Visions of the elderly on quality of life in the family health strategy: a study in the light of theory of giving

tlng=pt 34. Andrade AN, Nascimento MMP, Oliveira MMD, Queiroga RM, Fonseca FLA, Lacerda SNB, Nascimento A. Percepção de idosos sobre grupo de convivência: estudo na cidade de Cajazeiras-PB. Rev Bras Geriatr Gerontol [Internet]. 2014 Jan [cited 2016 Jul 02]; 17(1): [about 10 p.]. Available from: http://www.scielo.br/scielo. php?script=sci_arttext&pid=S1809-98232014000100039 35. Pimentel Á. A atitude etnográfica na sala de aula: descolonizando os processos de ensino. Realis [Internet] 2014 Jul [cited 2016 Jun 05]; 4(02): [about 23 p.]. Available from: http://www.nucleodecidadania.org/revista/index.php/realis/ article/download/128/117 International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice. IAM is considered a megajournal with independent sections on all areas of medicine. IAM is a really international journal with authors and board members from all around the world. The journal is widely indexed and classified Q2 in category Medicine. Publish in International Archives of Medicine


Introduction
Human longevity is a global phenomenon has increased the number of older people in all walks of life in most countries. The World recent data report that there are 810 million people aged 60 years old, representing 11.5% of the global population, and the expectation is this number reaching one billion in less than 10 years, doubling in 2050. The forecast for 2050 is that 64 countries can reach 30% of seniors of the total population [1].
In Brazil, the aging population is strongly evident in the current context. The IBGE Census of 2010 confirmed this fact, showing a very significant increase in this population segment: in 2010 increased to 10.8% of the population, which amounted to 20.6 million people. In half a century , life expectancy in Brazil increased by 25.4 years, from 48.0 to 73.4 years old [2]. There is a prediction that about 32 million people will be 60 years old or older in 2025 in the Brazilian population pyramid [1].
Aging is a set of changes in morphological, physiological, biochemical and psychological aspects, causing the progressive loss of the individual´s ability to adapt to the environment they live. [3] On the other hand, aging is considered a natural and processing phenomenon as part of the life, relating to the historical context of the individual who is aging and the society he is inserted. [4] People lives longer in the contemporary world. However, it is essential to question: what is the quality of life? Longevity only makes sense next to a healthy life. Thus, there is a preoccupation with the theme of "the quality of life for seniors." The term "quality of life" has currently been much debated. However, its meaning is very complex, subjective, comprehensive and varies as the time, the beliefs and the person, the way people live and feel their daily lives.
Given this complexity, the World Health Organization (WHO) has a subjective and multidimensional concept of quality of life as the individual´s perception of their position in life in the context of culture and value systems in which they live, and about their goals, expectations, standards, and concerns. Therefore, it is a broad concept that incorporates physical health, mental health, the level of independence, social interactions, the economic context and the relationship with health services, close to the concept of health. Also, the WHO states that the quality of life reflects the perception of individuals about the satisfaction of their needs, opportunities to achieve happiness, regardless of their state of physical health and social and economic conditions [5].
Currently, the most widely accepted concepts of quality of life seek to meet a multitude of dimensions discussed in the so-called general or holistic approaches. These approaches are based the concept of quality of life being multidimensional, presenting a complex organization and dynamics of its components, differing from person to person, according to their environment/context. Moreover, it is a fundamental aspect of good health [6].
In these argumentative lines, health appears as a central element that has a great impact on quality of life. The negative stigmas normally associated with the aging process, have the biological decline as one of its pillars, occasionally accompanied by disease and functional difficulties with advancing age. In Brazil, a demographic profile with the permanent aging trend of the population growth is delineated, which requires the need for adjustments to social policies such as health, social security and assistance [7].
In the health context, some aspects of the social sciences on the Gift Theory can be considered to enrich the understanding of interactions in social exchange circuits as explain the foundations of solidarity and bond as essential elements for the production of care through reciprocal movement of giving, receiving and giving back the symbolic and material goods in social relationships. The gift is one of the forms of social action explanation for the establishment of relationships [8]. While the gift system is shared, it is not charity. Each subject makes his material and/or symbolic, free and/or required, interested and/or disinterested, ambiguous solidarity movement. In the gift-charity, which is not the subject of these lines, the solidarity movement is unilateral, without consideration, service or obligation.
The awareness of these aspects of the interactive experiences can contribute to the maintenance of collective actions offered in community groups, as well as share the construction of new health promotion practices, strengthen the belonging and the relationship between the participants in search of an everyday life with more quality. Thus, this article shows some results of a dissertation of the Graduate Program in the Family Health Program in the Northeast, of the Northeast Network in Family Health Training (RENASF), by the Federal University of Rio Grande do Norte (UFRN) and aims to analyze the nursing perceptions of Francisco André Coexistence Group on quality of life based on the sociological contributions of the Gift Theory of Mauss [9].

