The aging of the world population has increased since the beginning of this century, due to the current demographic transition that has taken place not only in developed countries but also in developing countries.
Estimates show that 370 million seniors currently live in developing countries; and projections for the next 20 years point to a population of over one billion elderly, 70% of which reside in poor countries (Litvoc & de Brito, 2004) .
Between 1980-2000, there was an increase in the elderly population in Latin America, twice that of the total population in the period, which shows rapid aging in developing countries, such as Brazil, where the number of elderly increased from 15.5 million to 22.4 million in the period 2001-2011 (Mallmann, 2014) .
According to the population census conducted in 2010 by the Brazilian Institute of Geography and Statistics (IBGE), the Northeast is the third most aged region of Brazil, with 10.3% of the population comprised of seniors to have more than 5 million people aged 60 (Brasil, 2010) .
According to the World Health Organization (WHO), in 2020 three-quarters of all deaths observed in developing countries are related to aging, such as cancer, circulatory diseases and diabetes. Thus, there is need to know and develop alternatives to prevent and delay the onset of chronic diseases and their complications (Litvoc & de Brito, 2004) .
Veras (2012) reveals that the disease prevention, health maintenance, the independence and autonomy of the elderly are among the current challenges to health by aging. These elements are important to the search for quality of life, dignity and well-being (Veras, Caldas, & de Albuquerque Cordeiro, 2013) .
This quality of life can be achieved through active aging, including optimizing opportunities for health, participation in society and security, as people get older. The active aging expression goes beyond being physically active, and it encompasses the continued participation of the elderly, involving social, economic, cultural, spiritual and civil (de Lira, 2014) .
The promotion of health has received much emphasis on health discussions in general and in particular on the issue of health of the elderly. Health Promotion is understood as the community empowerment process to work on improving their quality of life and health, including greater participation in the control of these processes with the ability to identify and to realize aspirations satisfying needs that enable the transformation and adaptation to environment (Brasil, 2002) . Thus, individuals and human collectives are the largest objects of the new health promotion, and health as a resource for everyday life, not as a goal of life, as highlighted by Carvalho (2007) .
Highlighting the need to think about health education practices focused on the Promotion of the Elderly Health, involving the relationship between objective and subjective processes in health care, in order to facilitate the inclusion of the elderly in the context of the communities where they live starting from their concrete reality, paying attention to their skills, their interests, their desires, their emotions and their various forms of expression. This process should be directed towards a community empowerment experience, qualifying the political action of individuals and groups for intervention on reality, beyond the micro level, advancing to macro-structural spheres (de Lira, 2014) .
The Popular Education has great potential to contribute to the empowerment of the elderly, the power-sharing perspective and relationship with autonomy and political participation, seeking to facilitate the development of the capacity of individuals to find solutions and strive to ensure their social rights through participation (Ribeiro, 2009) .
In this direction, this study aimed to analyze the contributions of Popular Education in Health for the elderly empowerment in the community context.
This article is product of the Doctor Degree Thesis of Gildeci, at the Postgraduate Programs in Education and in Biomedical Gerontology, Pontifical Catholic University of Rio Grande do Sul, under orientation of Stobäus, in collaboration with Technical School of Health Sciences colleagues Marcilane and Kátia.
This study is characterized as a qualitative research, type action research as part of the doctoral research project in 2014. In this research were studied issues related to prevention and promotion of health of the elderly in their community context, through Popular Education in Health, from the Extension Project activities ‘Popular Education and Health Care for the Family’ (PEPASF), which operates since 1997 in outlying communities in the municipality of João Pessoa-PB. This extension project aims to build a commitment process, responsibility and complicity with the causes, projects and community needs and families, developing activities ranging from meetings and appearances with the leaders and social movements, to the intersubjective relationship and building links between residents and the extension. Among the activities, those that stand out are the home visits, held weekly, in an interdisciplinary manner, by pairs of students, and the elderly group.
