ABSTRACT

BACKGROUND:

Although studies have examined the relationship between variables associated with active aging and quality of life (QoL), no studies have been identified to have investigated the effect of a structural model of active aging on QoL in a representative sample of older people in the community.

OBJECTIVE:

To measure the domains and facets of QoL in older people and identify the effect of the structural model of active aging on the self-assessment of QoL.

DESIGN AND SETTING:

This cross-sectional analytical study included 957 older people living in urban areas. Data were collected from households using validated instruments between March and June 2018. Descriptive, confirmatory factor, and structural equation modeling analyses were performed.

RESULTS:

Most older people self-rated their QoL as good (58.7%), and the highest mean scores were for the social relationships domain (70.12 ± 15.4) and the death and dying facet (75.43 ± 26.7). In contrast, the lowest mean scores were for the physical domains (64.41 ± 17.1) and social participation (67.20 ± 16.2) facets. It was found that active aging explained 50% of the variation in self-assessed QoL and directly and positively affected this outcome (λ = 0.70; P < 0.001).

CONCLUSION:

Active aging had a direct and positive effect on the self-assessment of QoL, indicating that the more individuals actively aged, the better the self-assessment of QoL.

KEY WORDS (MeSH terms):
Aged; Quality of life; Models, statistical

AUTHORS’ KEY WORDS:
Older adults; Quality of life of older people; Active aging; Statistical model

INTRODUCTION

Active aging is defined as “the process of optimizing opportunities for health, participation, and safety, to improve the quality of life (QoL) as people age.”¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6... In the theoretical model proposed by the World Health Organization (WHO), this paradigm contemplates the determinants of culture and gender, which are considered transversal factors that shape people and the environment in which they live throughout life; behavioral and personal, which are specific to each individual; and physical environment, social, economic, social services, and health, which constitute the contextual factors.¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6...

In this scenario, the promotion of active aging has its primary objective to maintain or improve QoL.¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6... It can be understood as the “individuals’ perception of their position in life concerning the context and value systems in which they fit in, including its objectives, expectations, standards, and concerns.”²2. The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med. 1995;41(10):1403-9. PMID: 8560308; https://doi.org/10.1016/0277-9536(95)00112-k.
https://doi.org/10.1016/0277-9536(95)001... Thus, its complexity is highlighted in the face of the interaction of components such as physical and psychological health, level of functional independence and social relationships, and the environment.³3. Fleck MP, Louzada S, Xavier M, et al. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref” [Application of the Portuguese version of the abbreviated instrument of quality life WHOQOL-bref]. Rev Saude Publica. 2000;34(2):178-83. PMID: 10881154; https://doi.org/10.1590/S0034-89102000000200012.
https://doi.org/10.1590/S0034-8910200000...

Among older people, QoL can be assumed to be very good, or at least preserved, when they remain active, independent, and in good physical health and social relationships.⁴4. Ferreira LK, Meireles JFF, Ferreira MEC. Evaluation of lifestyle and quality of life in the elderly: a literature review. Rev Bras Geriatr Gerontol. 2018;21(5):616-27. https://doi.org/10.1590/1981-22562018021.180028.
https://doi.org/10.1590/1981-22562018021... ,⁵5. Lima GS, Souza IMO, Storti LB, et al. Resilience, quality of life and symptoms of depression among elderlies receiving outpatient care. Rev Lat Am Enfermagem. 2019;27:e3212. PMID: 31664416; https://doi.org/10.1590/1518-8345.3133.3212.
https://doi.org/10.1590/1518-8345.3133.3... Although studies have investigated the relationship between variables associated with active aging and QoL,⁶6. Sousa AAD, Martins AMEBL, Silveira MF et al. Quality of life and functional disability among elderly enrolled in the family health strategy. ABCS Health Sci. 2018;43(1):14-24. https://doi.org/10.7322/abcshs.v43i1.986.
https://doi.org/10.7322/abcshs.v43i1.986...

