjects in the construction of social bonds, in the formation of feelings and resignificance about themselves and the collective. It was concluded that the development of speech therapy actions capable of formulating and establishing strategies to promote the health of the elderly who are institutionalized in ILPS is urgent. Thus, speech therapy ought to invest in developing research projects around initiatives that value and promote dialogical practices that are able to empower and ensure autonomy for the elderly population.

Keywords
Aging; Language; Homes for the aged; Speech, language and hearing sciences; Health promotion

Este estudo teve como objetivo analisar o impacto de atividades linguístico-discursivas na promoção da saúde, em um grupo de idosos residentes numa Instituição de Longa Permanência (ILPI), situada no Paraná. Trata-se de um estudo de caso, de caráter qualitativo, realizado com dez sujeitos de idade igual ou superior a 60 anos, residentes em uma ILPI. Foram excluídos da pesquisa sujeitos com limitações linguísticas ou neurológicas. Os dados foram analisados segundo a perspectiva bakhtiniana de linguagem, sendo coletados a partir de entrevista semiestruturada, realizada oralmente e individualmente com os idosos, após a participação deles em 16 encontros de grupo focal. Os resultados permitiram verificar a importância de interação grupal e das atividades dialógicas entre os idosos participantes, uma vez que promoveram experiências de aprendizado, de autoconhecimento e sentimentos de acolhimento e pertencimento. Tais atividades resultaram, também, na participação ativa dos sujeitos em torno da construção de laços sociais, na constituição de sentidos e (re) significações acerca de si e da coletividade. Conclui-se ser urgente o incremento de ações fonoaudiológicas capazes de formular e implantar estratégias de promoção da saúde junto a idosos que se encontram institucionalizados em ILPs. Neste sentido, é necessário que a Fonoaudiologia invista no desenvolvimento de pesquisas em torno de iniciativas que valorizem e promovam práticas dialógicas capazes de empoderar e de garantir autonomia à população de idosos.

Descritores
Envelhecimento; Linguagem; Instituição de longa permanência para idosos; Fonoaudiologia; Promoção da saúde

INTRODUCTION

Population aging is a worldwide phenomenon. Today, despite guidelines from national public policies that raise the central question of quality of life in old age, it is clear that only a portion of the population has access to a healthy and autonomous lifestyle while aging, since the vast majority still live a fragile and dependent life at old age.

Dependent elderly people usually are attended by family members who assume responsibility for the care of their seniors(¹). The Brazilian Elderly Statute(²) emphasizes the obligation of the family, community, society and government to ensure that the elderly have the right to life and health, however, prioritizing the family’s own duty to ensure those fundamental rights that are inherent to the elderly, with a lesser role for institutional care, except for those who lack the ability or finances to care for an elderly family member.

So family decisions geared to the care of older people in general are guided by the socio-economic status of each family group or each senior (if living alone), that makes it possible to hire caregivers, in-home care professionals, or choose long-term care facilities.

In Brazil, life expectancy increases in proportion to the rise in demand for long-term care institutions for the elderly (ILPIs), nursing homes, or geriatric institutions(³).

The ILPI is an organizational system that should take responsibility for caring for the elderly patient when they lose contact or closeness with family and social networks by offering support or fulfilling the needs of the elderly patient. This is done in order to take care of the patient’s health and give them a good quality of life in the last years of their lives – meeting needs for housing, food, health, and a social life(⁴). However, the assistance usually offered by ILPIs is predominantly focused on biological care for the assisted population, with actions that promote relationships and social reinsertion for the elderly being non-existent or staying in the background, which often results in absolute isolation for the patient.

In this sense, ILPIs face the challenge of effectively meeting global guidelines aimed at health care for the elderly, which were gradually incorporated into Brazilian public policy in recent decades, especially those related to health promotion, such as the National Policy the Elderly (Law 8.842/94)(⁵), based, also on guaranteeing the social rights of this population, through favoring their autonomy, integration and participation in society and in defense of a partnership with SUS(⁶). These policies favor a healthy population, especially through the promotion of an active and healthy aging process for the elderly.

Healthy aging involves the recognition that, in addition to caring for an individual’s physical health, there are other factors affecting the quality of life for the aging population(⁷). Thus, such a concept articulates the right to equal opportunities and treatment in all aspects of life, and it refers to the awareness of this population as to their responsibility to exercise a voice in political processes and other areas related to the human experience(⁸).