The research had as subjects participating in the elderly group of Mary of Nazareth community in João Pessoa-PB accompanied by PEPASF, students of various courses of the field of Health (Nursing, Physiotherapy, Dentistry, Nutrition, Speech Therapy, Occupational Therapy, Nursing Technician) and Human (Public Management and Psychology) members of PEPASF, in addition to the Health Unit of the professionals of that community family.
Participant observation was made during the continuous period of September 2010 to May 2013, following a total of 90 students and 40 elderly.
The elderly who participated in the research were in the age between 60 and 88 years. Most of them were women, housewives or retirees, with a family income of a minimum wage or less (corresponding to 10,000 Euros). As for the number of members belonging to the family nucleus of the elderly, the majority comprised an amount ranging from 4 to 6 members, where three elderly women lived alone and one of them was blind and had no relatives.
The activities and processes carried out with the elderly in this period were observed and recorded by the researcher in a field diary.
Also semi-structured interviews were carried out guided by a roadmap that included questions that sought to identify elements of the work of the project, their contributions to the lives of older adults and suggestions for improving the work. We interviewed ten elderly, from the Health Unit Medical Local Family assistance, two community health workers (CHW) and three students of the Project.
To complement the analysis documentary sources were consulted minutes of weekly meetings of the Project and meetings of the Community Association, in addition to electronic messages sent to the mailing list and Facebook PEPASF.
Upon completion of data collection, conducted the analysis. First, a brief reading of all material collected was carried out by seeking a rapprochement with the corpus of research, as suggested by Minayo (1994) . Then a thorough reading was held of the collected material, seeking to systematize focused experience in a logical and procedural, identifying units of meaning, describing care so involved and concerned the implications for life of the elderly. This process took place in three successive stages, in which it sought to elucidate increasingly the research objectives, and extracted the dimensions considered relevant experience. After the identification of the categories, the researchers begun with a dialogical and dialectical analysis of the investigated object, as emphasized Amatuzzi (2001) .
The study was approved by the Scientific Committee of the Geriatrics and Gerontology Institute and by the Research Ethics Committee of the Pontifical Catholic University of Rio Grande do Sul, number of Brazil Platform 73581. Before starting each interview, all the interviewees signed a Free and Informed Consent Term.
3. Results and Discussion
Data analysis was conducted from a hermeneutic interpretation and dialectic based on the study objectives, arriving to the units of meaning, descriptive of the investigated object (Amatuzzi, 2001; Minayo, 1994) .
In the analysis, this article will highlight it one of the dimensions found on the implications of care so experienced through Popular Education for the promotion of health of the elderly: the autonomy and empowerment of the elderly - new positions in the face of life situations. In order to ensure the anonymity of the subjects, pseudonyms of flowers were used to name individuals whose lines are inserted in the text.
Care developed by PEPASF with the elderly showed significant changes that reflected significant implications for the promotion of their health. It is one of those transformations represented by autonomy gains and the elderly empowerment, which translated into new positions in the face of situations of life.
This performance with the elderly was given by the insertion of students from various undergraduate courses (Nursing, Medicine, Dentistry, Psychology, Nutrition, Physical Therapy, Social Work, Technical Nursing, Occupational Therapy, Speech Therapy, Biomedicine, Nutrition and Education) in association with Community reality of the outskirts of the city of João Pessoa, PB. The activities developed by the participants happened project through: weekly home visits to the elderly, group of elderly ‘Peace and Love’, with proposals for prevention and health promotion, psychological listening, participation in areas of social and political struggle, for improvements health promotion and quality of life of community residents.
Importantly, this development refers to a process that will give to some of the older of concomitantly with other implications in which they will transform into multiple dimensions at the same time, whether biological, social, cultural, emotional, relational, etc.
In this perspective, the research proposal was generated from observed speeches, interrelated way in the learning process experienced by older people involved in the care in question.
