Abstract

The research objective was to investigate the conception of quality of life in Uruguayan older adults, trying to build a model adapted to them. Based on Grounded Theory, a qualitative study was carried out between 2017-2018 in several regions of Uruguay. Semi-structured interviews were conducted in older adults (mean age 71 years, SD 5.4) with theoretical and snowball sampling. Theory emerged through the core category “living the best as possible”, interpreted as the conception of older adults about quality of life. The emerging themes were: “context events”, “link with others”, “activities facing life” and “adaptation strategies”. When facing stressful events, participants develop coping strategies through social support and internal locus of control, to achieve quality of life and successful aging. The empirical evidence developed from this qualitative research portrays a model established from a specific age and cultural context, in which social and psychological dimensions interact to face aging and achieve quality of life.

Keywords:
quality of life; ageing; qualitative research; Grounded Theory

Introduction

The concept of old age has different meanings and changed over time and in different cultures. The aging process shows both general and specific characteristics. By 2050, 15% of the world’s population is expected to be over 65 years of age (Huenchuan, 2013HUENCHUAN, S. Envejecimiento, solidaridad y protección social en América Latina y el Caribe: la hora de avanzar hacia la igualdad. Santiago de Chile: Naciones Unidas; CEPAL, 2013.). Uruguay is in the post-transitional demographic phase, with an advanced aging process, since it experienced its demographic transition at least thirty years earlier than other countries in Latin America (Brunet; Márquez, 2016BRUNET, N.; MÁRQUEZ, C. Atlas Sociodemográfico y de la Desigualdad del Uruguay: Envejecimiento y personas mayores en Uruguay. Montevideo: Trilce, 2016.b). This situation should be considered in terms of public health policies to maintain the well-being and ensure the human rights of older adults.

Although there are instruments aimed at assessing quality of life (QoL) in the older adult population, their development and validation do not usually include the perception of the older adults (Mollenkopf; Walker, 2007MOLLENKOPF, H.; WALKER, A. Quality of life in old age: International and multi-disciplinary perspectives. Dordrecht: Springer Netherlands, 2007.). The systematic review by Riva et al. focused on validation processes of QoL instruments associated with oral health, found a predominance of publications including external validation processes, with the specific instrument for older adults showing the highest proportion of publications including internal validation (Riva et al, 2022RIVA, F. et al. Adult oral health-related quality of life instruments: A systematic review. Community Dentistry and Oral Epidemiology, Hoboken, v. 50, n. 5, p. 333-338, 2022. DOI: 10.1111/cdoe.12689
https://doi.org/10.1111/cdoe.12689... ).

Likewise, despite the shift towards positive aspects of old age, the questionnaires generally reinforce a negative view focused on physical and psychological limitations at the expense of positive aspects, such as the activities they can enjoy due to their stage of life (Singh, 2019SINGH, J. A. Quality of Life. In: NAOMI SCHLESINGER, P. E. L. (org.). Gout. Amsterdam: Elsevier, 2019. p. 119-139. DOI: 10.1016/B978-0-323-54823-6.00011-7
https://doi.org/10.1016/B978-0-323-54823... ). In the specific area of oral health, the General Oral Health Assessment Index, one of the main QoL measurement instruments associated with oral health for older adults, includes in its items words such as “limitation,” “problems with chewing,” “problems with dentures,” etc. (Slade, 1997SLADE, G. D. (Ed.). Measuring Oral Health and Quality of Life. Chapel Hill: University of North Carolina, 1997.). Focusing on QoL models and their questionnaires, we need to consider the perspective of the subjects in their cultural environment (LAWTON, 1991b); especially considering that the conception of QoL varies among cultures and populations (Walker, 2005WALKER, A. Understanding Quality Of Life in Old Age. Berkshire: Open University Press, 2005.).

Moreover, differences in the concept of QoL associated with old age can be observed as these subjects face life events that vary during adulthood and aging. Many of the physical limitations of old age can have negative impacts on the QoL of young people, but not on the QoL of older adults due to adaptive behaviors (Brondani, 2010BRONDANI, M. The voice of the elderly in accepting alternative perspectives on oral health. Community Dental Health, Lowestoft, v. 27, n. 3, p. 139-144, 2010. DOI: 10.1922/CDH_2468Brondani06
https://doi.org/10.1922/CDH_2468Brondani... ). Thus, more QoL evidence is needed in order to advance cross-cultural adaptation of the questionnaires, contextualized in the environment in which people live (Walker, 2005WALKER, A. Understanding Quality Of Life in Old Age. Berkshire: Open University Press, 2005.).