Method
This is a descriptive, exploratory study with a qualitative approach that according to Minayo, it is applied to the study of history, relationships, representations, beliefs, perceptions and opinions, products of interpretations that human beings do about how they live, construct their artifacts and themselves, feel and think. [10] The subjects were eleven elderlies, members of the Francisco André Coexistence Group with twentyeight participants; twenty-two were female, and six were male. The inclusion criteria in the study were being registered in Francisco André group; residing in the covered area of the USF; being a member of the older group for at least four years, attending the scheduled activities. The exclusion criteria included people not residing in the covered area; being a member of the group for less than four years; not participating or having low attendance in the scheduled activities.
The age group of the research participants was 64-80 years old, 10 were female, and 01 was male. All of them are literate, none of them finished the elementary school. There were 04 of them living alone but living with their children and 07 live with relatives. All the group is hypertensive, and 03 also have Diabetes Mellitus. The selected participants received a written invitation, and direct contact was also made to clarify the research objectives. The group met at the same place where there are the meetings of the Francisco André Coexistence Group.
The adoption of interventions that create supportive environments and foster healthy choices are important at all stages of life. The multidisciplinary character has always been present and actions planning have been developed, always performed according to the coming demands of the group.
Data collection was through a focus group held in May 2016, in which the interaction is configured as part of the method. In the process, the group meeting allowed the participants to explore their views, from reflections on the topic discussed. In the discussion, the focus group can reach a reflective level that other techniques cannot reach, revealing dimensions of understanding that often are not explored by conventional data collection techniques [11].
The discussions were led by a moderator followed a guiding script, with the presence also of an observer who has additional records. The discussion occurred in 65 minutes, and it was recorded and subsequently transcribed for analysis.
The analysis was based on the Content Thematic Analysis method proposed by Bardin [12] and systematized by Minayo [10], which allows discovering the core meanings that communication is composed, whose presence or frequency mean something to the object of the search. The analysis technique was performed in three steps: pre-analysis, material exploration/processing and interpretation of findings. In the pre-analysis data, there was a brief reading of the material of the transcripts of speeches and reports of field diary prepared by the observer. In the exploration of the material, from the understanding of the text, the core senses were identified, and the category classification was performed based on the research objective and script used in the research.
For interpretation of the results and discussion, there were some thoughtful contributions on the Giving Theory [9], confronted with the empirical reality, trying to identify: what do they have to give or donate during the experience, the insight and self-awareness, self-care, skills got from the giving of themselves to the experience (donation); the feeling of openness to other possibilities, discoveries and curiosity for the new, reception and integration with the group (reception); and the consideration by the will to reproduce the practice, the desire for continuity of experience, the spontaneous commitment to incorporating activities in health services, the multiplier effect, the resonance in everyday life.
Regarding the ethical aspects, the research was approved by the Research Ethics Committee (CEP) of the Onofre Lopes University Hospital (HUOL), of the Federal University of Rio Grande do Norte (UFRN), in Opinion Nº 562 318 and recorded on the Certificate Presentation of Ethics Assessment (CAAE) Nº 21996313.7.0000.5537. Ancient philosophers codenames have been used to preserve the anonymity of participants in an allusion to accumulated wisdom with their age.

Results
The results are organized into two topics (categories): the first topic is on "the meanings of quality of life", that it is also divided into groups of meaning "health and well-being", "love, happiness and peace" and "good material conditions to live"; the second topic is on "changes and their effects on quality of life" and it is separated in "physical changes" and "psychic changes".

The meanings of quality of life
When asked about the meaning of quality of life, the group mentioned the polysemy of its meaning and its multiple relationships with various aspects. Some excerpts from the speech that identified the quality of life related to "health and well-being" stressed: Quality of life is to be healthy and live well. Some words have meanings that express a more general concept, though not dissociating the expanded concept of health when they referred to the core meaning of "love, happiness, and peace." The words showed a relationship between the quality of life and affection, reciprocity, peace, and happiness: It is to live happily, have peace and love. I do not speak of poverty, but the person being happy.

Hipácia.
It is living in a happy environment, among people who want good things.

Aristocleia.
It is to have peace and quiet. Living in a healthy environment with joy and peace.

Maronéia.
First is to have faith in God. Being well treated by others and love others. Olimpia.
Some views, covering the third core of sense listed in this topic, related to quality of life was "good material conditions to live":

Quality of life for me is to have my little house to live, have food to eat.
Heloísa.
It is also to have my house to live in and my salary to live.

Asioteia.
Quality of life is to have money to buy necessities, medicines, and food. Epicuro.

