Abstract

Studies have evaluated the quality of life (QOL) of many groups; however, such studies in relation to Reference Centers for the Elderly are scarce. This research identified factors associated with a good QOL of people using a Reference Center in the city of Belo Horizonte, MG, Brazil. Transversal study of 257 elderly people who used a Reference Center for the Elderly. The short version of the World Health Organization Quality of Life Assessment (WHOQOL-BREF) was used to evaluate the QOL of the elderly people. The analysis was rationalized by defining two groups in relation to perceptions of QOL and satisfaction regarding health. Logistic regression analysis was performed to assess the direction and magnitude of the association of each variable with QOL. The results showed that the majority (63.4%) of the elderly people considered that they had a good QOL and that they were satisfied with their health. The environmental domain received the lowest scores (average = 14.4). The factors of advanced age, being from the interior of the state of Minas Gerais, physical activity, diabetes, musculoskeletal diseases, hypertension and depression remained independently associated with QOL and satisfaction with health after the model was adjusted. The data that was obtained can be used to direct care strategies for the most vulnerable elderly people, with particular attention to issues that affect the environment.

Aging population; Quality of life; Transversal studies

Introduction

Population aging is a global phenomenon that is mainly due to a decline in mortality and fertility rates. Demographic projections indicate that the number of elderly people aged over 60 will exceed the number of children for the first time in 2047, growing from 841 million elderly people in 2013 to over 2 billion in 2050¹1. United Nations (UN). Department of Economic and Social Affairs. Population Division. World Population Ageing 2013. New York: UN; 2013..

According to the Brazilian Census in 2010, the number of elderly exceeded 20 million people and a factor of particular note was the proportional and faster increase of the group referred to as “very old” (over 80). This age group is currently the fastest growing population segment and it now represents more than 14.2% of the elderly population²2. Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Atenção à saúde da pessoa idosa e envelhecimento. Brasília: MS; 2010. (Série B. Textos Básicos de Saúde) (Série Pactos pela Saúde 2006, 12)..

In this populational macro environment, rapid demographic transition has occurred most sharply in developing countries and it has been accompanied by epidemiological changes. Complex changes have been observed in health-disease models, which have changed from a prevalence of communicable diseases to a higher prevalence of chronic non-communicable diseases (NCDs)³3. Mendes EV. O cuidado das condições crônicas na Atenção Primária à Saúde: o imperativo da consolidação da Estratégia da Saúde da Família. Brasília: Organização Pan-Americana da Saúde; 2012..

As a result of NCDs such as diabetes, cardiovascular disease and strokes, it has been estimated that decreased productivity at work and reduced household income will lead to a loss to the Brazilian economy of billion dollars. The strong socioeconomic impact of chronic diseases and their risk factors are having a negative effect on the Millennium Development Goals, which cover topics such as health, education and the reduction of poverty, and according to a study produced by the Pan American Health Organization and the World Health Organization this is to be found in most countries⁴4. Goulart FAA. Doenças Crônicas Não-Transmissíveis: estratégias de controle e desafios para os Sistemas de Saúde. Brasília: Ministério da Saúde, Organização Panamericana de Saúde, Organização Mundial de Saúde; 2011..

Transposing these demographic and epidemiological factors, the intensification of changing age structures and the increase in NCDs also results in a direct effect on the QOL of individuals.