7. Tiraphat S, Peltzer K, Thamma-Aphiphol K, Suthisukon K. The role of age-friendly environments on quality of life among Thai older adults. Int J Environ Res Public Health. 2017;14(3):282. PMID: 28282942; https://doi.org/10.3390/ijerph14030282.
https://doi.org/10.3390/ijerph14030282...

8. Talarska D, Tobis S, Kotkowiak M, et al. Determinants of quality of life and the need for support for the elderly with good physical and mental functioning. Med Sci Monit. 2018;24:1604-13. PMID: 29551764; https://doi.org/10.12659/msm.907032.
https://doi.org/10.12659/msm.907032... -⁹9. Toselli S, Campa F, Spiga F, et al. The association between body composition and quality of life among elderly Italians. Endocrine. 2020;68(2):279-86. PMID: 31893349; https://doi.org/10.1007/s12020-019-02174-7.
https://doi.org/10.1007/s12020-019-02174... no identified studies have verified the effect of a structural model of active aging according to the multidimensional design proposed by the WHO¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6... on QoL in a representative sample of older adults in a community.

Notably, structural equation modeling (SEM) makes it possible to understand the interrelationship between multiple variables,¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014. which enables the operationalization of the expanded concept of active aging adopted in this study,¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6... and to analyze its effect on the QoL of older people. The findings of this study may raise reflections on advanced gerontological practices in line with the current models of healthcare provision (which are not strictly focused on the physical aspects of senescence and senility), but, above all, on a multidimensional approach to active aging.

OBJECTIVE

This study aimed to measure the domains and facets of the QoL of older people in the community and identify the effect of the structural model of active aging on the self-assessment of QoL.

METHOD

Design

The Strengthening the Reporting of Observational Studies in Epidemiology tool guided this cross-sectional and analytical study. Further, the study employed a quantitative approach and was a part of a larger project titled “Active Aging, Global Functionality and Quality of Life among Older People in the Uberaba Health Microregion (Minas Gerais),” developed in the urban area of a health microregion in the state of Minas Gerais. This microregion consists of eight municipalities and comprises 57% of the older population of the Southern Triangle Macroregion.

Sample/Participants

The sample size calculation was based on the prevalence rate of 28.8% for lower participation in instrumental activities of daily living,¹¹11. Duarte LSS, Dutra CDT, Pires CAA, et al. Análise da capacidade funcional de idosos atendidos pela estratégia de saúde da família. Rev Para Med. 2012;26(4):1-7. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/lil-670719. Accessed in 2023 (May 31).
https://pesquisa.bvsalud.org/portal/reso... aiming for an accuracy of 3.0%, and a 95% confidence interval for a finite population of 43,166. Consequently, a minimum sample size of 858 older people was achieved. Considering a sample loss of 20%, the maximum number of attempts made was 980 older people.

Multistage cluster sampling was used for population selection. The first stage considered the arbitrary drawing using systematic sampling of 50% of the census tracts in each municipality in a health microregion. For each municipality, the number of households selected was calculated proportionately to the number of older adults residing in the eight cities in that region. The number of households was then divided by the number of census tracts to obtain a similar number of older people to be interviewed in each census tract. Finally, the first household was randomly selected in each census sector, and the others were selected in a standardized sense until the sector sample was saturated. Notably, one older person was recruited per household; if one more person aged 60 years or older was residing in that place, the person who had first contact with the interviewer was interviewed.

The inclusion criteria included individuals aged 60 years or older living in an urban area of a health microregion in Minas Gerais. Institutionalized older people were excluded if they had communication problems, such as deafness not corrected by devices, severe speech disorders, cognitive decline according to the Mini-Mental State Examination (MMSE),¹²12. Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. O Mini-Exame do Estado Mental em uma população geral. Impacto da escolaridade [The Mini-Mental State Examination in a general population: impact of educational status]. Arq Neuropsiquiatr. 1994;52(1):1-7. PMID: 8002795; https://doi.org/10.1590/S0004-282X1994000100001.
https://doi.org/10.1590/S0004-282X199400... no informant to answer the Functional Activities Questionnaire (FAQ),¹³13. Brasil. Ministério da Saúde. Envelhecimento e saúde da pessoa idosa. Brasília, DF: Cadernos de Atenção Básica; 2006. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/evelhecimento_saude_pessoa_idosa.pdf. Accessed in 2023 (May 31).
https://bvsms.saude.gov.br/bvs/publicaco... or a final score greater than or equal to six points in the FAQ.