4. Autonomy and Senior Citizen Empowerment: New Postures Front Life Situations
One of the important changes made in this study was the development of autonomy and empowerment of elderly, facing the experienced situations. Older people began to self-care, to perform the chores of which were removed for health reasons. Also began gradually to move more security on the streets, alleys and lanes of the community, and to deal with situations of life with more inner strength, feeling safer in your face. Some elderly people were also involved in organizational issues of community struggles.
Another important change observed was the output of social isolation situation for the expansion of their social relations. Older people began to interact more with family members and neighbors, meet new people within and outside the community, to attend the meeting of the Community Association, to participate in the group of elderly, to move alone to the ESF, for activities carried out at the University and local and state events. As evidenced by reports of elderly below:
[...] Did not do much to change after these boys got to come here at home and talked about it much, I understood more and more I get what I wanted, not like a, you know, needy, poor, but after that project fetched by law [...]. Today also go to the meetings of the community association, participate in events at the Federal University and so on, where students and teachers they invite me, I will; and talk about everything, even the workers’ health, also, I am part of the People’s Education Project in the occupational health (Mr. Cravo).
You learn more thing education with them, these students are a beauty. The visits have helped to us to join with other colleagues elderly and make the office here, we when it alone has nothing, but when she gets to know and starts to receive these students, learn more education, learn to live, learn to live with all manner of people (Mrs. Dahlia).
It is important to emphasize that impact the autonomy and empowerment of elderly, deepening a little more example of Dona Dahlia. It is a case that illustrates the encouragement and involvement of the elderly in care developed by the Project. Dona Dahlia is a lady of 71-year-old widow who lives alone; she had a daughter, but lost to thirty years old. To be visited by the pair of students who accompanied every Saturday and were also members of pregnant and postpartum women group developed by extension, Mrs. Dalia realized that the students came often to his house carrying boxes, papers, art supplies, lines crochet, among others. Demonstrating interest in what that meant, he asked, ‘What is this material?’ Then the students answered, “are materials for use in the workshop of pregnant and postpartum women group, which will happen soon in the afternoon in the Preschool”. At that time these students invited to visit the group. After making other questions
Dalia said, “It is the nursery is right here close I will not promise, but I will try to visit you this afternoon. But you can leave the stuff at home here not to be up and down the streets of the community with it in his hands. In the afternoon you go through right here it’s way and take me.” On Saturday the elderly was not to visit the group. The following Saturday the students did as she suggested. So, time to visit her, they kept the materials the group of pregnant women in their terrace and continued to encourage her to participate, saying,
For Mrs. Dahlia, the theme chosen to work this afternoon the group was violence against woman will be interesting, come visit us today. It will be a great pleasure for us and also your visit will praise our work will serve as a stimulus for women continue to participate. We are struggling to keep the group for lack of participants.
Early in the afternoon the students went to the home of Mrs. Dahlia seek the material and went to the nursery to participate in the project with pregnant and postpartum women. To the surprise of the students shortly after arrived Mrs. Dahlia all dressed up and smiling. And just saying: “I came to visit you”.
At this meeting the group she participated in the activity with the women present, made some interventions and made a speech congratulating the women who were part of the group, praising all participants of the project and encouraging women to continue participating in the group. He asked for pregnant mothers invite their friends to participate, and concluded his speech by saying, “I really enjoyed participating and from today I will invite and give ‘power’ to all community women who pass in front of my door”. She was applauded at the end of his speech and the students, the teacher and pregnant women at the time made a combination, imbued with the feeling of joy and appreciation of the elderly the feeling with the group, and it would be an important partner for the strengthening of that project, they elected “godmother of the group of pregnant and postpartum women”. From there it became part of the group.