As part of the growing body of scientific evidence that exists in relation to these issues, international studies have shown an inverse correlation between QOL and fragility⁵5. Gobbens RJ, Luijkx KG, van Assen MA. Explaining quality of life of older people in the Netherlands using a multidimensional assessment of frailty. Qual Life Res 2013; 22(8):2051-2061., depression⁶6. Brett CE, Gow AJ, Corley J, Pattie A, Starr JM, Deary IJ. Psychosocial factors and health as determinants of quality of life in community-dwelling older adults. Qual Life Res 2012; 21(3):505-516., and institutionalization⁷7. Chang HT, Liu LF, Chen CK, Hwang SJ, Chen LK, Lu FH. Correlates of institutionalized senior veterans’ quality of life in Taiwain. Health Qual Life Outcomes 2010; 17(8):70., which have been represented as factors of vulnerability and have resulted in low scores for the QOL of elderly people, however, physical activity⁸8. Van Dyck D, Teychenne M, McNaughton SA, De Bourdeaudhuij I, Salmon J. Relationship of the perceived social and physical environment with mental health-related quality of life in middle-aged and older adults: mediating effects of physical activity. PLoS One 2015; 10(3):e0120475. and social support⁹9. Bryła M, Burzyńska M, Maniecka-Bryła I. Self-rated quality of life of city-dwelling elderly people benefitting from social help: results of a cross-sectional study. Health Qual Life Outcomes 2013; 11:181. contribute positively in the various QOL domains.

In contrast, Brazilian studies regarding the assessment of the status of the QOL of very elderly people are incipient and have also been performed with different instruments, which mean that it is difficult to compare data¹⁰10. Carvalho VCHS, Rossato SL, Fuchs FD, Harzheim E, Fuchs SC. Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Public Health 2013; 13:605.

11. Tavares DMS, Bolina AF, Dias FA, Ferreira PCS, Haas VJ. Quality of life of elderly. Comparison between urban and rural areas. Invest Educ Enferm 2014; 32(3):401-413.^-1212. Vagetti GC, Barbosa Filho VC, Moreira NB, Oliveira V, Mazzardo O, Campos W. Condições de saúde e variáveis sociodemográficas associadas à qualidade de vida em idosas de um programa de atividade física de Curitiba, Paraná, Sul do Brasil. Cad Saude Publica 2013; 29(5):955-969..

It is important to bear in mind that demographic transition has resulted in the need to create assistance programs for the elderly in order to provide active aging and to maintain the QOL of this segment of the population.

Successful international example of initiatives aimed at improving the QOL of the elderly can be found in Canada, Spain, Italy, Portugal and Germany. The latter include programs such as “Active Living” (Alberta, Canada), “In Porto Life is Long” (Porto, Portugal) and “Wellness Project” (Terranuova, Italy), all of which demonstrate that it is possible to promote healthy aging¹³13. Benedetti TRB, Borges LJ, Petroski EL, Gonçalves LHT. Atividade física e estado de saúde mental de idosos. Rev Saude Publica 2008; 42(2):302-307..

Initiatives by the Federal Government in favor of the elderly in Brazil began in the 1970s; however, the first national policy for this age group was only implemented in 1994. The National Policy for the Elderly (PNI) was enacted in 1994 and it was regulated by Decree No. 1948 of June 3, 1996, which ensured the social rights of the elderly¹⁴14. Brasil. Ministério da Saúde (MS). Portaria do Gabinete do Ministro de Estado da Saúde de n° 1395, de 9 de dezembro de 1999, que aprova a Política Nacional de Saúde do Idoso e dá outras providências. Diário Oficial da União 1999; 13 dez.^,1515. Fernandes MTO, Soares SM. O desenvolvimento de políticas públicas de atenção ao idoso no Brasil. Rev Esc Enferm USP 2012; 46(6):1494-1502.. In addition, Ordinance No. 1395/GM created the Health Policy for the Elderly, which is designed to promote healthy aging, as well as the improvement and/or maintenance of the maximum functional capacity in order to ensure that elderly people can remain independent in the environment in which they live¹⁴14. Brasil. Ministério da Saúde (MS). Portaria do Gabinete do Ministro de Estado da Saúde de n° 1395, de 9 de dezembro de 1999, que aprova a Política Nacional de Saúde do Idoso e dá outras providências. Diário Oficial da União 1999; 13 dez..

In 2003, Law No. 10.741 created the Statute for the Elderly, which aims to provide facilities and opportunities for the preservation of physical and mental health, as well as improvements in the moral, spiritual, intellectual and social conditions of the elderly¹⁶16. Brasil. Casa Civil. Subchefia para assuntos jurídicos. Lei n° 10.741, de 1° de Outubro de 2003. Dispões sobre o Estatuto do Idoso e dá outras providências. Diário Oficial da União 2003; 2 out..