Changes and their effects on quality of life
Regarding the changes occurred affecting the quality of life, the group discussed several habits that have changed as a result of learning, exchanges, and motivation from experiences and activities shared. The testimonials confirm that the experiences in the group contributed greatly to improvements in quality of life in the various aspects of the physical and functional capacity as well as the emotional and social aspects related to creating linkages and improved self-esteem. They also mentioned a positive effect on general health.
Thus, the thematic analysis identified two groups of meaning: "the physical changes," associated with functional, physical, pain, health vitality; and "psychic changes" related to emotional aspects and mental health, about the resonance in the quality of their lives.
Regular physical activity can be considered a valuable tool to minimize memory declines and improve the quality of life, resulting from the aging process [3]. Regarding the perceptions of "the physical changes" associated with participation in group activities, the following statements were selected: Hildegarda.

I think my mood, my courage has improved, I have more willingness to do things. I am 67 years old and do not feel old. My physical situation is stronger.
Maroneia.

When I am walking I feel like a child. I stay long hours on crocheting and crosswords, and so I live.
However, also, I do things at home. Olimpia.

I feel good when I walk and when I dance. It is good for my body. The body needs. I feel it.
Asioteia.
Participants also recognized the opportunity of learning about the benefits of healthy eating for strengthening the body and enhancing the vitality and quality of life: I felt many headaches, but I learned to eat better and decreased.

Azioteia.
My diet has improved. I knew I could not eat too much salt, but I did not care. Now I am careful. I learned from the lectures. Apasia.

Diótima.
Before I came to the group, I did not drink much water. Now I drink more water because I learned that water is important to us.

Epicuro.
As for the core "psychic changes" that influenced the quality of life, we can highlight some references as to overcome anxiety states, loneliness, stress and panic attacks, after frequent participation in the elderly group:

I improved my self-esteem; I met friends and learned a lot from them and health professionals. I am very grateful for it.
Safo.

My nervous system is better, I get distracted, I forget the problems and return home better. I was in a situation that I do not think about living, and today I am much better. Coming here makes me feel good. Even my depression is over.
Diótima.

I am free of taking Rivotril and joining the group helped me.
Hipasia.
The group works as an alternative to minimize the effects of aging, leading to improved quality of life. It means the possibility to meet new people, build friendships, to travel, exercise, play, among other things, changes that happen in the life of older people and lead them to continue participating in the group and encourage others to attend it [13].
The activities developed by the groups improve the quality of life aspects relating to physical and mental health, increasing the period of active life and preventing the functional losses. The older people can assert their identity, expanding the boundaries of their value, recognized as a participant in the current life of the group and the world, through a shared memory [14].
The community groups encourage the individual to acquire more autonomy, improve their self-esteem, quality of life, sense of humor and promote social inclusion [15]. Some lines have references in this sense: Epicuro.