Within the framework of a larger study entitled Cross-cultural adaptation of QoL measurement instruments associated with Oral Health in older adults, the aim of this study is to investigate conceptions of QoL with a view to drawing a dynamic model of QoL for Uruguayan older adults to serve as a basis for the cross-cultural adaptation of specific instruments.

Method

Demographic characteristics of the Uruguayan population

Uruguay is located in the southeast of South America. It consists of 19 states in a total area of 186,926 km2. With a life expectancy of 76 years (72 for men and 79 for women), older adults account for almost 18% of the Uruguayan population, of which 12% are over 84 years old. In the region, Uruguay has the highest proportion of older women. 32.65% of older adults are widow, 45.97% are women and 33% live alone. Almost 90% of the older adults consider themselves to be of white ethnicity, 3.41% are of African descent, and 3.54% are of indigenous descent. Less than 4% do not know how to read or write, and more than half have completed elementary school (Brunet; Márquez, 2016BRUNET, N.; MÁRQUEZ, C. Atlas Sociodemográfico y de la Desigualdad del Uruguay: Envejecimiento y personas mayores en Uruguay. Montevideo: Trilce, 2016.a).

Design

This is the first step in a larger investigation that seeks to conduct cross-cultural adaptation of instruments to measure QoL related to Oral Health in older adults.

This includes the conception of the QoL construct that the subjects involved in this research report having. A qualitative research based on Grounded Theory was carried out to elaborate a new theory from the perspective of older adults.

In order to guide the interviews, a questionnaire guide was developed based on contributions from the literature together with the internal deliberations of the research team (Chart 1), including:1) presentation of the research and general information about the project; questions associated with the context in which the participants live, their lifestyle and quality of life; and questions about their perception of their oral health. This guide allowed the generation of open and axial coding, the selection of relevant codes and the construction of themes and categories. The strategies that guided the analysis and selection of participants were: observation, discussion among researchers and continuous comparative analysis, memoranda, interaction between researcher and participants, and preliminary diagrams (Figure 1).

Individual interviews were conducted between 2017 and 2018, targeting Uruguayan older adults living in different provinces of Uruguay.

Sampling decisions and information analysis

A purposive sampling was used and we employed strategies to rescue relevant contexts related to the research topic based on criteria of differentiality, heterogeneity, and accessibility, according to the country’s sociodemographic information. (Brunet; Márquez, 2016BRUNET, N.; MÁRQUEZ, C. Atlas Sociodemográfico y de la Desigualdad del Uruguay: Envejecimiento y personas mayores en Uruguay. Montevideo: Trilce, 2016.a). Also, we considered personal networks and emerging information in the field study (snowballing technique).

We contacted participants through acquaintances with no personal association with the researcher (opportunistic sample). When family or friendship associations between participants were identified, these were incorporated into notes and memoranda for inclusion in the analysis. The first contact was made by telephone or e-mail. Initially, they were informed about the objective and purpose of the research. Then, the process to be carried out was described, considering the possibility of interrupting the interview or refusing to record it, the possibility of the meeting taking place at home or in a public place chosen by the participant, and the possibility of being alone or accompanied.

To meet the criterion of maximum variation, we focused on ethnicity, social background, schooling, place of residence, family composition, and past experiences. For this purpose, we used an adaptation of Brondani’s form (Figure 2) (Brondani, 2010BRONDANI, M. The voice of the elderly in accepting alternative perspectives on oral health. Community Dental Health, Lowestoft, v. 27, n. 3, p. 139-144, 2010. DOI: 10.1922/CDH_2468Brondani06
https://doi.org/10.1922/CDH_2468Brondani... ).

The interviews were divided into the following stages: in the first phase, the participants were again informed about the objectives of the research, emphasizing the confidentiality of the process, seeking a comfortable environment for dialogue; in the second phase, the process began with open-ended questions: “Tell me about yourself” and “What do you do?”; followed by semi-structured questions related to well-being and QoL; and, in a third phase, participants were given the possibility to contribute anything they considered necessary. The focus was on aspects of life and health.