In 2006, the Guidelines for the Pact for Health were implemented through Ordinance/GM No. 399. These guidelines addressed the following three dimensions: the Pact for Life; the Pact in Defense of the SUS; and the Management Pact. The health of the elderly is one of the main priorities for the Pact for Life because of the demographic dynamics of Brazil¹⁷17. Brasil. Ministério da Saúde (MS). Portaria 399/GM de 22 de fevereiro 2006. Divulga o Pacto pela Saúde 2006 - Consolidação do SUS e aprova as Diretrizes Operacionais do Referido Pacto. Diário Oficial da União 2006; 23 fev..

All policies aimed at the elderly should take into account factors such as functional capacity, as well as the need for autonomy, participation, care and self-satisfaction. Furthermore, such policies should fundamentally encourage comprehensive health prevention and care that is based on QOL and active aging¹⁸18. Veras R. Envelhecimento populacional contemporâneo: demandas, desafios e inovações. Rev Saude Publica 2009; 43(3):548-554..

Given the aforementioned, this study examined the factors which contributed to maintaining the quality of life of elderly people attending a reference center in the city of Belo Horizonte, Brazil. This study was intended to expand the existing knowledge about this issue and to encourage the design of actions and interventions to have an effective impact on care policies for the elderly which are designed to provide improvements in health care and QOL.

Thus, this study identified factors associated with the quality of life of individuals attending a Reference Center for the Elderly in the city of Belo Horizonte, Minas Gerais, Brazil by using the short version of the World Health Organization Quality of Life Assessment (WHOQOL-BREF).

Method

This was a transversal study of 257 people, aged 60 or over, who were registered and active in the various programs provided by a Reference Center for the Elderly (CRPI) in the city of Belo Horizonte, Minas Gerais, Brazil.

This particular CRPI is a public facility that belongs to the city of Belo Horizonte. It offers services and programs aimed at promoting the health of elderly people, as well as preventing social isolation and protecting their rights. The scope of activities that are offered include a gym, ballroom dancing, Gypsy dancing, singing, Lian Gong, computer training, painting on fabric and screen, Biodanza, a youth and adults education project (EJA), “Active Life” and a talent show. The center currently has 590 elderly users who perform various social and educational activities.

The sample size was calculated using the Lwanga & Lemeshow formula¹⁹19. Lwanga SK, Lemeshow S. Sample size determination in health studies: a practical manual. Geneva: WHO; 1991., which requires the following information: a) the proportion of the population; b) the significance level and c) absolute accuracy. The sample size calculation was based on the proportion of 79.0% of elderly Brazilians whose self-perception of their QOL was satisfactory²⁰20. Trentini CM. Qualidade de vida em idosos [tese]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2004., with a 5% significance level and absolute precision of five percentage points. The sample size was 255 elderly people. Taking into account 5.0% possible losses, the final sample included 268 elderly people.

In total, data were collected from 269 elderly people, which were reviewed one by one. Of these, there were twelve losses - five due to the fact that the WHOQOL-BREF instrument contained more than 20.0% of questions that were not completed - and seven because the participants were aged under 60. Consequently, taking into account the sample losses, there were 257 completed and analyzed questionnaires (95.9% of the calculated sample). No participant was excluded from the sample due to severe cognitive impairment (24.8 ± 4.2).

The inclusion criteria were as follows: men and women aged over 60 who were registered at the Reference Center, and who frequented the center, who agreed to participate in the survey and answered the questionnaire.

Elderly people with severe cognitive impairment (who scored ≤ 9 on the Mini-Mental State Examination - MMSE) that prevented them answering the questionnaire were excluded from the study²¹21. Mungas D. In-office mental status testing: a practical guide. Geriatrics 1991; 46(7):54-58,63,66..