However, the living conditions in ILPIs usually demonstrates a very different reality than the one desired by public policies. A current and overriding fact concerns the limited relationship that the institutionalized elderly have with other residents as well as people living outside the walls of their own ILPI. The lack of such relationships leads the elderly toward inactivity and depression, i.e., these are conditions triggering a series of health problems(⁹). The isolation of seniors in ILPIs has been pointed out in the literature(¹⁰) as a recurring problem of these institutions, for which it is necessary to implement actions aimed at overcoming such isolation.

So in pursuit of improvement, it is understood that an essential component for promoting and maintaining the health of institutionalized seniors is the establishment of meaningful interactions among residents of these institutions, which presupposes an approach of favoring work aimed at language practices. Thus, dialogical practice is regarded as social work that gives meaning and direction to human life in its different cycles.

One factor that supports the importance of this research is that in speech therapy, scientific studies in the context of health promotion in the institutionalized elderly population is still scarce. Studies are strongly influenced by a vision focused on identifying changes/ losses related to the biological character of old age. Furthermore, most of the investigations related to the topic of language and aging focus on individual memory difficulties and neurological disorders(¹¹). Undoubtedly, such research has great relevance in the area. However, as indicated by the Federal and Regional Speech Councils, the great challenge of the speech-language pathologist, aligned with recent calls for reorientation of work in the sector and consistent with the promotion of health, lies precisely in proposing initiatives beyond the limited scope of curative and individual assistance.

Thus, this study assumes that, through initiatives set by the concept of language as interaction, it is possible to create “empowerment”, defined as “a condition that a person, a social group or community must expand systematically its ability to take action, negotiate, and compromise with other social actors in favor of the common good, but also to be heard, to be respected, and to act collectively to solve problems and meet common needs”(¹²).

Given the above, the objective of this study was to analyze the impact of socially discursive activities in health promotion for a group of elderly people living in a long-term care institution located in a city in the south-central region of Paraná state.

CASE REPORT

This qualitative study was approved by the Research Ethics Committee at theCentro Universitário de Maringá (CESUMAR) under number 114.859/12 and carried out in a private, philanthropic ILPI, located in a city in the south-central region of Paraná state.

The criteria for participant inclusion were linked to age and residence, i.e., participants had to be at least 60 years of age and reside in an ILPI located in the south-central region of Paraná. Subjects were excluded if they exhibited linguistic barriers and/ or limitations.

There were ten total participants, seven women and three men, between 60 and 92 years old. Regarding marital status, seven were single, two divorced and one widowed. The education of these subjects was varied: four had not completed elementary school, four had never attended school, and two had completed higher education. We found that the residence time in the ILPI was longer than ten years.

Initially, there were several visits to the institution in order to invite each elderly individually to participate. During these visits, the seniors were told that moments of group conversations would take place to share issues they considered relevant in their experiences. After this invitation, a meeting was scheduled to obtain a signed consent form for each of the research participants.

For the development of linguistic-discursive activities, 16 weekly focus group meetings were conducted from september to december 2012, at times determined by the participants. Each meeting lasted approximately 90 minutes and was guided by specific themes, such as: youth, childhood, work, religion, political activism, myths, beliefs and popular practices in health/ illness, life in an ILPI, living well, and aging, among others. All discussions were recorded via audio through a digital voice recorder (DVR Powerpack®-2089, RH 2160).

In the first meeting, with a view to health initiatives that propose the empowerment of individuals involved in the activity, the group of seniors was asked to consider which topics they would like addressed in the interactions. During subsequent meetings, based on the feedback from the participants, the topics of the next meetings discussions were chosen.

The focus group was then based on group interaction within a specific topic, according to the research objectives(¹³). The environment for conducting the meetings was the waiting room of the dental facility office for the ILPI. The site was previously organized, with the arrangement of chairs in a circle, in order to leave the space pleasant, quiet and cozy.

Prior to each meeting, an agenda was prepared, containing the purpose of the meeting, the dynamics to be used, as well as guiding questions to be developed. It is noteworthy that the elaborate agenda was used only as a guide for discussion, with the flexibility to incorporate issues of interest brought by the group of seniors. In this way, the sessions tried to favor the group’s inclusion process and the creation of complementary possibilities of sharing among elderly participants within the activity.

