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Revista Brasileira de Enfermagem

Print version ISSN 0034-7167On-line version ISSN 1984-0446

Rev. Bras. Enferm. vol.69 no.6 Brasília Nov./Dec. 2016

http://dx.doi.org/10.1590/0034-7167-2016-0390 

RESEARCH

Storytelling: a care technology in continuing education for active ageing

Nadia Pinheiro da CostaI 

Sandra Helena Isse PolaroII 

Eloa Aparecida Caliari VahlIII 

Lucia Hisako Takase GonçalvesII 

IPrefeitura Municipal de Ananindeua, Municipal Health Department, Family Health Strategy. Ananindeua, Pará, Brazil.

IIUniversidade Federal do Pará, Nursing Graduate Program. Belém, Pará, Brazil.

IIIUniversidade Federal de Santa Catarina, Third Age Studies Center. Florianópolis, Santa Catarina, Brazil.

ABSTRACT

Objective:

assessing relevance and effectiveness of care/educational technology in the form of "storytelling" as a strategy in the cultivation of active ageing (AA) for elderly users of a Basic Health Unit (BHU), from the Amazon region.

Method:

convergent care research (CCR) held in a BHU in Belém, state of Pará, with eight elderly ladies for testing this technology. An active ageing assessment questionnaire and WHOQOL-BREF - quality of life assessment were applied. After training with a view to continuing education, elderly ladies told stories for an audience that addressed the question: "What did you learn from it for your life?"

Results:

tThe popular stories elicited reactions from which the following categories emerged: solidarity; respect for the other; imagination, dreams, hopes and culture of the Amazonian. This practice had a positive result, producing changes in the quality of life of the elderly, particularly in the psychological domain.

Conclusion:

"storytelling" proved to be an innovative technology, a relevant and effective resource in health education, especially for active ageing.

Descriptors: Educational Technology; Health Education; Geriatric Nursing; Active Ageing; Storytelling

INTRODUCTION

An ageing population is a phenomenon that is taking place both in developed and developing countries such as Brazil. In the period from 2001 to 2011, the number of elderly citizens went from 15.5 million to 23.5 million, i.e., the relative proportion of elderly in the population increased from 9.0% to 12.1%. The group aged 80 years or more reached 1.7% of the population in 2011, corresponding to more than 3 million elderly, and the expectation is that this age group will still grow in the coming years. In 2025, Brazil is estimated to have the sixth largest elderly population in the world. This phenomenon is due to the continuous transformation of demographic indicators, particularly the decrease in fertility and mortality, in parallel with the increase in life expectancy. However, this statistic does not homogeneously affect the entire population, differing across socio-economic and geographical conditions(1-2).

Ageing is a natural process, which involves a progressive reduction in the functional capacity of individuals. It is also defined as senescence, a phase of life that is not characterized as pathological. However, external conditions, such as diseases, accidents, emotional stress, and also unfavorable socio-sanitary conditions, can lead to a pathological state defined as senility, which demands complex health care. The possibilities of future limitations can be avoided or delayed if professionals and society at large work together, seeking strategies for healthier living, with the incorporation of more favorable attitudes and behaviors to improve the quality of life in the ageing population(2).

In Brazil, many studies related to ageing are linked to hard and soft-hard technologies(3). However, in examining their relevance, especially for nurses working in primary care, researchers realize that soft technology is essential for life and health care and needs to be further explored. Such technology is that which is present in the relational space between worker and user with the production of care and education between the two subjects, in which the work occurs as a relational act(4).

Technology is a term that covers technical and scientific knowledge translated into tools, processes and materials created and used from such knowledge. Care and technology are often intertwined, thus nursing is committed to the principles, laws and theories of technology and to the expression of scientific knowledge and its transformation. Accordingly, nursing avails itself of technology in care-giving because care, which is the core of its performance, is comprised of processes that involve actions and attitudes based on scientific, technical, personal, cultural, socio-economic and political knowledge aimed at providing comprehensive care(5).

In primary health care, during nursing consultations, innovative interventions should be considered, with the application of specific care-educational technologies that add quality to the care offered, from the perspective of holistic assistance for the user(6). The "storytelling" proposed here may boost the elderlies' cognition and memory, in addition to enabling dialogue in a stimulating social interaction with a sharing of knowledge. This can redefine the process of ageing, and potentially benefit storytellers with one more leisure activity(7).