Data collection began in January 2012 in the Reference Center. Due to works being undertaken on site, data collection was suspended in August 2012. Data collection resumed in November 2013 and continued until May 2014. The data collection was performed by a previously trained team that was composed of three individuals receiving a fellowship from Scientific Initiation and one person studying for a Master’s degree in nursing. The team was supervised by members of the Center for Studies and Research in Health and Human Development (NEPCDH) of the Federal University of Minas Gerais. The participants in the study were approached by interviewers while waiting for activities in the Reference Center in the morning and afternoon sessions, depending on the availability of each interviewer.

A pre-test questionnaire was conducted in order to check inconsistencies in the questions and any difficulties in understanding by the participants. There was no difficulty in understanding the questions by the participants and the data were not incorporated into the study.

The information was obtained through a structured questionnaire that was organized into the following thematic blocks: socio-demographic variables (gender, age, place of birth, marital status, education and family income); clinical variables (number of comorbidities, self-reported comorbidities, cognitive function, depression and body mass index - BMI);and lifestyle variables (alcohol consumption, smoking, physical activity) and quality of life.

In order to assess the subjective perception of QOL we used the short version of WHOQOL-BREF in Portuguese. This instrument has shown a good response to analyzing the QOL in the elderly²²22. Dawalibi NW, Goulart RMM, Prearo LC. Fatores relacionados à qualidade de vida de idosos em programas para a Terceira idade. Cien Saude Colet 2014; 19(8):3505-3512.

23. Campos AC, Ferreira e Ferreira E, Vargas AM, Albala C. Aging, Gender and Quality of Life (AGEQOL) study: factors associated with good quality of life in older Brazilian community-dwelling adults. Health Qual Life Outcomes 2014; 12:166.^-2424. Silva PAB, Soares SM, Santos JFG, Silva LB. Ponto de corte para o WHOQOL-bref como preditor de qualidade de vida de idosos. Rev Saude Publica 2014; 48(3):390-397. and it was translated and validated in Brazil²⁵25. Fleck MPA, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, Pinzon V. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref”. Rev Saude Publica 2000; 34(2):178-183.. The WHOQOL-BREF includes 26 items; the first two questions assess the self-perceived quality of life and satisfaction with the person’s health. The remaining 24 questions were categorized in the following four domains: physical (7 items); psychological (6 items); social relationships (3 items) and environment (8 items)²⁶26. Fleck MPA, Leal OF, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, Pinzon V. Desenvolvimento da versão em português do instrumento de avaliação de qualidade de vida da OMS (WHOQOL-100). Rev Bras Psiquiatr 1999; 21(1):19-28.. Each of these 26 items was assigned scores that ranged from 1 to 5. The score for each domain was transformed into a linear scale from 0 to 100 according to the syntax proposed by the WHOQOL group²⁷27. Organização Mundial de Saúde (OMS). Como pontuar o WHOQOL-bref e o WHOQOL-100. In: Organização Mundial de Saúde. Versão em português dos instrumentos de avaliação de qualidade de vida (WHOQOL). 1998. cap. 8. [acessado 2015 jul 24]. Disponível em: http://www.ufrgs.br/psiq/whoqol85a.html
http://www.ufrgs.br/psiq/whoqol85a.html... , reflecting a better or worse assessment of QOL.

There were no cut-offs to determine scores below or above what could be evaluated as a “bad” or “good” QOL. Thus, it was decided to rationalize the analysis by defining two groups in relation to the perception of QOL and satisfaction with health. Group 1 was defined as: satisfactory/good QOL; self-reported QOL as being “good” or “very good” and feeling “satisfied” or “very satisfied” with their health. Group 2 was defined as: unsatisfactory/bad QOL; self-reported QOL as being “bad”, “very bad” or “neither bad nor good”; and feeling “unsatisfied”, “very unsatisfied” or “neither satisfied nor dissatisfied” with their health.

The parameters set by the BMI classification followed the cut-offs established for elderly individuals i.e. low weight: < 22 kg/m²; eutrophic: 22-27 kg/m²; and overweight: > 27 kg/m²²⁸28. Lipschitz DA. Screening for nutritional status in the elderly. Prim Care 1994; 21(1):55-67..

