MULTIDIMENSIONAL EVALUATION OF DETERMINANTS OF ACTIVE AGING IN OLDER ADULTS IN A MUNICIPALITY IN SANTA CATARINA

This study aimed to evaluate the determinants of active aging in older adults aged 60–70 years old, resident in Rodeio, Santa Catarina, Brazil. It is a quantitative study of the exploratory-descriptive type. Data collection occurred between April and August 2011. 264 older adults were interviewed at home, using the instrument for multidimensional evaluation of active aging and postvalidation of content, undertaken by experts. The Sestatnet program was used for data analysis and descriptive analysis was carried out. The older adults participated in the community and undertook certain forms of unpaid work (90.9%), and presented a significant rate of falls (30.68%), although they had a low rate of hospitalization (4.92%). In spite of comorbidities presented, they were shown to be satisfied with life and regularly undertook leisure and physical activities. It is concluded that, although not all the older adults had a positive evaluation in each determinant of active aging, in general they were independent and satisfied with their quality of life. DESCRIPTORS: Nursing. Older adult. Aging. Quality of life. AVALIAÇÃO MULTIDIMENSIONAL DOS DETERMINANTES DO ENVELHECIMENTO ATIVO EM IDOSOS DE UM MUNICÍPIO DE SANTA CATARINA RESUMO: Este estudo teve como objetivo avaliar os determinantes do envelhecimento ativo em idosos de 60 a 70 anos, residentes em Rodeio-SC. Estudo quantitativo, do tipo exploratório-descritivo, cuja coleta de dados ocorreu entre abril e agosto de 2011. Foram entrevistados 264 idosos em seus domicílios, utilizando-se o instrumento para avaliação multidimensional do envelhecimento ativo, pós-validação de conteúdo, realizada por experts. Para análise dos dados utilizou-se o programa SestatNet e realizou-se análise descritiva. Os idosos eram participativos na comunidade e realizavam algum tipo de trabalho não remunerado (90,9%), e apresentavam índice significativo de queda (30,68%), porém baixa hospitalização (4,92%). Apesar das comorbidades apresentadas, mostravam-se satisfeitos com a vida e realizavam regularmente atividades de lazer e físicas. Conclui-se que, embora nem todos os idosos tenham uma avaliação positiva em cada determinante do envelhecimento ativo, de maneira geral, apresentaram-se independentes e satisfeitos com sua qualidade de vida. DESCRITORES: Enfermagem. Idoso. Envelhecimento. Qualidade de vida. EVALUACIÓN MULTIDIMENSIONAL DE LOS DETERMINANTES DEL ENVEJECIMIENTO ACTIVO EN ANCIANOS DE UN MUNICIPIO DE SANTA CATARINA RESUMEN: Este estúdio tuvo como objetivo evaluar los determinantes del envejecimiento activo en ancianos de 60 a 70 años residentes en Rodeio-SC. Estudio cuantitativo, exploratorio-descriptivo, cuya recopilación de datos ocurrió entre Abril y Agosto del 2011. Entrevistados 264 ancianos en sus hogares mediante utilización del instrumento para evaluación multidimensional del envejecimiento activo, después de la validación de contenido, realizada por peritos. Los datos fueron organizados en una hoja de cálculo en Microsoft Excel, y después se utilizo lo programa SestatNet para el análisis descriptivo. Los ancianos eran participativos en la comunidad y realizaban trabajo no remunerado (90,9%). Presentaron índice significativo de caídas (30,68%), pero, baja hospitalización (4,92%). Apesar de las comorbidades, los ancianos se mostraron satisfechos con sus vidas, realizaban actividades de recreación y físicas, regularmente. Se concluyó que si bien no todos los ancianos consiguieron una evaluación positiva en cada determinante del envejecimiento activo, de manera general, se mostraron independientes y satisfechos com su cualidad de vida. DESCRIPTORES: Enfermería. Anciano. Envejecimiento. Calidad de vida. 370


INTRODUCTION
Populational aging, at the present time, is a worldwide phenomenon.Brazil is no different, and has a significant increase in older adults, shown in the demographic data: in 2000, older adults formed 8.6% of the total population; whereas in 2010, they made up 10.7%.2] It is not enough, however, to extend the quantity of years lived -it is necessary to invest such that the increase in life expectancy may be accompanied by improvements in conditions, such that it may be possible to enjoy an active and healthy old age for the longest period possible.