In the context of basic care researched within the framework of gerontology, one can observe the use of strategies, such as theatre activities, coral memory workshops, aerobics and dance. However, the practice of "storytelling" is rare. It fits Merhy's mold of soft and soft-hard technology(4), which considers health education as a living act which includes knowledge that organizes human actions. It also encourages participants in developing attitudes for the cultivation of active ageing, through reflection on useful knowledge for their lifestyles and for emancipating self-care behaviors(4,8-9).

In line with the programs and policies of active ageing in the context of care and health education, it is essential to encourage personal responsibility and to create age-friendly environments, stimulating connections between generations. Families and individuals must learn to plan and prepare for old age; they must understand the need to adopt healthy habits at all stages of life. At the same time, the supporting environments must assure that "the healthy options are the easiest"(10).

"Storytelling" aimed to assess its relevance and effectiveness as a care-educational strategy in the cultivation of active ageing (AA) by elderly users of a Basic Health Unit in the city of Belém, in Pará.

METHOD

Theoretical-methodological framework

The study was conducted by the convergent care research (CCR), to test an alternative intervention in nursing care(11), develop the "storytelling" technology, making a pledge of permanent education(12) to cultivate active ageing(10), and develop nursing guidelines on self-care behavior.

Methodological procedure

The study setting was a Basic Health Unit (BHU), which holds the Health Program for the Elderly, with 3,000 registered users. The unit offers multiprofessional consultations in various specialties. The Health program for the elderly holds activities of a gerontological nature, such as coral, physical activity, memory exercises, theatre and dance. This space was chosen because it is coordinated by a unit nurse engaged in causes of the third age, who, in conjunction with other professionals in the team, includes seniors in various activities that promote healthy ageing and at the same time integrating academic and research outcomes of universities.

Study participants were eight elderly women, members of the theater group of the unit, who had been invited and selected because of convenience and also considering the characteristic of this group as being open to new experiences. When asked, they answered the Mini-Mental State Examination (MMSE), being positively evaluated as to their cognitive state to meet the inclusion criteria for the application of technology(13). The elderly women signed the Informed Consent Form after accepting the invitation and being informed about the study Meetings were held in order to inform them in detail about the activities they would perform, as well as on the preparations and training needed to participate in the "storytelling".

By adopting the CCR(11) approach, the research team (a nurse graduate student as lead researcher, a guidance counselor as researcher in charge, two nursing students as research assistants) was immersed in the study site and experienced the context of the care and educational practices of the BHU among the elderly participating in the Elderly Program activities.

In order to support the planning of the technology in question, a diagnostic evaluation of the elderly participants was performed, applying initially the multidimensional instrument of active ageing - AA(14-16), which evaluates the socio-sanitary and life conditions representatives of active ageing determinants. The WHOQOL-Brief(17) was also applied to evaluate health-related quality of life. This planning was also subsidized by a prior two-day preparatory experience of qualification and training in the art of the storytelling experience, focusing on orality with techniques for exercising identity, memory and creation. The initial impetus of appropriating the technology of storytelling, followed the principle of permanent education for life(12) and of "learning to know", of the pleasure of discovering or rediscovering, inciting curiosity in the quest for new learning(7). The "learning to know" which implies "learning to learn", meant exercising attention, memory and critical thinking.

The training plan of storytelling by each elder was outlined in detail when they chose the stories they decided to tell or retell. The story was selected by the elderly, according to her preference, worldview and affinity and by consulting popular storybooks and the Internet. These actions were facilitated by the researcher, who took into account the socio-cultural context of the elderly participant. As "learning to do" goes along with "learning to know"(12), following the story-telling training in pairs and in small groups, each group played the role of self-evaluator and advisor with the support of the lead researcher. In the exercise of storytelling, the elderly were guided by the educator Gislayne Matos(18), who recommends that storytelling in the modern world should provide a space in which people experience themselves and realize their own limitations and potential. Simply assessing whether something is right or wrong is not part of this learning, which seeks self-knowledge above all. Spontaneity and the possible forms of taking advantage of one's own life experience, places the person at the service of the "telling word". The educator stressed that, to tell stories, first of all one needed to know and understand the story they want to tell, not just memorize it. The teller should dive into the story and, if necessary, during the course of the story, make use of vocal resources and even gestures to give life to the narrative, making it attractive and interesting. It was imperative that the story contemplated local elements and was suitable for the historical and socio-cultural context of that population, in addition to being told by those who found pleasure in doing so(18).