The presence of depression was assessed using the Patient Health Questionnaire-2 (PHQ-2). For this study, the cut-off point of ≥ 3was adopted (sensitivity: 83%; specificity: 92%), which, according to the literature, suggests probable depression²⁹29. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care 2003; 41(11):1284-1292..

The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) was used to evaluate the consumption of alcoholic beverages. Based on a previous validation study, a score of ≥ 4 for men and ≥ 3 for women suggested alcohol abuse and was adopted as a criterion in this study³⁰30. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT Alcohol Consumption Questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998; 158(16):1789-1795..

The data were entered and analyzed using the Statistical Package for the Social Sciences (version 22.0). In the descriptive statistics the continuous variables were compared between groups using the Student’s t-test for independent samples or the analysis of variance test (parametric ANOVA with a classification criterion), which was supplemented where necessary by Tukey’s test. The categorical variables were compared using Pearson’s chi-square test (χ2) or Fisher’s exact test. In the statistical modeling, a critical level value of p ≤ 0.20 was adopted for entry in the multivariate model. The analysis of the normality of the continuous variables was performed using the Kolmogorov-Smirnov test. The Spearman’s-Rho correlation test was used for the overall QOL (OQOL)and QOL/satisfaction with health groups; it was also performed for the WHOQOL-BREF domains. The logistic regression model using the Forward method was designed to assess the direction and magnitude of the association of each independent variable with the response variable (good QOL/satisfied with health). In this analysis, p < 0.05 was considered as statistically significant. The values that were obtained were expressed as odds ratios and their 95% confidence intervals. The adjustment of the final model was evaluated by the goodness-of-fit test.

Results

Characteristics of the individuals

Some of the general characteristics of the study sample are shown in Table 1. The average age of the participants was 70.8 ± 6.4 years and 82.5% were female. The majority came from the interior of the state of Minas Gerais (60.9%), and 63.8% did not have a spouse. In terms of education, 8.6% of the elderly did not attend school; 21.4% had zero or less than four years of study. In relation to employment and income, it was found that 22.6% of the elderly people were currently working and 80.2% were retired. It is noteworthy that 11.7% of pensions were due to disability. The monthly income of this sample was low and most received 19.1% less than the minimum wage. Only 9.7% of the elderly people reported an absence of illness and 33.0% reported more than three comorbidities. The most common comorbidities were hypertension (63.4%), dyslipidemia (26.5%), diabetes (23.7%) and osteoarticular diseases (23.3%). Altered cognitive level was detected in 16.7% of the sample. The depressive symptoms index obtained a median of zero (IQ 0-2.0) and 9.7% received a sum of the scores (total PHQ) equal to or more than three points. Among those who were potentially depressed, 3.5% had a score of six points, indicating more serious problems. Regarding nutritional status, half of the sample was overweight and 11.6% were underweight. In terms of behavioral habits, 9.5% of the elderly had a diagnosis of probable alcoholism; 3.9% of respondents currently smoked; 45.7% reported smoking or having smoked more than 10 cigarettes per day, and approximately 75% of the elderly reported having smoked for more than 10 years. Regarding physical activity, 8.9% did not exercise. Walking was the most common form of exercise and 67.7% of those who performed physical activity said that they walked.

Quality of life of the elderly according to WHOQOL-BREF

The average scores for QOL of the four domains of WHOQOL-BREF were as follows: 63.91 ± 9.62 for the physical domain; 64.05 ± 10.83 for the psychological domain; 67.90 ± 17.90 for the social relationships domain; and 14.44 ± 1.96 for the environmental domain. Regarding the overall score for QOL (OQOL), the average was 52.57 ± 7.74 (Graph 1).