Once codes began appearing, preliminary syntheses and introductory diagrams relating codes and categories were generated until the themes became apparent. When categories came out of the fieldwork, the concepts were articulated with the existing evidence (Corbin; Strauss, 2015CORBIN, J.; STRAUSS, A. Basics of qualitative research: techniques and procedures for developing grounded theory. 4. ed. Los Angeles: SAGE, 2015.). With the information gathered, the data were summarized, and the final report was produced. The process involved examining and eliminating existing theories, as well as proposing new contributions.

In order to reduce bias, at each stage of the process, a researcher (MS) conducted the analysis; determined the categories, themes, and emerging theory; and it was audited and discussed by a second researcher (RDM, expert in qualitative research). The findings were discussed and shared within the research team and the literature based on theoretical and empirical arguments.

The analysis was performed using the software MAXQDA v. 2018 software (copyright © VERBI GmbH Berlin 1995-2017).

Saturation was reached around interview 25, finding that no new evidence came out of the interviews related to the focus of the study (Corbin; Strauss, 2015CORBIN, J.; STRAUSS, A. Basics of qualitative research: techniques and procedures for developing grounded theory. 4. ed. Los Angeles: SAGE, 2015.). A recording system was followed for the interviews: interview and number = E#; gender of subject, M=male and F=female, and age.

Ethical aspects

This process involved voluntary participation of the subjects and confidentiality of the information. The Ethics Committee of the Facultad de Odontología de la Universidad de la República, in Uruguay, approved the research protocol (10/11/2016, # 323/16) in accordance with the Declaration of Helsinki. At the beginning of each interview, the text of the informed consent form was read, explained, and copied to the participants, who signed it indicating their consent. All participants were given the possibility of suspending the interview if they considered it necessary.

Results

We conducted 30 interviews with older adults with an average age of 71 years (SD 5.4), of whom 20 were women and 10 were men (Table 1). Nobody refused to be interviewed. However, one interview had to be suspended because the participant began to feel anguish due to the memory of her dead son. When this was seen, the topic was changed in an attempt to focus on positive aspects of her life, such as her grandchildren, which led to a pleasant dialogue and so the participant became calm (E9). One participant signed her consent with a fingerprint because she was illiterate (E23). These aspects were considered in the analysis.

One parent category resulted from the analysis, “living the best as possible” and four related themes: “contextual events,” “adaptation strategies,” “bonds with others,” and “attitudes toward life” (Table 2). According to one of the interviewees, the “quality of life is, within the problems that one may have as the years go by, to feel healthy, to feel good; if I want to go out, there is nothing to stop me. And not be afraid …” (E10-A, F-68, Pos. 44).

Context events

Contextual events in this population can have a negative impact on QoL, whether they are external situations (the death of a sentimental partner) or internal (illness). They visualize experiences that they accept, but also stressful situations they had to face.

Loss of emotional ties

For this population, the loss of emotional ties has a special meaning, it represents the proximity to death and the cause of loneliness and psychological problems. “I am at the age where [my friends] are leaving. When I go to San José I don’t ask many times, I’m afraid to ask” (E8-M68, Pos. 49). This category is perceived as negative even though it is viewed as a natural event by the participants.

Loneliness

For some participants, divorce, widowhood or being single was the cause of loneliness, associated with feelings of fear and seen as a threat that limits participation in parties or family gatherings. “I ask God to be with me, to be the one to guide me, because I feel very lonely without my family” (E19-F87, Pos. 117).

Physical and psychological changes due to aging

The aging process has consequences for the lifestyle of the participants. Codes such as chronic diseases, physical limitations, retirement, and sedentary life were presented. These may limit their ability to perform activities but may also motivate them to seek help from others. “There are days when I wake up feeling very bad…” (E26-F76, Pos. 56); “well now I can’t even clean, because it’s the daughter who cleans everything… [me] … quiet… reading the Bible” (E26-F76, Pos. 37).

Social concerns

Social situations were expressed mostly associated with violence and security, as well as politics and economics. “…I am affected by everything that is happening right now. It’s very hard for me to adapt,… what’s happening with society, the problems of violence, domestic violence, social violence... (E14-F68, Pos. 44).

Adaptation strategies

Adaptation to loneliness

When faced with loneliness, older adults may cope with stressful situations by seeking family companionship and participating in social activities. “And now I have a group of older adults […], where […] we have different activities” (E14-TAP, F-68, Pos. 9); “[…] makes me feel good. […], because I spend a lot of time alone” (E14-F68, Pos. 36).