At such times the appreciation of the elderly becomes more explicit and, realizing the feeling of appreciation by the extension workers and project participants, the elderly become interested increasingly in the activities developed by the students, teachers and PEPASF professionals, the community as a whole. This involvement of the elderly with the group, and contribute to their independence, also favored the development of self-esteem making it more active and proud. With that his health began to show a gradual improvement over time. It is noteworthy that, in a social context in which the elderly is often seen as useless and obsolete this appreciation is very important, not only for the elderly but also for the students and for young pregnant women in the group change its view of aging. It is a learning experience for everyone.
In this perspective, the experience of autonomy and empowerment in the face of life issues in some older people had as reference the experience and strength of the other in coping with critical situations. As older people the empowered, passed to recognize that alone could not solve their problems and together became more strengthened collectively. From the exchange of experiences with others, either within the family or community context, the elderly felt comforted and sometimes found solutions to the problems experienced.
During the coexistence in the group, discovered older the problems they individually passed were not only his, but experienced also by others in the community, and in interaction with others, they found strength, comfort, exit to the problems, as well as the appropriate redirection of experienced situations. This approach brings the concept of understanding the reality of the other, stimulating the issue of respect and trust each other, feeling therefore affected and identified with life situations, and empathy with the difficulties and dilemmas perceived in relation to other people, allowing the flourishing of its otherness.
According to de Carvalho Mesquita (2001) otherness lived defines us as individuals; thus it can be seen that this experience contributes to social reconstruction of the elderly as individuals.
This perception can be identified in the following statement of elderly excerpt Mrs. Orquídea, moved with the serious problem of health of a representative of the community association, breast cancer. The elderly narrowed the bonds of friendship with the said representative in the meetings of an existing association in the community the Community Association Maria de Nazaré (ACOMAN) and other spaces for debate community problems which participated and felt motivated to look at their problems health differently, realizing how the association companion faced his illness:
I see so [...] that girl there with that problem and it, as they say, but it is always there, right, fighting, trying to win, overcome and that there gives me strength too. It seems, therefore, that this approach to the other, with the strength of the other, also strengthens, and if she can have strength, I can also (Dona Orquídea).
It is noticed that social interaction and sharing fears, weaknesses, pains and sorrows, strengthens the creation of ties and social ties that reflect in the disease process and healing of individuals, as highlighted Lacerda & Valla (2005) . In some cases, the support given by the elderly to the suffering of another person reverberates in more constant and systematic assistance, through effectively to the caregiver of someone affected by a serious health problem. This was also the case of Mrs. Girassol, visited by participants PEPASF thirteen years ago and who accompanied and took care of a neighbor stricken with cancer until his death. His career really caught the attention of the participants of the Project and the Health Strategy professionals who attends the local family, as this professional report in his interview about their learning, watching the old experience.
Mrs. Girassol same, which I identify it is an occupation with community activities, which certainly those people who were articulated with the absolute truth that your life is to take care of the house, take care of her husband, to the fair. Suddenly finds himself busy with care of other people. This promotes human development and community growth. She is a person, for example, who took care of another elderly in a very fragile health situation, which had a more fragile family still not realized, and was instrumental in Gerbera owner care. But she was very firm about it, very proactive. Certainly the support, the support of two institutions: the design and PSF so she (Mrs. Girassol) assumed it was important, if not that, she was alone, with all the questions that the grandchildren (Mrs. Gerbera) were (...) Dona Gerbera could have died before (PSF Rosa Professional).
On this issue, a project teacher posted the following statement on the Internet via Project mailing list, talking about the context experienced by the elderly.
Mrs. Gerbera was monitored intermittently for over 10 years by design. Earlier, Mrs. Girassol had not assumed responsibility for management of their pension. Mrs. Gerbera was very badly treated by his daughter, who was in his house with his children. Her daughter has always been very involved with drugs and was begging. We managed to Mrs. Girassol assume the financial management of their pension, delicate and conflictive process. Then it was achieved the accompaniment of a granddaughter who has multiple disabilities and was left out. It is very difficult to follow home. The important thing was the methodology to count on the neighborhood to overcome these barriers. My surprise is that all her grandchildren survived and grown despite the care conditions so tumultuous (Professor Flor de Cactus).