It was found that all the domains were significantly correlated with the OQOL. The least and the most correlated domains were environment (r = 0.622, moderate correlation, p < 0.001) and social relationships (r = 0.842, strong correlation, p < 0.001), respectively. However, when the correlation between the domains and the groups (G1 and G2) was verified there was a significant loss in relation to the physical domain (r = 0.098, p = 0.116).The social relationships domain correlated weakly (r = 0.241, p < 0.001) and the psychological domain (r = 0.408, p < 0.001) and environment domain (r = 0.432, p < 0.001) showed a moderate correlation.

Approximately 77.8% of the elderly perceived their QOL as good or very good and 3.1% as bad or very bad; 75.1% felt satisfied or very satisfied with their health, while 9.3% were unsatisfied or very unsatisfied.

Of the 200 elderly patients with a good or very good QOL, 81.5% were satisfied or very satisfied with their health and they formed the G1 group (satisfactory/good QOL). The others made up the G2 group (bad/unsatisfactory QOL) (Table 2).

Table 3 shows that the scores for OQOL showed a linear trend, as the response was more positive, both in WHOQOL-1 and WHOQOL-2, which was statistically significant (p < 0.001). When the OQOL score was evaluated according to the groups defined by the analysis (G1 and G2) it was significantly higher in G1 (a better perception of QOL and greater satisfaction with health).

Factors associated with QOL in the studied sample

Logistic regression analysis was conducted to identify possible independent predictors in the perception of QOL and satisfaction with health defined by the groups G1 and G2. Table 4 shows the results of the final model with the respective odds ratios (OR) and 95% confidence intervals (CI). The age groups 70 to 79 years (OR: 2.24; 95% CI: 1.19 to 4.22) and ≥ 80 years (OR: 3.90; 95% CI: 1.21 to 12.58); place of birth (interior of the state of Minas Gerais; OR: 0.47; 95% CI: 0.24 to 0.92); frequency of physical activity 1-3 times per week (OR: 3.42; 95% CI: 1.25 to 9.42) and 4-7 times per week (OR: 7.67; 95% CI: 2.43 to 24.25); diabetes (OR: 0.49; 95% CI: 0.24 to 0.98); musculoskeletal disorders (OR: 0.49; 95% CI: 0.24 to 0.97); arterial hypertension (OR: 0.38; 95% CI: 0.19 to 0.74) and PHQ ≥ 3 (OR: 0.12; 95% CI: 0.04 to 0.33) remained independently associated with QOL and satisfaction with health after multivariate analysis of the data. The independent variables explained 20.47% (Pseudo R2 = 0.2047) of the response variable (good QOL and satisfaction with health). The results of the adjustment tests of the multiple logistic regression models (Hosmer and Lemeshow) showed a good fit for the final model (Prob > chi² = 0.5722).

Discussion

This study showed a positive relationship between QOL with advancing age and physical activity. Furthermore, a negative association was found between QOL, being born in the state of Minas Gerais and comorbidities (diabetes, musculoskeletal diseases, hypertension and depression). These findings confirmed the multifactorial nature of the studied phenomenon, i.e. QOL was influenced by demographic factors as well as clinical and behavioral factors.

Older age was associated with a better perception of QOL, which was consistent with a previous study. This finding may indicate that the “older elderly” conformed to the inevitability of old age, while the “younger elderly” were faced by the dilemma of aging and presented such a condition²²22. Dawalibi NW, Goulart RMM, Prearo LC. Fatores relacionados à qualidade de vida de idosos em programas para a Terceira idade. Cien Saude Colet 2014; 19(8):3505-3512.. This can provide fruitful discussion about how the perceptions of aging, working and resilience of this sector of elderly people were reflected in higher scores in relation to QOL.