For people to have quality of life in aging, it is necessary for there to be more and more personal investments and services offered which meet the requirements of this segment of the population.Naturally, one cannot deny that older adults live with potential risks derived from the process of aging itself, which can make them more susceptible to incapacities resulting from physical, social or emotional conditions. 3This is a dynamic process and is particular to each individual, and even among older adults, the younger tend to present different conditions to those who are more longlived. 4t was for this reason, in April 2002, that in the World Assembly on Ageing, held by the United Nations Organization in Madrid, the experts sought to propose a guideline focussing on Active Aging as a priority for the twenty-first century. 5he objective of Active Aging is to increase the expectation of a healthy, quality life for all people who are aging, considering quality of life as the individual's perception of their position in life, in the context of the culture and values systems in which they live and related to their objectives, expectations, standards and concerns. 6amilies and individuals need to plan and prepare for old age, and must make efforts, personally, to adopt an attitude of healthy practices in all phases of life. 7One significant characteristic of this movement is the commitment to act, based on the idea that the social determinants related to health are products of people's action. 8he process of aging involves a series of factors, which are interlinked and apply to the health of people of all ages.The World Health Organization (WHO) defined the principal determinant fac-tors of active aging as: social and health services, behavioral determinants, personal determinants, physical environment, social determinants and economic determinants.One cannot attribute a direct cause to each of the determinant factors, but the evidence suggests that all the factors in themselves and the interaction between them reflect the aging of individuals and populations. 5earing in mind the proposal made by the WHO, of making active aging a health policy for the twenty-first century, and the fact that this was agreed to by all leaders, the need was ascertained to investigate how these determinants are expressed in the daily life of Brazilian older adults.Based on the study 7 which led to -among other contributions -the development of an instrument for evaluating active aging, it was decided to validate the content of this instrument and, later, to apply it to a group of elderly residents in a municipality in the State of Santa Catarina.In this context, the present study's objective was to evaluate the determinants of active aging presented by older adults aged between 60 and 70 years old, resident in Rodeio-SC.

METHOD
This is a study with a quantitative approach, of the exploratory-descriptive type.Data collection took place in the months April -August 2011, following the favorable decision of the Research Ethics Committee (Protocol n. 1096/2011), and all the subjects signed the Terms of Free and Informed Consent.
The locale selected for the administration of the research instrument was the municipality of Rodeio-SC, where the elderly population corresponds to 15% of the total population, which in absolute numbers means 1,645 older adults. 2 Rodeio has a significant textile and timber industry.Agriculture is very important in the region, as the municipality has a significant quantity of rural properties. 9In agriculture, the intergenerational transmission of knowledge is very common, in which the forms of cultivation are passed on from grandparents to their children and grandchildren, who give continuity to their work.
The older adults resident in the municipality of Rodeio-SC were identified with the help of the Community Health Workers (CHWs), who presented a nominal list, containing the birth dates, ages and addresses of all the older adults registered with them.Using this data, the older adults in the age range of 60-70 were selected as potential study subjects.This age group was defined because it was the most significant in the muicipality, containing a population estimated at 848 persons, the equivalent of more than 50% of the municipality's older adults.
Based on this population, the sample was of the simple random type, made up of 264 older adults, calculated using the SestatNet program. 10he 848 older adults were numbered sequentially from 1 to 848 and, later, those older adults whose numbers corresponded to the table of random values calculated by the SestatNet program were checked. 10In the event of an older adult not meeting the inclusion criteria or refusing to participate in the study, the next number in the table not to have been chosen was selected.
The criteria for inclusion in the research were adults of both sexes who were in the age range selected and who were able to communicate, interact personally, and respond to the questions which made up the data collection instrument.
Data collection took place in the older adults' homes, on pre-arranged days and times, and was undertaken by the Master's degree student and three helpers, who had been trained to administer the research instrument.
The instrument, developed by a nurse as part of her Master's dissertation, 5 for the multidimensional evaluation of active aging, passed through a process of content validation, 11 which was undertaken by a panel of four experts, specialists in gerontology and with training in different areas of knowledge (physical education, physiotherapy, nursing and psychology).In this evaluation, the judges agreed that the instrument proposed covers the determinants of the Active Aging Policy 5 and that the items have conceptual relevance.