Based on the eligibility criteria, 977 older people were interviewed; in this sample, 15 had severe cognitive decline, and five did not undergo a full interview. Therefore, 957 older adults were included in this study.

Data collection

Interviews were conducted at the homes of older people from March to June 2018. Trained interviewers with previous experience in collecting data conducted these interviews. Five previously selected supervisors checked the interviews to verify the completion and consistency of the items and ensure quality control.

Cognitive decline was assessed using the MMSE, considering the following cutoff points: ≤ 13 for illiterate, ≤ 18 for low (1–4 incomplete years) and medium (4–8 incomplete years) education, and ≤ 26 for high (≥ 8 full years) education.¹²12. Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. O Mini-Exame do Estado Mental em uma população geral. Impacto da escolaridade [The Mini-Mental State Examination in a general population: impact of educational status]. Arq Neuropsiquiatr. 1994;52(1):1-7. PMID: 8002795; https://doi.org/10.1590/S0004-282X1994000100001.
https://doi.org/10.1590/S0004-282X199400... If an older person presented a cognitive decline in the MMSE assessment, the informant was asked to participate, and the FAQ was applied, which verifies the presence and severity of cognitive decline based on the assessment of functionality and the need for assistance from other individuals.¹³13. Brasil. Ministério da Saúde. Envelhecimento e saúde da pessoa idosa. Brasília, DF: Cadernos de Atenção Básica; 2006. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/evelhecimento_saude_pessoa_idosa.pdf. Accessed in 2023 (May 31).
https://bvsms.saude.gov.br/bvs/publicaco... The FAQ associated with the MMSE indicates the most severe presence of cognitive decline when the score is greater than or equal to 6 points.¹³13. Brasil. Ministério da Saúde. Envelhecimento e saúde da pessoa idosa. Brasília, DF: Cadernos de Atenção Básica; 2006. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/evelhecimento_saude_pessoa_idosa.pdf. Accessed in 2023 (May 31).
https://bvsms.saude.gov.br/bvs/publicaco...

Sociodemographic and economic data were obtained through a structured questionnaire, which was elaborated upon and widely used by Collective Health Research Group members.

QoL was assessed based on the application of the World Health Organization Quality of Life-BREF (WHOQOL-BREF), which is composed of four domains: (1) physical, (2) psychological, (3) social relationships, and (4) environment,³3. Fleck MP, Louzada S, Xavier M, et al. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref” [Application of the Portuguese version of the abbreviated instrument of quality life WHOQOL-bref]. Rev Saude Publica. 2000;34(2):178-83. PMID: 10881154; https://doi.org/10.1590/S0034-89102000000200012.
https://doi.org/10.1590/S0034-8910200000... and the World Health Organization Quality of Life-OLD (WHOQOL-OLD), which is a specific instrument for the older population, consisting of six facets: (1) functioning of the senses; (2) autonomy; (3) past, present, and future activities; (4) social participation; (5) death and dying; and (6) intimacy,¹⁴14. Fleck MP, Chachamovich E, Trentini C. Development and validation of the Portuguese version of the WHOQOL-OLD module. Rev Saude Publica. 2006;40(5):785-91. PMID: 17301899; https://doi.org/10.1590/s0034-89102006000600007.
https://doi.org/10.1590/s0034-8910200600... both validated in Brazil. Notably, the domains and facets of these instruments are composed of questions whose scores on a Likert scale vary according to the degree of satisfaction (1–5 points). The final scores (0–100 points) were calculated using Syntax, with the highest value corresponding to the best QoL.