Resignation - acceptance of aging

This category appears in participants who face old age, giving up activities they used to do when they were younger and changing their lifestyles, showing resignation and acceptance. “I tried to assimilate old age, to make it less difficult” (E3-M73, Pos. 27); “and now I just want to place myself in a phase of which I probably didn’t know about …” (E20-F67, Pos. 86).

Adaptation to aging

The participants perceive their active role, incorporating themselves into the aging process, comparing themselves with their experiences during their youth. “I think it’s in the person, in the person’s ability to adapt to everything, because it’s the same as with vision. When I had to get multifocal lenses, everyone told me that I was not going to adapt, I put them on and I did” (E8-M68, Pos. 118).

Decision making

Decision-making brings together a series of codes associated with responding to situations that generate fear, finding solutions, making treatment decisions, and participating in health promotion activities. “For the age I am, I think I could already be ill, [but], I feel healthy, […], I have all the tests done (E14-F68, Pos. 62); “… I do everything I need to do on a bicycle, I go for bike rides with my friends… right after the surgery, the gynecologist authorized me to ride a bicycle and I felt encouraged” (E14-F68, Pos. 63).

Bonding with others

Most participants emphasize the role of family and “others” in their QoL. It appears as a positive theme, enabling better aging and improving QoL.

Recreational activities with others

Many codes emerged in this category: reading, gardening, gastronomy, meditation, yoga, walking, church, metaphysics, and crafts. “Recreational activities” expresses actions that have three common characteristics: they are developed with other people, giving the possibility of dialogue and exchange; they are a compensation for loneliness, since they provide company; and they promote healthy habits by maintaining physical and cognitive activity, healthy nutritional habits, and good values. “Marvelous, we get together, we chat, we celebrate birthdays […] we go out, we make fried cakes. Then we have fun” (E16F-68, Pos. 38).

Family and social networks

The codes that emerged in this category were: tranquility, security, safety, protection, care, and companionship, even in the face of death. Family ties, as well as friends and neighbors can improve QoL in psychological, social, and physical dimensions. “… I feel loved, I have a friend… and this other lady here is an amazing person” (E7-F82, Pos. 83); “I have neighbors who are adorable” (E7-AV, F-82, Pos. 87); “for me my quality of life is the support I receive” (E7-AV, F-82, Pos. 87).

Health support

“Bonding with others” can be a health promoter and improve QoL. Family and friends, as well as health professionals can provide health support. Family can promote health compensating physical problems. “Sometimes my sons call me, I’m tired, and I say ‘no, no, let’s go’, and so I go see my grandchildren do the activities that they do. I go home to my sons and all of that” (E1-F65, Pos. 76).

Meaning of life

The “bonding with others” was also expressed as a “meaning of life,” with in vivo codes. “I am a team” (E13-F67, Pos. 60); “[my grandchildren] are my life.” (E7-F82, Pos. 41); “it gives me a lot of pleasure to go out with my friends, I love it” (E5-F64, Pos. 43).

Attitudes towards life

This theme reflects participants’ beliefs and perceptions about general aspects of life, including their health.

General internal attitudes

The following codes were incorporated into this category: optimism, autonomy, feel oneself, knowing own limits, self-confidence, finding solutions. This reflects internal mechanisms that some participants mention to improve their QoL. “I am a person who plans my life. I don’t leave it to chance […] I plan my life […] I set goals for myself, if I want to reach 80 years old, I have to do some things and not others” (E10-B, M-68, Pos. 29). Participants with “general internal attitudes” are critical and optimistic, as they accept and analyze contextual events (such as aging), but seek solutions by planning their lives and/or seeking help.

Internal attitudes related to health

When participants think about their own health, beneficial internal attitudes were expressed through the following codes: trying to find a solution, self-care, spirituality, diet, habits, self-analysis, and vitality. The in vivo code “do your part” expresses the participants’ perspective on their role in health and disease. “The doctor does his part but you have to do your part” (E18-M74, Pos. 44).

Category body/parent “living the best as possible”

A body or central category emerged consisting of the following subcategories: physical activities, cognitive activities, economic well-being and spiritual well-being. All these subcategories relate to the themes described.

Physical activities

Walking, swimming, exercising, mobility, and cycling are codes found in this category. Physical activities can be described as “strategies to adapt to…” the consequences of aging. They are important for maintaining independence and socializing. “If I [walk] 6 or 7 km, I go and back three times a week […] and then at home I have an exercise bike. So, you see […] I don’t stop […] and now I am retired. But I am always active, I don’t stop” (E27-M72, Pos. 6).