At the beginning of each session/ meeting, a speech therapist researcher/ mediator stated the purpose of the discussion in order to promote equal speaking time, lead the discussion, and keep it within the topics of interest to the group. After the last meeting of the focus group (the 16th), there were oral and individual semi-structured interviews with the subjects, which make up the corpus of this research.

The interview was organized with ten open questions in a script that included questions in order to investigate the meanings attributed by the elderly to the linguistic-discursive activities with the focus group. The questions also addressed the changes generated in their relationship with others/senior residents in the same ILPI from those who participated in the group.

The interviews were transcribed and the analysis and interpretation of statements have been prepared on the basis of Bakhtin perspectives on language(¹⁴), based on the principles of discourse and otherness, which allow us to state that the constitution of a subject depends on otherness, or is, of interpersonal relations established by each throughout its existence.

It should be noted that this analysis view consists of a dialogical understanding of the answers given in the individual semi-structured interviews, which resulted from dialectical relationships with discourse in the form of statements.

Bakhtin(¹⁴) states that the true substance of the language does not consist of an abstract system of linguistic forms, not the isolated monologic utterance, not the psychophysiological act of its production, but by the social phenomenon of verbal interaction, performed by an utterance, which It is the fundamental reality of language. The utterance – a moment of language use - is marked both by interaction between subjects, as well as by the social environment that surrounds them. During the process of interaction, the statements made in dialogic relationships are structured from the responsive activity, as utterances that have already been experienced in other relationships.

In the light of Bakhtin’s view of language, one learns that it is from the coexistence with others that a human being is human. The dialogic principle creates otherness and establishes intersubjectivity as an antecedent to subjectivity.

The identification of the utterances made by the subjects in this study was made by means of the letter “s” corresponding to “subject” followed by a number from 1 to 10, e.g., the letter “s” accompanied by the number 1 (s1), which indicates that the statement in question was given by the subject identified by the numeral 1.

Before the corpus of the research is presented, it should be emphasized that during the initial visits for organizing the meetings with the elderly, we observed that the institution in question is an organized place, offering hygiene, health, safety and accessibility. At the entrance, is the main building with administrative offices, a TV room, a large dining room, a kitchen, dorms separating men and women, with some older people in individual rooms. On the back of the main building, there is a wing of rooms and a laundry room, and next door is a room where the dental office is located. In the outdoor area, there are chairs arranged side by side, which can facilitate conversations among the institutionalized patients. However, while many of these elderly people sit in these chairs, many spend much of their time looking at the horizon, that is, despite the physical proximity among residents, there is no movement on their part to have intersubjective interaction and closeness.

The corpus of the survey consists of sets of utterances produced by the elderly in individual interviews. Therefore, the impact of socially discursive activities in promoting the health of older people that make up this study was considered after a series of conversations established during the meetings of the focus group and from the application of semi-structured interview.

For them, such encounters, marked by a dialogical perspective, indicated the possibility of learning and personal growth, as shown in the utterances produced in response to the question about what it meant to participate in dialogic activities.

“Learning from each other, I learned a lot. One tells his story and you get to learn what life was like for the person, as we lived a different life, we will compare the way of life of each and think, oh boy, was it good or not? And as I felt welcomed in this group, I felt comfortable”(s1).

“An opportunity to grow through conversations, we give our opinions, enrich our vocabulary. I had a chance to express my ideas, talk, get to know the people who live with me” (s10).

The importance of learning experiences, growth, acceptance and the ability to organize and express ideas and opinions are clear in the statements. For the institutionalized elderly, participants in this study, the proposal of the focus group, based on dialogical activity, was an open opportunity to learn about different non-overlapping histories with each other and, rightfully so, facilitated the sharing of feelings, giving way to dialogue which, by the way, only exists when we recognize the otherness, the differences relative to each other.

The linguistic-discursive activities give the elderly the recognition of other residents in the same institutional space. However, this was marked by the restriction in relations to otherness, because when asked about what it meant to participate in the meetings, the following was noted in the statements.

“For me it was a self-help, because I got to gradually know my colleagues, many I did not know about what knowledge they have, because many seem to be so cold. But when we see they have such spectacular experiences, I ended up mingling better here. In my opinion, I think someone should have to continue to do the meetings, urgently, just like these. When that day of the week arrived, we were already looking around to see if we would have a meeting or not. I could always tell by the car” (s4).