The self-assessment of QoL was measured using the question, “How would you assess your quality of life?” This question had five response options: very poor, poor, not bad/not good, good, or very good. Notably, the questions regarding QoL were answered based on the last two weeks of life.

Furthermore, a structural model of active aging developed in a previous study, based on the theoretical framework of the WHO,¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6... was used.¹⁵15. Oliveira NGN, Tavares DMDS. Active ageing among elderly community members: structural equation modeling analysis. Rev Bras Enferm. 2020;73(suppl 3):e20200110. PMID: 33111807; https://doi.org/10.1590/0034-7167-2020-0110.
https://doi.org/10.1590/0034-7167-2020-0... The instruments applied at a single moment to measure the determinants of the active aging model were defined considering the most used ones in gerontology and validated in Brazil (Chart 1).¹⁵15. Oliveira NGN, Tavares DMDS. Active ageing among elderly community members: structural equation modeling analysis. Rev Bras Enferm. 2020;73(suppl 3):e20200110. PMID: 33111807; https://doi.org/10.1590/0034-7167-2020-0110.
https://doi.org/10.1590/0034-7167-2020-0...

16. American Dietetic Association, American Academy of Family Physicians, National Council on the Aging. Nutrition interventions manual for professionals caring for older Americans. Washington (US): Nutrition Screening Initiative; 1992.

17. World Health Organization. Obesity: preventing and managing the global epidemic: report of a WHO consultation. Geneva: WHO; 2000. Available from: https://apps.who.int/iris/handle/10665/42330. Accessed in 2023 (May 31).
https://apps.who.int/iris/handle/10665/4...

18. Pagotto V, Santos KFD, Malaquias SG, Bachion MM, Silveira EA. Calf circumference: clinical validation for evaluation of muscle mass in the elderly. Rev Bras Enferm. 2018;71(2):322-8. PMID: 29412289; https://doi.org/10.1590/0034-7167-2017-0121.
https://doi.org/10.1590/0034-7167-2017-0...

19. Burr ML, Phillips KM. Anthropometric norms in the elderly. Br J Nutr. 1984;51(2):165-9. PMID: 6704367; https://doi.org/10.1079/bjn19840020.
https://doi.org/10.1079/bjn19840020...

20. Frisancho AR. Anthropometric standards for the assessment of growth and nutritional status. Ann Arbor: Michigam Press; 1990.

21. Benedetti TB, Mazo GZ, Barros MVG. Aplicação do questionário internacional de atividades físicas (IPAQ) para avaliação do nível de atividades físicas de mulheres idosas: validade concorrente e reprodutibilidade teste-reteste. Rev Bras Ciên Mov. 2004;12(1):25-33. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/lil-524649. Accessed in 2023 (May 31).
https://pesquisa.bvsalud.org/portal/reso...

22. Strelec MA, Pierin AM, Mion D Jr. The influence of patient’s consciousness regarding high blood pressure and patient’s attitude in face of disease controlling medicine intake. Arq Bras Cardiol. 2003;81(4):349-54, 343-8. PMID: 14666277; https://doi.org/10.1590/s0066-782x2003001200002.
https://doi.org/10.1590/s0066-782x200300...

23. Brasil. Ministério da Saúde. Calendário Nacional de Vacinação 2017. Brasília, DF: Ministério da Saúde; 2017. Available from: https://saude.rs.gov.br/upload/arquivos/carga20170803/22180312-16111737-calendario-nacional-de-vacinacao-2.pdf. Accessed in 2023 (May 31).
https://saude.rs.gov.br/upload/arquivos/...

24. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003,18(2):76-82. PMID: 12964174; https://doi.org/10.1002/da.10113.
https://doi.org/10.1002/da.10113...

25. Solano JP, Bracher ES, Faisal-Cury A, et al. Factor structure and psychometric properties of the Connor-Davidson resilience scale among Brazilian adult patients. São Paulo Med J. 2016;134(5):400-6. PMID: 27191249; https://doi.org/10.1590/1516-3180.2015.02290512.
https://doi.org/10.1590/1516-3180.2015.0...