Cognitive activities

Cognitive activities were perceived as promoting good aging and QoL. They are expressed by codes: activities they enjoy, keeping working, mental activities, teaching, socializing, painting, writing, studying, using internet, reading, politics, sharing, and enjoyment. “I do a lot of physical activity, a lot of mental activity. I read, but also with the sudoku” (E10-B, M-68, Pos. 7); “I care a lot about the knowledge of things, what we eat, everything that helps us to have a better quality of life” (E10-B, M-68, Pos. 33).

Economic well-being

This subcategory is associated with retirement, as well as with the analysis of past achievements. Codes expressed as limitations or opportunities to achieve better QoL in the aging process were: tranquility, autonomy, strength, limitations, and decisions. “I think I did things right, […] then I sold it [my car] because I decided to finish paying my house and say ‘when I retire, whatever happens to me, I won’t pay rent.’ What more could you ask from life, not having to pay rent?” (E13-F67, Pos. 68).

Spiritual well-being

Codes were incorporated, among which the following stand out: simplicity of life, dignity, relaxation, freedom, self-esteem, equilibrium between body and mind, avoiding loneliness, being grateful, and feeling good. “…And now I want to place myself in a phase that I may not have known about, and that is to look for this field [metaphysics] here on this side, and it has been very hard for me to calm down, don’t think it’s easy…” (E20-F67, Pos. 86). “Living the best as possible” can be interpreted as the way in which participants described their own life in a positive way, including critical analysis of the aging process.

Discussion

This qualitative research showed the perception of Uruguayan older adults based on the emergence of the themes “context events,” “adapting strategies,” “link with others,” and “attitude towards life” connected to a central category “living the best as possible.” From a literature search, the themes were interpreted and portrayed in a dynamic model (Figure 3) that combines strategies and processes described by this population to achieve their QoL in a specific cultural context. The findings presented are related to other studies in older adults associated with a variety of conditions, in which coping strategies, spirituality and social support contribute to successful aging (Balducci, 2019BALDUCCI, L. Geriatric Oncology, Spirituality, and Palliative Care. Journal of Pain and Symptom Management, Amsterdam, v. 57, n. 1, p. 171-175, 2019. DOI: 10.1016/j.jpainsymman.2018.05.009
https://doi.org/10.1016/j.jpainsymman.20... ; Hall et al., 2020HALL, R. K. et al. Quality of life in older adults receiving hemodialysis: a qualitative study. Quality of Life Research, Berlin, v. 29, n. 3, p. 655-663, 2020. DOI: 10.1007/s11136-019-02349-9
https://doi.org/10.1007/s11136-019-02349... ).

This study has some limitations associated with the fact that no participant comes from critical social contexts and not all geographic locations in the country were included. However, the theoretical sampling process allowed maximum diversity and saturation in the categories and themes to be achieved. Moreover, the variability of the subjects was considered (Corbin; Strauss, 2015CORBIN, J.; STRAUSS, A. Basics of qualitative research: techniques and procedures for developing grounded theory. 4. ed. Los Angeles: SAGE, 2015.).

The themes and body category were consistent with models of life trajectory influence, given that strategies proposed by participants and the positive effects of their behaviors on QoL were present (Walker, 2005WALKER, A. Understanding Quality Of Life in Old Age. Berkshire: Open University Press, 2005.).

“Contextual events” were related to the aging process and to other external situations (violence, loss of a loved one) that can be perceived as stressful events, in which the subject faces or sees their welfare resources exceeded (Biggs; Brough; Drummond, 2017BIGGS, A.; BROUGH, P.; DRUMMOND, S. Lazarus and Folkman´s psychological stress and coping theory. In: COOPER, C. L.; CAMPBELL, J. (Ed.). Hand book of stress and health: A guide for research and practice. Hoboken: Wiley Blackwell, 2017. p. 351-360.; Lazarus; Folkman, 1984LAZARUS, R. S.; FOLKMAN, S. Stress, appraisal, and coping. New York: Springer Publishing Company, 1984.).