During training, the elderly participants practiced by telling stories to each other repeatedly till they felt secure, because the more the tellers rehearsed, the "cleaner" their gestures became, for storytelling is an artistic undertaking. However, rehearsing a lot did not mean losing spontaneity and naturalness, it was about being adequately prepared and confident for their performance(19). This rehearsal took place once a week for three months, and thus they learned how to "learn to live together/learn to live with others"(12), were involved in a common project, with collective participation which favored a valuable experience of a mutually helpful relationship. When the elderly felt adequately prepared, the storytelling session was scheduled before an audience composed of the very elderly who participated in the study and by members of the research and health team.

The selection of the story, the storytelling training the repeated corrections, as a result of the elderly's self-awareness, and the storytelling session itself were closely monitored by the lead researcher. This researcher exercised her/his role as a BHU nurse educator and was attentive to the criteria of the expansion of educational acts and of concurrency. He/she sought to find in such acts, the emergence of constructs as potential discoveries to register and interpret, in accordance with the precepts of the CCR adopted(11).

The storytelling session occurred at a selected time, lasting a total of 3 hours, with a snack break. With the consent of the elderly, the session was recorded on audio and video, in order to produce more complete data needed for the research itself and to provide feedback into the educational practice. After each story was told, it was requested that 3 people from the audience answer these questions: "What did the story tell you?" "What did you learn from it for your life?" The answers were recorded for later analysis.

At the last meeting, there was a subjective evaluation of each of the elderly storytellers about their experience, guided by the question: "Tell me a little about your experience of having prepared and told the story". The WHOQOL - Brief(17) was applied to them again, in order to compare the elderly's quality of life before and after the experience of storytelling and to identify possible changes in the perception of their own quality of life.

The data obtained, which was of a subjective nature, were analyzed and interpreted from the process of storytelling, which was the object of this study, and then were summarized in the form of a diagram (Figure 1), which then was submitted to the elderly participants, in order to observe their reactions, to make possible adjustments and to validate the results. This presentation, which was previously scheduled, took place in the presence of all the participants, who enjoyed the findings of the study and expressed themselves positively, confirming the data from their experiences. Then, the main researcher and nurse announced that she was leaving the field and thanked the participants and the whole team of the Health Program for the Elderly of BHU for the valuable help provided to the study. On this occasion, all were invited to a public presentation for the support of his/her dissertation at the University, one of the occasions for the dissemination of the results of the study to the academic audience, the health services and the community of users of health interventions.

In relation to the aspect of ethical care, the study observed all guidelines of the Resolution 466/12, of research involving human beings, having been submitted to and approved by the Research Ethics Committee of the UFPA/CIS.

RESULTS

Characterization of the participants

According to the diagnostic evaluation through the instrument of active ageing, regarding the aspect of socio-sanitary variables, the elderly were aged between 65 and 87 were independent and preserved their autonomy. Four were Catholic, and the other four Christians. All resided in the area assigned to BHU, in a less privileged urban context. Four of them lived alone, the others lived with family or aggregates. The physical environment at home was, in general, precarious and inadequate for the elderly, since almost all of them suffered falls in the previous year. The majority had low education level and earned less than the minimum wage. Not all received Social Security benefits and still engaged in self-employment activities to supplement the family income. However, they took part in third age groups and movements and enjoyed socio-cultural activities and religious festivities, such as the Círio de Nazaré, the June and July festivities, among others. They engaged in daily routine activities, such as reading newspapers, magazines and books; they also watched television, listened to the radio and performed craft work.

The violence and abuse reported by the elderly were an obstacle to AA, because most of them had already been stolen from at home or on the street, had been forced to do something against their will or suffered sexual abuse; and there were those who complained of being abandoned by their own families.

All the elderly sought health services in the BHU to control their poly pathologies, especially hypertension, diabetes mellitus, arthrosis and osteoporosis, among others, and also to monitor the consequent use of polypharmacy. They also participated in the vaccination campaign for the elderly each year.

In the assessment of the determinants of AA it was found that, although almost all the elderly had comorbidities and did not have a positive assessment of all determinants, they responded positively as to their subjective state of health and quality of life in general, despite having multiple pathologies and dealing with unfavorable home and community environments.