The validated instrument, in its final version, has 44 questions related to active aging and its determinant factors, these being divided into seven domains, extracted from the Active Aging Policy Framework: 5 cross-cutting determinants, economic determinants, determinants related to the social environment, determinants related to the physical environment, determinants related to personal factors, behavioral determinants, and determinants related to health and social service systems.
Organization of the database was carried out using a specific spreadsheet in the Microsoft Excel® program.After single typing, a review of the data's consistency was undertaken.Following that, the SestatNet program was used for the descriptive analysis of the data, applying simple and crossed frequencies, both in absolute and percentual terms, and the results were organized in graphs and tables.

RESULTS
On analyzing the socio-demographic data, presented in table 1, it was possible to observe that 54.1% of the interviewees were female.As there was a certain parity in female and male participation in the sample, it was decided to present the results by sex.
The great majority (71.5%) of the older adults said they were of Italian origin, Roman Catholic (86.7%), and white (98.1%).It was observed that 75.7% of the older adults lived with spouses or partners, 14.7% were widowed and 9.4% were separated or single.Regarding occupation, 70% of the older adults in this study are retired and do not carry out paid work.20% reported undertaking paid work and 10% defined themselves as housewives.Regarding income, the majority of the older adults (76.5%) receive between one and three minimum salaries per month.

Table 1 -Distribution of the socio-demographic variables of older adults aged between 60 and 70 years, by sex, in the municipality of Rodeio-SC, 2011
Even retired, or working outside the home, 90.9% of the older adults reported undertaking some type of unpaid work, either in the home or in voluntary services in the community, such as: participating as a volunteer at church, schools or community associations (73.4%), providing home care for other members of the family (63.6%),undertaking work in the garden or vegetable patch or caring for domestic animals (74.6%), and being directly responsible for the organization and maintenance of the house (67.8%).
As may be seen in table 2, the majority (50.3%) of the older adults had had between two and four years of formal education.Regarding living arrangements, 9.8% of the interviewees live alone, 32.5% live with a spouse or partner, and 42.4% live with spouses and children, or with their children's families.
It was observed that 17.8% of the older adults spend most of their time at home and do not live with people apart from their family or close friends and neighbors, 87.1% attend church and/or religious groups and 21.2% reported participating in older adults' community groups.
When asked about violence or maltreatment, 66.6% of the older adults reported not having experienced any situation of this type.Considering, however, that this municipality is in the countryside, the level of robbery suffered was considered high: 18.1% had been robbed at home and 6% on the street.
In relation to basic sanitation, 43.1% of the homes were connected to the public water supply provided by the state service (Companhia Catarinense de Águas e Saneamento -CASAN) and 47.7% obtained water from a well or spring.In the majority of the older adults' homes (90.9%) the sewage system is linked to a septic tank and 82.9% were attended by the municipal garbage collection service.
The majority (94.7%) of the older adults lived in their own homes and had their own room for one person or the couple.In relation to the houses' characteristics, 97.7% had a good lighting system, in 7.9% the toilet was separate from the main building, 43.1% had steps or stairs, 6.8% had uneven or slippery floors, and 54.1% had carpets in various rooms.
As may be seen in table 3, 82.2% of the older adults had been diagnosed with some illness or health problem, with high blood pressure being mentioned most (52.6%)among the interviewees.In spite of the presence of co-morbidities, which are very frequent among the older adults in this sample, the majority (69.3%) showed that they were satisfied with life in the last year, 25.7% considered that they were neither satisfied nor dissatisfied, and only 4.9% asserted that they were dissatisfied with life.
Concerning activities undertaken routinely, 31.44% are used to playing dominos, 65.9% have the habit of reading, 27.2% do craftwork, 93.1% watch television, and 79.9% listen to the radio.
Among the older adults researched, 14% are smokers and 29.1% stated that they had smoked at some point in their lives, while not having this habit any more.Regarding consumption of alcoholic drinks, 56.4% do not consume them, and 23.4% consume them only sporadically, at social events.50.6% of the older adults regularly practise physical activities, among which the use of a bicycle, walking and gymnastics stand out.