Regarding behavioral habits, a study involving 115 elderly women and 61 elderly men from the Palestinian West Bank (average age 68.15 ± 6.74 years) showed a strong association between higher levels of physical activity and a positive influence on all dimensions of QOL related to health³¹31. Halaweh H, Willen C, Grimby-Ekman A, Svantesson U. Physical activity and health-related quality of life among community dwelling elderly. J Clin Med Res 2015; 7(11):845-852.. In the present study, a direct and gradual relationship was also observed between the frequency of physical activity and the score for QOL. It is known that physical exercise, if performed regularly and properly, slows functional losses and provides elderly people with autonomy and a better QOL. Therefore, physical activity programs for the elderly should be directed towards the development of physical and functional improvements, as well as teaching people the limitations and aptitudes of their body³²32. Vidmar MF, Potulski AP, Sachetti A, Silveira MM, Wibelinger LM. Atividade física e qualidade de vida em idosos. Rev Saude Pesq 2011; 4(3):417-424.. However, a recent study conducted in Brazil, with a population-based sample of elderly people, indicated a prevalence of physical inactivity of 46.7%, mainly in octogenarians³³33. Queiroz BM, Coqueiro RS, Leal Neto JS, Borgatto AF, Barbosa AR, Fernandes MH. Inatividade física em idosos não institucionalizados: estudo de base populacional. Cien Saude Colet 2014; 19(8):3489-3496.. In this regard, encouraging healthy habits and behavior should be discussed in government programs in order to contribute to active and healthy aging, with minimal incapacities.

One of the most worrying factors regarding the elderly is their overall health and the issue of morbidities is of fundamental importance. Thus, health prevention and promotion can impede functional decline and offer a better quality of life for elderly people³⁴34. Schneider ARS. Envelhecimento e quedas: a fisioterapia na promoção e atenção à saúde do idoso. RBCEH 2010; 7(2):296-303..

However, the aging process is not necessarily related to disease and disability: chronic degenerative diseases are often found among the elderly. Thus, the current trend is that there are an increasing number of elderly individuals who, despite living longer, have higher levels of chronic conditions. The increase in the number of chronic diseases is directly related to greater functional disability³⁵35. Santos SAL, Tavares DMS, Barabosa MH. Fatores socioeconômicos, incapacidade funcional e número de doenças entre idosos. Rev Eletrônica Enferm 2010; 12(4):692-697.. Brazilian and international studies have demonstrated significant associations between chronic diseases, functional disability and the QOL of the elderly³⁵35. Santos SAL, Tavares DMS, Barabosa MH. Fatores socioeconômicos, incapacidade funcional e número de doenças entre idosos. Rev Eletrônica Enferm 2010; 12(4):692-697.

36. Onunkwor OF, Al-Dubai SA, George PP, Arokiasamy J, Yadav H, Barua A, Shuaibu HO. A cross-sectional study on quality of life among the elderly in non-governmental organizations’ elderly homes in Kuala Lumpur. Health Qual Life Outcomes 2016; 14:6.^-3737. Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, Meinow B, Fratiglioni L. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev 2011; 10(4):430-439..

In relation to the overall scores for the WHOQOL-BREF domains, the environmental domain obtained extremely low scores, which negatively influenced the QOL. This particular domain refers to aspects such as physical safety and security, health and social care (availability and quality), opportunities to acquire new information and skills, participation and opportunities for recreation/leisure, etc.

A study conducted in metropolitan areas of Brazil between 1991 and 2000 assessed the Quality of Human Life Index (QHLI). The QHLI consists of five indicators (quality of housing, living conditions, income, health and environmental safety, and sanitary services), and it also measures aspects related to human development and the quality of the built environment. According to the results of the aforementioned study, the quality indicators which most influenced a decrease in QHLI in metropolitan areas were quality of housing, health and environmental safety. These aspects are related to a high prevalence of respiratory and parasitic diseases, which are strong instruments of indirect estimates of the quality of air and water enjoyed by the population, as well as mortality from external causes and violence in its broadest sense³⁸38. Umbelino GJM. Aplicação do Índice de Qualidade de Vida Humana (IQVH) nas regiões metropolitanas do Brasil. Rev Bras Est Pop 2007; 24(2):339-340..