Stories told and meanings assigned

Eight stories were selected and told by the elderly: the legends of the açaí berry, the Victoria regia, Matinta Perera, the Mãe d'Água, the Snake River and the turtle and the Caipora, besides the stories of Little Red Riding Hood and Hansel and Gretel. From the reaction of the audience which was composed of the elderly tellers themselves, it was possible to extract some categories of analysis and of implications with the determinants of AA (Figure 1), such as: 1. Solidarity; 2. Respect tfor the other; 3. Imagination, dreams, hopes; 4. Cultural imagination of the Amazon region.

Figure 1 Diagram of the pleasure of storytelling 

Category 1 - Solidarity

The theme of Solidarity emerged from the elderly's reactions when they heard stories of human evil, as with the stepmother in the story of "Hansel and Gretel", dangers of the forest in "Red Riding Hood" and cleverness in "The Tortoise and the Caipora".

Upon hearing the stories, the elderly stressed how they were related to current reality. They commented on the lack of humanity and were angry with the violence and abuse towards people, especially those directed at children and elderly:

You know that street game, I don't remember the name, that which is a scam, that says you pay 100 reais to win 200, there was an old lady who gave him the 100 reais and lost, I mean lost her 100. Nowadays, we have to be alert. We must warn each other. (Violet)

This happens today, yes, many people are abandoned, children, the elderly ... I met an old woman who suffered a lot until she died abandoned. (Spring)

Category 2 - Respect for the other

It is assumed that active and healthy ageing occurs if the elderly are part of an adequate social support network, amidst respectful interactions and community participation. However, when they heard stories like 'The Tortoise and the Caipora', 'Little Red Riding Hood' and 'Snake river', the elderly were encouraged to make comments on the need to be alert, to be more considerate and respectful to their neighbors and even to listen to the advice of others. They mentioned the need for respecting others by listening to and appreciating sensible advice against violence, so common these days.

Oh, we have to respect our peers... Each one has her own way. We go on telling stories, exchanging ideas, and thus getting along. (11 Hours)

This is wrong, they would not let me take part in an art course, just because I am elderly, but we have to stand up. (Jasmin)

We, adults, the elderly, because sometimes we're very stubborn ... we gotta be warned, to be more careful. (Rosa)

Oh, I worry about my children's family... don't take care of themselves, also won't take advise. (Violet)

Category 3- Imaginary, dreams, hope

Hearing stories like the 'Victoria regia', 'Mãe d'água' and 'Snake River', the elderly surrendered to memories, moving from reality to introspection and searching in their past, for much needed positive sensations and feelings. Some scholars claim(20) that significant emotional experiences in the field of leisure, can meet human inner needs and contribute to one's self-development and quality of life. Some of the elderly also warned for the need to be cautious on the subject of dreams, without losing hope.

Love is everything, isn't it ... love is beautiful. I loved a lot. Then I dated a lot, but there was only one I was in love with. (Perfect love)

In the case of the moon. when I was younger I had the illusion that I would reach the moon, so I'd really like to play in the yard, and when there was moonlight I would try to reach the moon. There are many things that I have always wanted to achieve, I'm old and haven't achieved yet, but ... who knows, maybe from now on out I will. (Perfect love)

Naiá deluded herself, she was under the illusion that the moon was coming for her ... she was lost in that thought, wanted the moon to come get her... but recklessly jumped into the moon's reflection in the lake... see? Drowned to death. Sometimes it's an illusion that is not real, right? (Spring)

I take this message for my life: we should never act without thinking, just as he did, right? Seen the girl very beautiful, became interested in her, didn't know what was going to happen later, rushed, married ... and went to live with the girl, delighted from the bottom of the sea; at first he lived happily ... but soon went back to square one and got nothing. He saw the girl, very beautiful, was interested, did not know what was going to happen later... rushed, married... and went to live with the enchanted girl at the bottom of the sea; in the beginning he lived happy... but was soon back to the scratch and left with nothing. (Spring)

Category 4 - Cultural imaginary of the Amazonian

The imaginary is remarkably present in the legends, myths and customs from Pará, and was evident in the reaction of the elderly when hearing 'Matinta Perera' and the 'Legend of the açaí berry'. Sometimes this imagery is intertwined with reality and, sometimes, it is taken in fact as true, a cultural aspect valued by the elderly:

When I was young people spoke of this story of Matinta Perêra, and then one day I happened to hear; it's horrible, an ugly whistle and to find out who this Matinta Perêra was, people would offer tobacco, they said that on the following day a woman always appeared, her hair all messy, and asked: "look, you got a cigarette?", anything there for me to smoke? I'm in need and have no way to buy". And thus they would recognize who was Matinta Perêra. (Rosa)

The acai berry, for us from Pará, is not to be eaten with certain fruits. So, my son-in-law, his family is all from Ceará ... There they take mango, banana, milk and all kinds of fruits and mix with the acai berry in a blender and take it and that's fine. You know? So I think each one has its own customs, don't you agree? It's all in our minds, in our consciousness; I, if I am to drink acaí and eat other fruit I'm certain I'm going to die. (Orchid)

The elderly tellers - their pleasure in telling stories

The storytelling was an opportunity for the elderly to practice self-awareness. Encouraged in the process of reading, listening and actually telling the story, their creativity was enhanced in "learning to know"(12). Their testimonies confirm how the experience of storytelling left in them the impression that it is something inherent to human beings and, therefore, they could learn how to build their own stories which were integrated with the surrounding environment.

I really enjoyed what I've learned. I can already tell stories at home, I tell in front of my kids, that story of Mãe d'água's husband of... that one speaks a little about me. (Margaret)

Exercising one's own mind or memory is a valuable skill, which occurs in "learning to learn"(12), and it is essential because together with this skill, people may acquire other skills to grow in their lives.

In my opinion, it was very good and I really liked it, having developed my mind, my memory! As I'm very forgetful, for me it was great. (Spring)

I was feeling more outgoing, because I'm a little shy, so it encouraged me. I was more communicative. (Spring)

Learning can be a permanent activity(12), for life, there is no set age or time to learn; the more you learn, the more experience you get. And it's never too late for "learning to know", as the elderly themselves acknowledged.

I liked it a lot, I felt good; when I was younger I didn't learn what I'm learning now; After a certain age, I'm learning a lot and I intend to learn more and more, because if I didn't have a chance before, why can't I have it now? So, I'm enjoying! (Jasmine)

With this mutual learning, it is possible to "learn to live together"(12), for the sharing of experiences enhances the bond between people, stimulating their interaction and integration. This harmonious coexistence and the development of activities undertaken together were pleasant to them, so much so that certain elderly have attributed the way they view their life and health to this interaction. This is noted in their narratives and field records, and which occurred during the process of the implementation of the "storytelling", as seen below.

Well, I arrived here feeling this pain, with health problems, and then came to know and participate in this group; once I started attending... I only realized when I got home... the pain I felt was gone; since then I feel the need to be here and participate. (Jasmine)

In the rehearsals for the storytelling, in pairs, the elderly always attended to their fellow tellers, and even those who did not need to be there, would, in a token of companionship, tell and listen to the stories, collaboratively improving the storytelling. (Field diary)

The "learning to be"(12,18) was observed in the elderly's actions throughout the learning process of storytelling, in their recounting of their histories and in the statements of self-assessment. Learning this new educational technology became a pleasant entertainment for the elderly and allowed them to attain a more comprehensive self-development and greater life satisfaction.

The significant change in the quality of life (Table 1) was observed in the psychological domain, more precisely in body image and appearance, which denotes gains in self-perception and self-esteem. In the cognitive field, there was a feeling of becoming more knowledgeable and having a greater understanding of the facts around them. They awoke to their rights as citizens, were supportive of fair behavior in the matters of inhumanity they experienced, such as discrimination, neglect and violence. In the field of imagination and dreams, they did not let desires die, even in advanced age.

Table 1 Means and standard deviations of the scores of the domains of the WHOQOL-brief, obtained in the pre and post storytelling activities among the 8 elderly women of the Basic Health Unit of Marambaia, Belém, Pará, 2015 

Domains Before After t* p value
Mean Standard deviation Mean Standard deviation
Physical 3.64 0.86 3.64 0.88 2.00 1.000
Psychological 3.60 0.84 4.00 0.81 2.01 0. 008
Social relations 4.00 0.58 4.20 0.65 2.06 0.170
Environment 3.35 0.80 3.46 0.95 1.99 0.486

Note:

*T-test of paired Student.

DISCUSSION

The World Health Organization(10) has recommended the adoption of healthy lifestyles and the effective participation of individuals in the care of their own health at all stages of life. Such behaviors are decisive for active ageing, considering it is never too late to adopt healthy lifestyles. However, there is evidence that an individual's health trajectory is the result of a combination genetics, environment, lifestyle, nutrition and also of unforeseeable circumstances.