“I enjoyed every meeting. All led to one common link – for me to get to know some people whom I had been afraid of here, who seemed so serious that I had not exchanged a word with them” (s3).

“You know that I have few friends here. And the group was for listening too, right, so I got to know them better” (s2).

“If it were not for these conversations I would not have gotten to know better those who live with me, and I learned to see people here as my friends. Because I felt that I knew nobody really well, I didn’t have confidence” (s7).

“I know the people here, I know that, but I just did not know their backgrounds. Because here in the group we got more confidence in everything, because I have some confidence, but not that much confidence”(s9).

Based on the statements above it is clear that, through dialogue, older people got to know each other in a process of listening, of rapport and building trust between them. It was possible to verify, in its statements, that their relations with others, in institutionalized everyday life, tend to be marked by indifference, a lack of trust and confidence, and not being aware of the stories of those living spatially close, but dialogically far away.

As they formed a group, they came to share common needs, which resulted in the strengthening of ties and a sense of belonging, as is evidenced in the following statements.

“I made strong friendships during our conversations. Knowing the opinions of each person a little bit more each time, I confirmed that we need to put our ideas forward” (s6).

“I could see more people here as my friends even. I saw that there are people who a like a box of surprises” (s8).

“The good thing is the friendship that we have with everyone, thank God. We always take care to not aggravate others here, otherwise it turns into fights. The group was able to strengthen that, see what was said”(s5).

It can be noted that, during the meetings, the focus group was placing importance in the lives of its participants. In the testimonials, there are repeated references to building bonds of friendship made possible through inclusion and mutual knowledge in the group. This became possible due to the quality of mediation implemented by speech therapists and researchers in order to ensure the active position of the “chosen” participants to take as subjects of discourse. In other words, the elderly for whom the words were directed were not mere recipients, but assets in the course of live interaction. Through dialogues, they recognized the uniqueness and otherness of each person, and did not feel indifference to that uniqueness in others. Note that the type of mediation used facilitated inclusion, building social ties and the active participation of the subjects, i.e., the constituent elements of empowerment, whose concept and role in health promotion initiatives were described earlier.

In the statements by the elderly, it is also noted that the interaction allowed them to record their stories and how, in this way, they could update and reflect on significant moments of the past, present, and even reflect on the future.

“Because a lot of people forget, and in talking we remember, reliving moments that we really miss” (s5).

“I saw that each person complains about themselves and wondered at how similar it is to my life. And the meetings helped me to think better about life” (s1).

“Now we even pay more attention to the other people near us and we do not notice, do not pay attention to what they are talking about. Now so we give more attention, more care, treat others with even more affection. So that helped me a lot” (s4).

When asked during the interview, about what motivated them to participate in the meetings, the participants announced the following.

“Leaving there a little, changing the environment and feeling important, getting out of that routine of every day doing the same thing, I went from one side to the other, to and fro. The chair to bed, the bed to chair. A different activity motivated me a lot” (s1).

“At the meeting we had fun. It’s not easy to be alone there. I was always waiting for Thursday, without it, the week seemed empty” (s3).

There is evidence of the participants’ commitment to the group in the high attendance at meetings. They attended regardless of whether they participated in some other activity in the institutional environment or not, and even on rainy days, when getting to the meeting space was not so easy.

DISCUSSION

The elderly, upon arriving at an institution, carries a cultural background, a life story and everyday habits, which are usually forced into the background during their insertion process in a new condition of guided institutionalized life that is, most of the time, just geared toward meeting their basic biological needs. Many seniors residing in ILPIs live in a silence caused by the new condition of life, which is correlative to the removal/avoidance of the dialogue process.

Thus, in the search to minimize the effects of this hard process of segregation, this study focused on promoting the health for these people from a dialogical action of language, which is, as already mentioned, at the same time, “taking possession” of their own voice and the recognition that they are alive. Using language in its interactive, historical, cultural natures, and with the subject as the author of social transformation in their relationships with other subjects, was crucial to the results that this study achieved.

The use of language invariably implies the possibility of meaning. Thus, the idea that speech frees the subject from a mere abstract body, stressed the need to place the aging individual in an ILPI within a historical and social dimension. Questions concerning the use of language demonstrated a perspective of analysis that is not limited to organic and physiological aspects in aging people, but understands the universe itself as a permanent constitution of consciousness for that person, socially marked by inter-subjectivity(¹⁵).