Violence significantly undermines environmental safety and this issue is the subject of much discussion by those who live in urban areas in Brazil. This topic has a fundamental influence on the daily life of individuals, social groups, the media in general, and the relationship between state, society and social organizations in the world and in Brazil. Violence is a complex phenomenon that affects both developed and developing countries. In many societies, various expressions of violence are often treated as a form of acting “normally” and it is hidden within the customs and relationships that exist between people. Both in Brazil and worldwide, violence against older people is expressed in the ways that relationships are organized between the rich and the poor, between genders, races and age groups within the various spheres of public, institutional and family power³⁹39. Guimarães SJ, Miranda JLS, Macedo LTA. Violência contra o idoso: uma questão social a ser discutida. Universidade Federal Do Maranhão - III Jornada Internacional de Políticas Públicas: Questão Social e Desenvolvimento no Século XXI. São Luís, MA, Ago. 2007._. Thus, violence against the elderly significantly affects the environment in which they live and interact.

Given the seriousness of this situation, in 2014 the Human Rights Secretariat of the Presidency of the Republic of Brazil published the “Manual to Deal with Violence against the Elderly”. The goal of this manual was to reach a wide audience of people who, by law, must respect, protect and care for the elderly. The latter include managers, service providers, health and social services professionals, law enforcement officers, security officers and their families⁴⁰40. Minayo MCS. Brasil: Manual de Enfrentamento à Violência contra a Pessoa Idosa. É possível prevenir. É necessário superar. Brasília: Secretaria de Direitos Humanos da Presidência da República; 2014.. In the case of the city of Belo Horizonte, in 2010 the rate of violence against the elderly was 62.75 per 10,000 inhabitants (admissions in the public system of people aged 60 or over from causes related to possible aggression per 10,000 inhabitants in this age group, by place of residence)⁴¹41. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico 2010: características gerais da população, religião e pessoas com deficiência. Rio de Janeiro: IBGE; 2010..

Brazilian elderly people live in daily fear of violence, a lack of medical care and hospitals, and suffer from scarce leisure activities, as well as financial problems caused by the low values of their pensions¹⁸18. Veras R. Envelhecimento populacional contemporâneo: demandas, desafios e inovações. Rev Saude Publica 2009; 43(3):548-554..

Consequently, it is important to reflect on the possible causes that negatively affect the QOL of the elderly, especially environmental factors, in order to search for possible improvements. Nursing could be incorporated into the ambit of Family Health teams and could be used as an intervention strategy for home visits. This could provide better knowledge about the area of coverage and could result in intersectoral actions to minimize the impact of the environment on the QOL of the elderly.

Moreover, it should be noted that there are other factors that affect the QOL of elderly people, which were not analyzed in this study but which have been examined in other studies. These include the positive link that has been made between higher levels of satisfaction with life and a better self-perception on the part of the elderly in relation to their oral health⁴²42. Rigo L, Basso K, Pauli J, Cericato GO, Paranhos LR, Garbin RR. Satisfação com a vida, experiência odontológica e autopercepção da saúde bucal entre idosos. Cien Saude Colet 2015; 20(12):3681-3688._, and the presence of cognitive decline directly affecting the QOL of elderly people with hypertension due to the fact that the latter limits the capacity to perform everyday activities, particularly if this is associated with painful conditions and emotional changes⁴³43. Chaves AS, Santos AM, Alves MTSSB, Salgado Filho N. Associação entre declínio cognitivo e qualidade de vida de idosos Hipertensos. Rev Bras Geriatr Gerontol 2015; 18(3):545-556..

It is important to note that there are limitations associated with the present study due to its transversal design and convenience sample. A further limitation was the lack of similar Brazilian national studies regarding reference centers for the elderly, which prevented comparisons being made.

Nevertheless, the results of this study provide important information regarding the predictors that influence the QOL of elderly people and they indicate the need for government investment and action strategies to guarantee improvements in health promotion and the prevention of disease prevention, as well as improvements in the local infrastructure.

The data presented in this study can be used to direct care strategies for the most vulnerable elderly people, with particular attention to issues that affect the environment.

Acknowledgments

The authors would like to thank FAPEMIG for financial support for this study.

References

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