Education for life is essential to humanity, because it transmits knowledge about the diversity of the human species, making evident the similarities and interdependence among human beings. Discussion and dialogue are key instruments for a harmonious coexistence in this century, as they encourage a culture of peace. Discrimination, rivalries, prejudices and conflicts will surely dissipate if well-conducted projects of continuing education always seek cooperation, understanding, mutual help, respect and friendship(12). According to Morin(21), we are not self-reliant beings: we must always seek to interact and help each other.

Tested as an educational strategy for seniors, "storytelling" proved to be relevant and effective when adjusted with the social determinants of active ageing in elderly participants. The results corroborate studies that consider this technology as a therapy for the storytellers themselves(22-23), providing them with an opportunity to recollect the past, which is an essential part of the human condition(22-24), and an educational resource particularly suited to the elderly(23).

Respect for others, a trait necessary to conviviality as was identified by the elderly, can be taught through education in the most varied spaces and in all stages of life. There must be a social construct of a positive image of ageing. This can be started in the family environment, because loved ones are essential for human development. The construction of this positive image can also be extended, for instance, to educational institutions, through dialogic groups and intergenerational spaces among the elderly and between them and the community. Value should be given to the skills, abilities and, above all, the experiences of the elderly(10,25).

The results of the light technology of "storytelling", put into practice in a group of elderly users of Basic Health Unit, led to the conclusion that the study had achieved the objective of assessing its relevance and effectiveness as an innovative strategy applicable in health services, and in developing behaviors that lead to the cultivation of healthy AA. This observation is also described in some studies(22-24) in which the benefits go beyond health care towards personal spirituality and the reconstruction of their values in life. It also fosters subjective well-being, which comes from the satisfaction of the elderly in learning and in telling stories and in welcoming the experience of being heard and appreciated by others.

As explained by Morin(21), when considering the importance of the emotional dimension in intellectual evolution, the development of intelligence is associated with affection, but in balance with and working within rationality. Dreams, desires and fantasies are necessary to the psychic world. However, thoughts must always be accompanied by reflection, so that they are close to reality. Man is a complex being, endowed with reason and emotion. Thus, life lessons are learned not only through formal sciences, but also through literature in the form of stories and folktales which allow for reflection on the complex human situation and its dreams, for life should also be guided by passion and enthusiasm.

The limitations of the study are the initial focus, the restricted sample and minimum time for the educational process. However, it can be stated that the goal was reached, both in relevance and in the effectiveness of "storytelling" as seen in the performance of elderly participants. It was shown to be an innovative strategy applicable to health services, in terms of training of behaviors that lead to the cultivation of healthy ageing.

The implications of this successful testing of soft technology "storytelling", performed by nurses and applied in elderly users of the Basic Health Unit, bring to the category and health team of BHUS, ESF, an open university for the third age, among other services and programs involving the elderly. There is the need to replicate it in each context, according to the sociocultural characteristics, and also to seek safer evidence of its effectiveness in adopting it to healthcare, especially with elderly users.

FINAL CONSIDERATIONS

The objective which was to assess the relevance and effectiveness of nurses' educational technology of "storytelling" was met. It was shown to be an innovative strategy applicable to health services, and in the training of behaviors that lead to the cultivation of active and healthy ageing.

As to the issue of relevance, the elderly participants joined without restrictions in the practice of "storytelling", joyously taking part in the activities, demonstrating that the technology tested was appropriate, even for those with unfavorable factors to active ageing, such as low schooling or illiteracy. The technology stimulated the elders' memory, provided an opportunity for interesting dialogues in social interaction and sharing of knowledge, as well as producing conviviality stemming from a mutual aid group. This redefined the process of growing old and gave emphasis to ageing with quality.

As to its effectiveness, the "storytelling" by the elderly resulted in positive outcomes, as shown by the self-assessment statements which were favorable to the practice. Significant changes were observed in scores measuring quality of life in the psychological domain, more precisely in body image and appearance which denotes an improvement in self-perception.

FUNDING

This research received financial support from the National Council for Scientific and Technological Development (CNPq) - Universal/Proc. 480422/2013-3.

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Received: June 17, 2016; Accepted: August 19, 2016

CORRESPONDING AUTHOR: Nadia Pinheiro da Costa. E-mail: enfnadya@gmail.com

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