The language, based on the dialogical perspective, as assumed in this research, enables the rescue, within the space of dialogue, of the elderly individual’s role as a social, historical and cultural being, who is subject and author of social transformation, as it is within the linguistic phenomenon.

In this research, it is evident, in the statements of the subjects, inside the group activity engendered in/ through language, that the activities brought the possibility of a new insertion space inside the ILPI, provided by the interactions among its residents, since, despite the elderly having lived and shared the same space and time at the ILPI, actions were not developed to promote interaction, featuring the formation of a group and not just a grouping of individuals.

Already through focus group meetings based on dialogical activities, seniors were recognized as members of a group, with the possibility of sharing their life stories.

It is emphasized, thereby to distinguish between being a member or individual of a group. The individual may be part of a group of people who live in and sharing the same space, but with interrelational distance, yet may qualify as a group. In ILPIs, there is this assemblage of people, in which the relationship between the institutionalized individuals is shallow.

The transformation of a simple group into a group of members is a dynamic process and requires that the subjects view each other from the position of interlocutors. In the meetings proposed in this study, the elderly started to act with language and about language, with a collective integration toward a common purpose. The interaction that took place from the reports of organizing their lives, ideas, opinions, experiences was in the group and for the group.

You can then highlight the decisive role that language as discursive practice, can take on in the life of the institutionalized elderly. It brings the possibility that these individuals can recognize this dialogue and do this in the institution where they live.

In light of the utterances produced by the elderly, it was also possible to see that the focus group strategy was able to promote dialogue. In the meetings, the elderly were asked to talk about themselves, about their experiences, their opinions; and each person had time to talk, so that all of them could hear and be heard. They could talk about themselves, and they had the opportunity to talk without worrying about prejudices, or departing from dichotomous notions, for example, polarized notions about “right/ wrong”.

Also noteworthy is the importance of speech therapy in effectively working with language and about language in order to promote interactive situations among the institutionalized elderly, with a view to promoting good health. From this point of view, it is pertinent to note that health promotion happens through actions that facilitate the empowerment of the individual.

It is also worth noting that empowerment in promoting good health is associated with alternative ways of handling social realities, in a process that helps individuals to recognize their personal potential (group and individual) and understand that organized actions are socially essential for the changes towards the improving their living situation.

In this perspective, the dialogic activities promoted in the focus group brought the elderly the opportunity to glimpse and to experience an active role in a relational context. In the given dialogues, the richness of the stories of each subject, interacting with the people who lived in isolation in the same environment, provided to the elderly the experience of “feeling integrated” and to perceive themselves as “belonging to a group”.

To the extent that older people were summoned to join the group, they came to share needs because of common goals. Thus, the incentive to strengthening the ties of friendship emerged as a strategy to positively influence on where the institutionalized elderly resided, what favored their health, and what made them experience the pleasure of the connections in their lives.

FINAL COMMENTS

Given the goals indicated in this study, the impact of socio-verbal activities can be evidenced from the formation of a group of elderly subjects, and that the group’s creation was motivated by meaningful interactions. The effects of this initiative are manifest in the formation of emotional bonds among those in the elderly group, the feeling of friendship and trust among them, their mutual solidarity, the growing possibility of sharing their lives and, above all, the ability to see themselves as active subjects – all from experiences promoted through dialogue.

Focus group meetings may indicate the possibility of promoting empowerment and the health of elderly participants, to the extent that this empowerment involves a process causing changes in social relations that favor freedom and respect for others.

These results also allow reflection on the importance of speech therapy actions, guided by promoting good health, especially when considering the fast-paced growth of the senior population in the country. Such actions imply the strengthening of the social role of the elderly subject, promoting initiatives to preserve their uniqueness, autonomy and citizenship. Group work, dialogue facilitators, and recognition of otherness may assume significant importance. Therefore activities with/ about language affect the quality of life of any person. Such activities can positively influence the living conditions of the institutionalized elderly, empowering them, to the extent that they recognize themselves as subjects and therefore agents of their own lives and the institutions in which they live.

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• Study carried out in the Post-graduate Communication Disorders Program, Universidade Tuiuti do Paraná – UTP – Curitiba (PR), Brazil.

Publication Dates

• Publication in this collection
  Apr-Jun 2015

History

• Received
  24 Sept 2014
• Accepted
  14 Apr 2015