In the development process of individual autonomy and empowerment of elderly people, some elderly began to engage in collective processes in the community. Thus, some elderly accompanied by PEPASF were inserting in the community movement in the struggle for housing, for better conditions of community infrastructure (transportation, sanitation, safety, traffic flow organization).
In this sense, de Melo Neto (2006: p. 11) says:
Popular Extension practices aimed at the construction of generating autonomy actions, especially in the most disadvantaged sectors of society. Implementing the institutional walls, covering educational activities in social movements and other organizational tools of civil society.
This perspective can be observed in the statements below:
If it was not the project I was like formerly isolated in my house would not anyone opened up more, I go everywhere, talk to the doctors, I am more confident, gathered me with two teachers who came to the meeting with seniors, I went to HU. Even the clowns I went to the dance classes I was (Mrs. Dahlia).
The work of the Project (PEPASF) with the elderly in the community Mary of Nazareth, has contributed enough to their self-esteem, helping him face to face your problems, participate in existing movements in the community claiming their rights, look wider to health, taking care of yourself and family. Several contributions to the way of seeing reality, to live differently, improves his quality of life, is a stimulus, because they start to take better care of themselves, with family (Professional Copo de Leite).
From there some elderly people came to realize that they had rights as citizens. The feel more masters of their own history, having more knowledge about how and where to turn when they needed some claim their rights in a health promotion process aimed at the humanization of their health. This generated a great satisfaction in the elderly and the feeling of being in control of your life. They understood that they need a qualified and humanized care, not accepting, so any kind of care. Question thus based care begging, as if it were a favor granted by health professionals.
Freire (1983) , one of the pioneers of theoretical systematization of Popular Education, realizes the understanding of man, with his ability to emerge from time discerning about their one-dimensionality, in its relation to the world from a given and consequent sense. The man, therefore, is not reduced only to natural dimensions, being biological and cultural, to be creative, but it becomes a being eminently capable to modify it. As heir of experience in creating and recreating, inserting the contextual conditions, “responding to its challenges, aiming to himself, discerning, transcending, launches man in a field that is her exclusive- the History and the Culture”, according Freire (1984: p. 42) .
This thinker highlights thus the importance of the idea of relationship between us humans. It reinforces that we are related beings in the world and the world in search of human emancipation that can be made possible also by the educational path. These relationships through education allow the course of self-consciousness and the world. “Relationships in which subjectivity, which is embodied in the objectivity, is, with this, a dialectical unit, where it generates a meeting in solidarity with action and vice versa”, said Freire (1983: p. 51) .
All seniors who are accompanied by the Project are different from others. They are more encouraged to do what they have will, to speak of them is different, they have another view. The affection, attention, they feel safe in what they want to do, pass security. Visits they do guide, and return to learn, and there it was? If it does not work you try again and so will (Professional Copo de Leite).
In this sense, the impact of the stimulus given by the Project for the development of autonomy and empowerment of elderly people about their rights and their personal and collective demands, causes them to become highly selective about the quality of services, especially the ESF, as with regard to their health issues. This autonomy and empowerment sometimes is not well understood and accepted by some sectors linked to ESF because the demands made by the elderly can generate constraints and confrontations related to technical procedures developed for the care of the elderly. As mentioned in the account of professional health following local ESF:
[...] working in my view, a matter which, for us sometimes weigh a certain triangulation design with the unit, when that person and then only comes to mind now examples of older people, when that person wishes any procedure, any way to call the FHP does not to your liking, resorts to PEPASF to try to mediate this or even just to let off steam. So we have had a situation that for some PSF workers were embarrassing, of questions, and some techniques, which for some people could be interpreted as embarrassment, and this matter of triangulation same, that person want your service to be that way and it is not made that way, and the person leaves stressed (Professional Rosa).