A cognitive evaluation can indicate the perception of an event as stressful (having a physical problem, being alone, losing a loved one) and its possible consequences (Lazarus; Folkman, 1984LAZARUS, R. S.; FOLKMAN, S. Stress, appraisal, and coping. New York: Springer Publishing Company, 1984.). The subject’s environment can be understood as a determinant of the QoL, since it affects the individual’s well-being, just as the individual can affect the environment (Lawton, 1991aLAWTON, M. P. A Multidimensional view of quality of life in frail elders. In: BIRREN, J. E. et al. (Ed.). The concept and measurement of quality of life in the frail elderly. Cambridge: Academic Press, 1991a. p. 3-27. DOI: 10.1016/B978-0-12-101275-5.50005-3
https://doi.org/10.1016/B978-0-12-101275... ). Loneliness was associated with fear and limitations related to ceasing participation in social activities. Loneliness and lack of connection to an environment may be mediators of the QoL perceived by older adults, affecting their QoL (Vitman Schorr; Khalaila, 2018VITMAN SCHORR, A.; KHALAILA, R. Aging in place and quality of life among the elderly in Europe: A moderated mediation model. Archives of Gerontology and Geriatrics, Amsterdam, v. 77, p. 196-204, 2018. DOI: 10.1016/j.archger.2018.04.009
https://doi.org/10.1016/j.archger.2018.0... ). Participants revealed strategies for coping with these situations; living alone and feeling safe were described as being associated with QoL for older adults (first empowering it and the latter improving it) (Banister; Bowling, 2004BANISTER, D.; BOWLING, A. Quality of life for the elderly : the transport dimension. Transport Policy, Amsterdam, v. 11, n. 2, p. 105-115, 2004. DOI: 10.1016/S0967-070X(03)00052-0
https://doi.org/10.1016/S0967-070X(03)00... ).

Contextual events may affect QoL in this population by modifying the social circumstances that promote social participation (Walker, 2005WALKER, A. Understanding Quality Of Life in Old Age. Berkshire: Open University Press, 2005.). The assessment of “event contexts” as stressful and the “strategies to adaptation” were interpreted as the adaptive processes described by Lazarus and Folkman (Biggs; Brough; Drummond, 2017BIGGS, A.; BROUGH, P.; DRUMMOND, S. Lazarus and Folkman´s psychological stress and coping theory. In: COOPER, C. L.; CAMPBELL, J. (Ed.). Hand book of stress and health: A guide for research and practice. Hoboken: Wiley Blackwell, 2017. p. 351-360.; Lazarus; Folkman, 1984LAZARUS, R. S.; FOLKMAN, S. Stress, appraisal, and coping. New York: Springer Publishing Company, 1984.).

These require an effort by the subjects to handle specific demands that are initially valued as threats. Then, a new cognitive assessment is necessary to evaluate the adaptive strategies. Demands and context can influence the positive and negative outcomes of these adaptive strategies. The way in which older adults cope with loneliness is perceived as a secondary cognitive action necessary for the adaptation process (Biggs; Brough; Drummond, 2017BIGGS, A.; BROUGH, P.; DRUMMOND, S. Lazarus and Folkman´s psychological stress and coping theory. In: COOPER, C. L.; CAMPBELL, J. (Ed.). Hand book of stress and health: A guide for research and practice. Hoboken: Wiley Blackwell, 2017. p. 351-360.). Retirement can be valued differently according to the nature of the environment and interactions with other subjects (Walker, 2005WALKER, A. Understanding Quality Of Life in Old Age. Berkshire: Open University Press, 2005.). Caring for grandchildren may be another adaptive behavior that improves this variable. Participants showed how they adapt with stressful events in ways that improve their QoL. Adaptive efforts may vary over time and promote dynamism in each individual’s assessment of their QoL (Allison; Locker; Feine, 1997ALLISON, P. J.; LOCKER, D.; FEINE, J. S. Quality of life: a dynamic construct. Social Science & Medicine, Amsterdam, v. 45, n. 2, p. 221-230, 1997. DOI: 10.1016/s0277-9536(96)00339-5
https://doi.org/10.1016/s0277-9536(96)00... ).