One important factor, which has a close relation with dietary and social habits in the life of the older adult, is oral health: 78.4% of the older adults researched use some sort of dental prosthesis or bridge and, of these, only among 5.3% do the prostheses not fit properly.More than half of the older adults interviewed (53.7%) had not seen the dentist in the last year.
In relation to the use of medication, 78% of the older adults use them daily, taking medication alone, without forgetting or mixing them up (68.5%).The medications taken may be observed in table 4. A significant number of older adults (86.7%) had had a doctor's consultation in the previous year, which represented an average of 3.14 consultations/year per older adult.Asked about access to mental health services, 14% of the older adults had needed this service, through private health insurance or privately (7.2%), or via the Unified Health Service (SUS) (6.8%).Regarding hospitalization, only 4.9% of the older adults had received inpatient care in the last six months, and 20.4% had had some sort of surgery in the last two years.Concerning vaccination against flu, 26.1% of the older adults reported that they had never had the vaccine, and 67% take it regularly every year.
In relation to home visits, 99.2% of the older adults in this study said that they receive a monthly visit from the CHW in their home.In addition to this, 9.47% of the interviewees had received home visits from other professionals in the health team in the last six months.

DISCUSSION
All the determinant factors of active aging have in common the convergence on culture and sex, which are considered cross-cutting determinants.Culture encompasses all people and populations and models our form of aging as it influences all the other determinant factors of active aging.The appropriateness of various policy options, as well as the effect of these on men and women's well-being, are considered by gender. 5] Economic determinants have a relevant role in active aging, with the factors which compose it standing out: income, social protection, and work.5] Retirement income performs an important role in older adults' incomes, this being more evidenced as their age advances.It may be concluded that the older adults' degree of dependency is also related to their income. 16t is older Brazilian women, rather than the men, who participate in activities in the community and in community groups and, in contrast to what they were accustomed to doing in their adult life, take on the role of head of family and provider. 17It may be noted in this study that the women's participation in community activities was greater than that of the men.
The social determinants of active aging are the older adult's schooling, situations of violence and maltreatment, living arrangements and social support networks. 5In relation to schooling, 50.3% of this study's older participants had between two and four years of formal schooling, which is in line with the national scenario, in which 50.2% of the older adults studied for less than 4 years. 2n research carried out with older adults in Florianópolis, the numbers are similar: 42.7% of the older adults researched had had up to four years of formal education. 18altreatment of older adults includes physical, sexual, psychological and financial abuse, as well as negligence and conflict, the confront and reduction of which requires a multisectorial and multidisciplinary approach. 5This phenomenon is expressed also in aggressions caused by the family itself, abandonment of the older adult, loss of rights, prejudice and social exclusion.It is necessary to reflect on these more veiled but no less cruel forms of violence, as the older individuals rarely report the adversity they face, and the professionals who help do not always manage to identify situations of aggression. 19his study's older adults said that they co-existed with other people in the community, which is very important for the creation of a support network and for social support.Inadequate social support is associated not only with increase in mortality, morbidity and psychological problems, but also with reduction in health and wellbeing in general, and can lead to social isolation, causing physical and mental decline. 5The lack of family and social support also represents the most frequent cause of the institutionalization of older adults, which -although it is not always a bad option -brings important compromises regarding the older adult's physical and emotional health.
In Active Aging Policy Framework, 5 the social and health aspects are not the only ones emphasized, as those related to the physical environment are too; having access to clean water, pure air and assurance of regular, good food are considered to be highly influential environmental factors.Such aspects are fundamental for the whole population, especially the more vulnerable populational groups, such as older adults.It is worth remembering that having access to a healthy physical environment depends not only on the older adults' individual choices, but is directly related to the living conditions provided by leaders and to care of the environment, which is the responsibility of the whole of society.Be that as it may, the absence or lack of one or other of these factors entails worse living conditions, reducing the possibilities of a long life which is full, safe and healthy; thus, it makes active aging impossible.