It is worth noting that one of the most evident problems relating to social demands related to Maria de Nazaré community concerns the struggle for housing, to community redevelopment to better adapt the houses to the urban space, since this community is the result of the occupation of public land and is in an extremely poor area. Toward this end, some seniors have joined the discussions on the issue, much debated in the meetings of the local community association. This is the example of Mrs. Girassol, who was interested in participating in this process of engagement in life and community movement, enabling a closer experience of the problems faced by the community and engaging with their coping process. This issue of housing, above is one of the most serious problems that are being faced by the residents of Maria de Nazaré community, since the formation of the neighborhood.
I have attended meeting at the school with a lot of people. For many years ... I left it out too, meeting (Project meetings UFPB meetings in City Hall)... those business houses are you always this right? I’m always there, in the struggle for houses. Okay, then I have nothing to complain about. These houses, which have to complain about is outside of you, the houses there (Mrs. Girassol).
This old participated in the project since the beginning of its activities in the community, she expressed quite easily, attended the meetings of ACOMAN regularly, opining, questioning, charging. Seeing her reach alone meeting only with the help of a cane, distributing smiles to those who are surprised by the way and set an example for other seniors and motivated students to continue with the modes of care developed by the Project. His involvement in activities in the community is something striking, comments reason the people of the community, professionals and ESF project participants. In addition to its inclusion in the community movement, she went on to attend every Friday the group of seniors from one of PEPASF partner projects, the Physical Therapy Project in the Community, which takes place in the ACOMAN headquarters, with stretching activities, physical activities with guidance students of physiotherapy and wheels conversations on topics of interests of the elderly. This impact of the care process in the life of the elderly can be illustrated from the following statement:
It’s like bring more life, more knowledge. Getting more, always so saying, for we do not stay at home. Look I’ve been in the post this week twice, I went down the hill and went up, things that even three months ago I would not do it, now I’m feeling more secure, I was afraid more people always giving me that support, moral support, words of support (Mrs. Orquídea).
However, not always all the elderly had this collective involvement with community issues. Considering the number of elderly accompanied by PEPASF, he noticed how small the number of those elderly who have to participate effectively in community struggles. This is a fact also observed in other contexts and age groups of our society. However, community participation is a key element in ensuring the improvement of health care and promoting conditions for its promotion.
According to Côrtes (2009) participation in Brazil is far from homogeneous and is modified depending on the local political culture, the level of social mobilization and the authorities to respect and value the involvement of society in the process. Thus, there is transformative participatory experience in many places, but in other situations there innocuously participation and mobilization scarce.
In this perspective, this Project seeks a reorientation of work in promoting health of the elderly directing you to the autonomy and empowerment of these individuals, enabling them to become more active, participatory, problem-solv- ing, proactive and healthy living this phase of life in a lighter way, more hopeful, excited, motivated, happy, leading them to the fullness of your being and your overall health, with dreams and projects with dilemmas, like any stage of life, but having also, the blessings and potential of this new phase of life.
It became clear in the study that care so developed by PEPASF contributed to the promotion of the health of the elderly followed, covering so much the physical dimensions as social and subjective, inherent in the human being. By valuing aspects of the subjectivity of the elderly, their knowledge and stimulating their potential, the project has expanded the prospects for comprehensive health promotion, demonstrating significant benefits to improve the quality of life of these people, opening new horizons for the search for autonomy and empowerment, as well as the transformation of unjust and exclusionary social realities.
Given this finding opens up new paths in the construction of care modes to promote elderly health and education and health, and Popular Education in Health as a promising avenue for the creation and reflection of new models, inside and out university, encompassing effective knowledge and practices and needed to be made possible and implemented within the Community framework of primary health care.
Noteworthy is thus the potential of working with elderly guided the perspective of Popular Education with a view to promoting health. The orientation of PEPASF actions based on this educational perspective contributed to greater involvement of the subjects involved, improving the self-esteem of these people and stimulating generating processes of autonomy.