The “bonding with others” was interpreted as a social level of interaction, a social support, which is important for this population in relation to their perception of QoL (Banister; Bowling, 2004BANISTER, D.; BOWLING, A. Quality of life for the elderly : the transport dimension. Transport Policy, Amsterdam, v. 11, n. 2, p. 105-115, 2004. DOI: 10.1016/S0967-070X(03)00052-0
https://doi.org/10.1016/S0967-070X(03)00... ). There are studies that assess the effect of social support in older adults (Hall et al., 2020HALL, R. K. et al. Quality of life in older adults receiving hemodialysis: a qualitative study. Quality of Life Research, Berlin, v. 29, n. 3, p. 655-663, 2020. DOI: 10.1007/s11136-019-02349-9
https://doi.org/10.1007/s11136-019-02349... ). Both the quality and density of social contact presented a significant positive effect on QoL in this population (Walker, 2005WALKER, A. Understanding Quality Of Life in Old Age. Berkshire: Open University Press, 2005.). Likewise, the emotional and instrumental support received from the family is significantly associated with psychosocial well-being (Thanakwang, 2015THANAKWANG, K. Family support, anticipated support, negative interaction, and psychological well-being of older parents in Thailand. Psychogeriatrics, Hoboken, v. 15, n. 3, 2015. DOI: 10.1111/psyg.12107
https://doi.org/10.1111/psyg.12107... ). Social support acts promoting QoL, stimulating the continuation of activities despite the presence of physical problems. Social sources, family and friends were associated with positive perceptions of health and life satisfaction (Dumitrache; Rubio; Cordón-Pozo, 2018DUMITRACHE, C. G.; RUBIO, L.; CORDÓN-POZO, E. Successful aging in Spanish older adults: the role of psychosocial resources. International psychogeriatrics, Cambridge, v. 31, n. 2, p. 181-191, 2018. DOI: 10.1017/S1041610218000388
https://doi.org/10.1017/S104161021800038... ). However, the loss of emotional ties is a factor that can negatively affect QoL in vulnerable people, intensifying the feeling of loneliness and isolation. In the presence of social bonds, participants showed that they managed to benefit from others to compensate for their loneliness, adapting to these stressful events. A sense of connection to place was shown to be associated with QoL, improving the bond with neighbors and the feeling of being loved and cared for (Vitman Schorr; Khalaila, 2018VITMAN SCHORR, A.; KHALAILA, R. Aging in place and quality of life among the elderly in Europe: A moderated mediation model. Archives of Gerontology and Geriatrics, Amsterdam, v. 77, p. 196-204, 2018. DOI: 10.1016/j.archger.2018.04.009
https://doi.org/10.1016/j.archger.2018.0... ).

The “attitude towards life” was conceived as a way of controlling contextual events and how an individual’s own behavior or external forces (independent of actions) determine the rewards in life. A multidimensional view of this construct considers control by internality, power of others, and destiny (Lefcourt; Martin; Saleh, 1984LEFCOURT, H. M.; MARTIN, R. A.; SALEH, W. E. Locus of control and social support: Interactive moderators of stress. Journal of Personality and Social Psychology, Washington, DC, v. 47, n. 2, p. 378-389, 1984. DOI: 10.1037/0022-3514.47.2.378
https://doi.org/10.1037/0022-3514.47.2.3... ). For older adults, specific circumstances such as becoming ill or aging are stressful and caused by events beyond their control (Skinner, 1996SKINNER, E. A. Personality processes and individual differences: A guide to constructs of control. Journal of Personality & Social Psychology, Washington, DC, v. 71, n. 3, p. 549-570, 1996. DOI: 10.1037//0022-3514.71.3.549
https://doi.org/10.1037//0022-3514.71.3.... )designed to organize the heterogeneous constructs related to \”control,\” is based on 2 fundamental distinctions: (a. Greater internality was associated with this population that wants to live longer, does not accept the idea of dying and actively seeks new life goals (Cicirelli, 2011CICIRELLI, V. G. Elders’ attitudes toward extending the healthy life span. Journal of Aging Studies, Amsterdam, v. 25, n. 2, p. 84-93, 2011. DOI: 10.1016/j.jaging.2010.08.011
https://doi.org/10.1016/j.jaging.2010.08... ). In this study we observed that internality allowed participants to evaluate possible situations to the problems associated with aging, because they consider themselves responsible for their own behaviors. Internality can influence the adoption of healthy behaviors, greater resilience, and the way in which this population uses health resources, and it can be an important psychological strategy for low-income individuals (Musich et al., 2020MUSICH, S. et al. The impact of internal locus of control on healthcare utilization, expenditures, and health status across older adult income levels. Geriatric Nursing, Amsterdam, v. 41, n. 3, p. 274-281, 2020. DOI: 10.1016/j.gerinurse.2019.10.008
https://doi.org/10.1016/j.gerinurse.2019... ).

The body category, “living as best as possible,” was interpreted as the participants’ ultimate goal combining cognitive evaluation in the face of “contextual events,” showing positive “attitudes towards life,” and being motivated to find solutions by “linking with others” as a “adaptation strategy.”