In the face of the results found, it was observed that some adaptations are necessary in the older adults' physical environments of coexistence, which for them can represent the difference between independence or dependence, between positive social interaction or isolation.The majority of traumas suffered by the older adults happen due to falls, therefore preventive and safety measures must be taken, principally in situations linked to environmental factors. 20he present research's results also point in this direction, as 30.6% of the older adults report having suffered a fall of some sort in the previous year, with the place of the fall being principally the house's back yard or garden.This may be attributed to the fact that these are, mostly, rural properties, in which the older adults care for the maintenance of the fields or plantations.In another study carried out in the countryside region of Santa Catarina, with older adults aged 80 or over, falls were evidenced in 43.6% of the interviewees. 21part from environmental factors, another important aspect in aging is the personal determinants, which represent a set of processes, which are: health problems, psychological factors, and satisfaction with life, among which one must consider the personal characteristics and each person's genetic predisposition for the development of specific illnesses.It is known that genetics is involved in the etiology of illnesses, although the cause of most of them is more environmental and external than hereditary. 5he psychological factors, which involve intelligence and cognitive capacity, are also indicators for active aging and longevity.It is important to adapt to changes arising from old age, making adjustments and keeping the capacity to resolve problems. 5The decline in some cognitive capacities with age is common, which can be compensated for if the older adult continues to participate in the community in which he or she lives, creating links and networks of support and social support.Thus, it may be surmised that the personal determinants involve -as well as the biological aspects -also the individual competences of interpersonal and social interaction, which are so important for an active and healthy aging with quality of life.
In the same way that the personal aspects are important, the behavioral determinants may be the most significant for an active aging, as it is these which may be changed at any periodand such changes may represent a relevant gain.Involvement in appropriate physical activities, healthy food, abstinence from tobacco and alcohol, and, also, the use of medications, wisely, can prevent illnesses and functional decline, as well as increase the individual's longevity and quality of life. 5The practice of physical exercise, as well as promoting health, can have a positive influence on older adults' self-esteem, which is a determinant factor for them to be motivated to maintain active behavior in the community in which they live. 22t is known that people age in the same way they lived, but nothing stops them from changing life habits or behaviors; everything depends on their motivation to do so, on the support and the access which they find, principally in the health services.For many, the process of aging and leaving the world of work provide the opportunity to discover new interests and skills.All this occurs most frequently when the older adult has a family or community support network, which encourages the adoption of new habits or even the changing of some determinant behavioral factors for active aging.The older adults tend to choose their goals and ways of interacting with this support network so as to be able to maximize the resources which are available to them. 23he social and health services need to have a perspective on the life course which aims to promote health, prevent illnesses and provide equal access to quality care so as to, as a result, promote active aging.This determinant can be identified through access to medical consultations, home assistance, participation in therapeutic groups, provision of medications by the public health network, vaccination, dressing services and mental health.
The home context is also a space for care and health promotion, in which the health team can exercise an important role, establishing partnerships through interaction with the older adults' family members, in the community relationships and with the support network.The majority of the older adults who participated in this study receive monthly home visits from the CHW, although the coverage of the visits from the remaining professionals in the health team remains low.
The family care may be complemented through support to the families in performing care activities for the older adults; this may include guidance, training and psychological support, varying in accordance with the needs.This support has the aim of substituting or mitigating the work undertaken by the families, which often takes place in poor or dysfunctional conditions.Policies and programs of formal home-based care remain insufficient in Brazil, although this service is stipulated in legislation. 24

FINAL CONSIDERATIONS
We know that people age in different ways, and -based on the data found in the present study -one can conclude that in spite of the fact that not all the older adults obtained a positive evaluation in each domain of the multidimensional evaluation instrument for active aging, in a general way they are active.The majority (90.9%) of the older adults participated actively in the community and undertook some sort of unpaid work, which was only possible because they had an active process of aging made possible by their behaviors and social context.
It was also ascertained that the instrument for evaluating the determinants of active aging was an important research tool, allowing the identification of factors which constitute the active aging of the elderly population studied in Rodeio-SC.
Through using the instrument, one can see the good performance of the subjects researched in relation to the determinant factors, such as: carrying out appropriate physical activities, healthy eating, formation of social support networks, abstinence from tobacco and alcohol, correct use of medications, and access to health services and information.Such results allow one to say that the group of older adults studied had fairly healthy behaviors, which, possibly, influenced the longevity achieved and the quality of life.
As a limitation of this study, however, it stands out that the instrument used was validated only regarding its content, making it necessary to investigate the other psychometric properties based on the other stages of validation, such as reliability and internal consistency.