Discussion
The relationship between quality of life and health appointed by a group of senior citizens has been discussed in several investigations. A study [16] emphasized that the term "quality of life" related to "health" is very common in the literature and has been used for purposes similar to the more general concept.
Therefore, in the current theoretical perspective, health is conceived as a social construct, expressing as a historical, political, social and psychobiological phenomenon. Health promotion has a great importance in the health conjunction with other concepts not only the disease, becoming the possibilities of ways of living. [17] The traditional concept of health as complete well-being, physical, mental and social, even with its limitations, already announced the polysemy of the meaning of health, pointing its relationship with life and its quality [5] indirectly. Almeida [18] recognizes the health related to the quality of life. However, it is an epistemological critique emphasizing that there is still no general theory of health to explain clearly such a relationship. In this sense, he stresses that when discussing health, their polysemic concepts, plural, multifaceted, both ontological and heuristics should be considered.
A classical review published some time ago [19] pointed out that "quality of life is an eminently human notion, which has been approximated to the satisfaction found in family, love, social and environmental life and existential aesthetic." It also emphasizes that the term encompasses many meanings, reflecting knowledge, experience, and values of individuals and collectivities reported at different times, spaces and different stories, and therefore a social construction with the brand of cultural relativity. These aspects were also highlighted in the meanings expressed by the group of elderly.
There is no consensus on what quality of life means. A tentative definition encompasses, from health, as well as a variety of aspects such as environment; economic resources; relationships; time to work; and leisure. Thus, two trends in the conceptualization of the term are identified: a generic concept and other health related concept [20].
The perception of quality of life linked to reciprocity evidenced in some lines reminds us of the gift system as fundamental to the establishment of the social bond. [9] In this case, exchange occurs between the act of care and the act of being cared to structure the care practice.
Reading about the gift in today's market society has a non-structuralist view, understanding it as the foundation of a new paradigm, in which the social bond involves dialectically freedom and obligation, spontaneity and standard, superimposing the material utilitarianism, identified with anti-utilitarianism. This design strengthens the understanding of reciprocity and solidarity as fundamental values in the constitution of society [21].
Reciprocity is defined as the dynamic reproduction of benefits, generating social ties, allowing the recognition of the other, depending on the sense of belonging to a group, forming a collective identity, illuminating the solidarity practices, making flourish experience sharing and mutual assistance in the construction of social life [22].
The senior citizen builds his identity, dependence and/or independence, and his existence through the affective bonds with the health service is hosting him, through established relationships with professionals who integrate these services and the other actors involved in the scenarios of their lives. The virtuous circuit provided by reciprocal exchanges of gifts do not just intermediate these contacts, but also provides for mutual recognition of all subjects as they feel valued [23].
It is also evident in the discourses reference on the affections that mediate relationships. Words like "love," being "treated well," "love others" reporting the solidarity and reciprocity, reinforcing the importance of the circulation of symbolic goods in the relationships.
References about love as fundamental in hominid history are affirmed by many students of human nature [24,25].
For an alliance or bond in human relationships, they reaffirm the strong presence of emotions and love in the lives of men in all kinds of relationships established.
Peace and tranquility were also mentioned by some of them, expressing the need for security and the concern with violence. On violence against the elderly, study shows that this phenomenon is growing worldwide [26]. For a long time, the various acts of violence against the elderly were problems of each family, but now it becomes the responsibility also of the community and the state.
The gift does not involve only the symbolic aspects. In its ambiguity and its paradoxes, the material issues must also be considered, because the material goods also contribute to a better quality of life, the necessary provisions for the health, like medicine, food, housing, among others. These aspects refer to the concept of this health in Article 196 of the Brazilian Constitution, which recognizes health as a living and working conditions, ensured through social and economic policies. [27] Thus, the material aspects indicated by some elderly are also important because they ensure the very existence, articulating the group members, and helping in the maintenance of social networks.
About the changes and impacts on quality of life identified by the group, there is unquestionable that decreased physical activity contributes to the onset of some chronic diseases that can increase functional disability, which in turn, generates emotional and mental effects. The study found a positive correlation between the degree of dependence, physical and functional capacity and the quality of life index [28].
About the living group, it may work as a system of relationships that promotes interaction and/ or binding of people, ideas, and practices, which the world of theory feeds based on the concrete experiences and vice versa, using an educational everyday, historical, physical and emotional reciprocity. This circuit is a gift because they share learnings, kindnesses, emotions and senses of life and culture. [29] In this interaction channel, which is received regarding education must also be returned, also reproducing the feeling of responsibility, the concern with each other to produce and share ethical values such as peace, trust, respect, and esteem. The learning experiences require a dedicated structure for collaboration, cooperation, and exchange of ideas. [30] It is important to highlight that it is clear that social relationships between those who accept and welcome are permeated by theories of gift and reciprocity, since who relates/hosts, always have something to offer, but also expects the other something exchange, and this reciprocal process is also for who is welcomed [31]. Elements of reciprocity such as affectivity, a welcoming attitude, respect and care for each other appear as instigators of this relationships. Understanding the interdependence of each other regarding changes means recognizing that users are also careful to producers and not just consumers of services.
The concrete man (total) should be seen as a biological, psychological and social history, synthesizing this three-dimensionality constitutive of man as body, emotions, and rationality [32]. His totality can only be seized under the aegis of an interdisciplinary approach.
Being part of a group is an achievement for the elderly, a way to break away from the daily routine of household chores, and bond with their children and grandchildren when they acquire knowledge and enjoy the feeling of greater freedom during this phase of life. Groups can act as a support network that mobilizes people in search of autonomy, resilience, and decreasing vulnerability. In the interaction between people, links that enable social inclusion are created [33].
Research that analyzed the perception of the elderly about social groups found that the participation in groups represents for them a return to social life, leisure activities, boosting the sense of freedom and the will to live and, consequently, improving the quality of life [34].
During the opportunities of meetings, be around with others is what defines the speaking, also allowing to follow the social production of knowledge, doing, undoing and redoing relationships with people. Speaking is to move between sensitive similarities and differences needed to build multiple perspectives interactions between different knowledge practices since we talk to those with whom we understand each other. [35]

Conclusion
The points of view of the older people were recognizers of the importance of participation in the group and reflections designed in the life of each. Learning in educational activities; the exchange of knowledge/experiences and reciprocity present in the living group have built bonding, generated a network of support, and showed changes in quality of life.
Such events lead to reflection on the relationships in the group as gifts as symbolic relationship system promoting the alliance, the triple obligation and freedom of giving, receiving and return, recognition and life, among others.
This study provided an opportunity for a better understanding of the importance of listening to the elderly on the quality of life, their relationships with the aging process and the experiences that contribute to changes in quality of life, from the aggregation of knowledge and experience, strengthening reciprocity and gifts.