Social support may mediate adaptive processes to improve QoL. Recent studies show interrelationships between successful aging, social relationship characteristics, and QoL in older adults with HIV (Yoo-Jeong; Nguyen; Waldrop, 2022YOO-JEONG, M.; NGUYEN, A. L.; WALDROP, D. Social network size and its relationship to domains of quality-of-life among older persons living with HIV. AIDS Care, Abingdon, v. 31, p. 1-8, 2022. DOI: 10.1080/09540121.2022.2057907
https://doi.org/10.1080/09540121.2022.20... ). When this population faces physical limitations, the presence of other people can generate a beneficial effect that motivates them to participate in social networks and perform light physical activities, because it optimizes other actions as the bond with others is enjoyed and cognitive functions are exercised.

Both social support and internal locus of control are described as mediators of adaptive processes (Lefcourt; Martin; Saleh, 1984LEFCOURT, H. M.; MARTIN, R. A.; SALEH, W. E. Locus of control and social support: Interactive moderators of stress. Journal of Personality and Social Psychology, Washington, DC, v. 47, n. 2, p. 378-389, 1984. DOI: 10.1037/0022-3514.47.2.378
https://doi.org/10.1037/0022-3514.47.2.3... ; Sandler; Lakey, 1982SANDLER, I. N.; LAKEY, B. Locus of control as a stress moderator: The role of control perceptions and social support. American Journal of Community Psychology, [s. l.], v. 10, n. 1, p. 65-80, 1982. DOI: 10.1007/BF00903305
https://doi.org/10.1007/BF00903305... ). Older adults can adapt to the loss of family support when they show high internality, which gives them the feeling of good QoL. They can analyze the absence of family members and assume detachment, even if they recognize their own limitations, achieving a sense of peace and tranquility and thus improving their QoL. Recent studies highlight the importance of these associations in relation to the possibility of empowering older adults in the face of possible situations of abuse (Estebsari et al., 2018ESTEBSARI, F. et al. Design and implementation of an empowerment model to prevent elder abuse: a randomized controlled trial. Clinical Interventions in Aging, London, v. 13, p. 669-679, 2018. DOI: 10.2147/CIA.S158097
https://doi.org/10.2147/CIA.S158097... ).

The role played by internal and external beliefs in the adaptation process may change depending on the nature of the stressor (Sandler; Lakey, 1982SANDLER, I. N.; LAKEY, B. Locus of control as a stress moderator: The role of control perceptions and social support. American Journal of Community Psychology, [s. l.], v. 10, n. 1, p. 65-80, 1982. DOI: 10.1007/BF00903305
https://doi.org/10.1007/BF00903305... ). However, contextual events may not be important in themselves when compared to the degree of control exercised over them by another person (Mollenkopf; Walker, 2007MOLLENKOPF, H.; WALKER, A. Quality of life in old age: International and multi-disciplinary perspectives. Dordrecht: Springer Netherlands, 2007.). For some subjects, social networks can be used as an adaptive tool during aging. The categories found together with the proposed association coincide with studies that address resilience in older adults. We was found that the internal locus, optimism, and social support are considered as protective factors that can favor resilience processes in older adults, thus improving QoL (Musich et al., 2022MUSICH, S. et al. The association of increasing resilience with positive health outcomes among older adults. Geriatric Nursing, Amsterdam, v. 44, p. 97-104, 2022. DOI: 10.1016/j.gerinurse.2022.01.007
https://doi.org/10.1016/j.gerinurse.2022... ).

Final Considerations

In summary, the participants’ contributions allow us to appreciate that, through primary and secondary assessment (necessary in any adaptation process), older adults can decide to strengthen their internality (locus of control) and seek solutions, making an effort (adaptation) in order to reestablish their emotional support (social support), which will allow them to achieve good aging, thus improving their QoL.

The model presented here could be the starting point for assessing QoL reflexes and, consequently, contribute to the process of adapting known generic and/or specific measurement instruments in a specific cultural and age context.

Finally, the empirical evidence developed from this qualitative study shows a model generated from a specific cultural and age context, in which social and psychological dimensions interact to show how older adults cope with aging and manage to improve their quality of life.

Acknowledgments

To the School of Dentistry of the Universidad de la República and the School of Dentistry of the Universidade Federal do Rio Grande do Sul that made it possible for us to receive a scholarship to obtain a Doctorate in Dentistry.

References

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