26. Almeida OP, Almeida SA. Confiabilidade da versão brasileira da escala de depressão em geriatria (GDS) versão reduzida [Reliability of the Brazilian version of the ++abbreviated form of Geriatric Depression Scale (GDS) short form]. Arq Neuropsiquiatr. 1999;57(2B):421-6. PMID: 10450349; https://doi.org/10.1590/s0004-282x1999000300013.
https://doi.org/10.1590/s0004-282x199900...

27. Ramos LR, Perracini M, Rosa TE, Kalache A. Significance and management of disability among urban elderly residents in Brazil. J Cross Cult Gerontol. 1993;8(4):313-23. PMID: 24389964; https://doi.org/10.1007/bf00972560.
https://doi.org/10.1007/bf00972560...

28. Griep RH, Chor D, Faerstein E, Werneck GL, Lopes CS. Validade de constructo de escala de apoio social do Medical Outcomes Study adaptada para o português no Estudo Pró-Saúde [Construct validity of the Medical Outcomes Study’s social support scale adapted to Portuguese in the Pró-Saúde Study]. Cad Saude Publica. 2005;21(3):703-14. PMID: 15868028; https://doi.org/10.1590/s0102-311x2005000300004.
https://doi.org/10.1590/s0102-311x200500... -²⁹29. Dias EN, da Silva JV, Pais-Ribeiro JL, Martins T. Validation of the advanced activities of daily living scale. Geriatr Nurs. 2019;40(1):7-12. PMID: 29909023; https://doi.org/10.1016/j.gerinurse.2018.05.008.
https://doi.org/10.1016/j.gerinurse.2018...

Chart 1 shows the instruments used for data collection and categorization of the observed variables in the SEM analysis.

Data analysis

An electronic database was built using Excel (Microsoft, Redmond, Washington, United States) with double entries. After checking for inconsistencies between the two databases, the data were imported into the SPSS (IBM, Armonk, New York, United States) version 22.0 and Analysis of Moment Structures (AMOS – SPSS, IBM, Armonk, New York, United States).

The data were subjected to absolute and relative frequency analyses for categorical variables and mean and standard deviation for quantitative variables. A confirmatory factor analysis was performed using AMOS version 23.0 and SPSS version 22.0. This was to identify the effect of active aging on the QoL of older people and assess the quality of fit of the measurement model to the correlational structure among the observed variables.¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014.

In the adjustment of the model, the identification strategy of the causal model with latent variables in two steps (two-step) was used: (1) specifying and identifying the measurement sub-model and (2) identifying the structural sub-model, that is, establishing the trajectories for endogenous latent variables.¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014. This method ensures that the measurement model is adequately validated and makes it possible to assess the plausibility of the structural model after ensuring the quality of the measurement model.¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014.

In Step 1 of the two-step strategy, a structural model of active aging was used, as described in a previous study.¹⁵15. Oliveira NGN, Tavares DMDS. Active ageing among elderly community members: structural equation modeling analysis. Rev Bras Enferm. 2020;73(suppl 3):e20200110. PMID: 33111807; https://doi.org/10.1590/0034-7167-2020-0110.
https://doi.org/10.1590/0034-7167-2020-0...

In both stages, the parameters were estimated using the asymptotic distribution-free method, which is the most traditional method used in SEM analysis.¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014. We also previously conducted an analysis of normality for the items observed through the asymmetry coefficients (sk) and kurtosis (ku), considering the deviation from normality sk indices > 3 and ku > 10.¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014.

The quality of the global fit of the models was evaluated according to the following indices and their respective values: chi-square and degrees of freedom (χ2/gl) ≤ 5.0, the goodness of fit index (GFI) ≥ 0.90, comparative fit index (CFI) ≥ 0.90, Tucker-Lewis index (TLI) ≥ 0.90, Parsimony goodness of fit index (PGFI) ≥ 0.60, Parsimony comparative fit index (PCFI) ≥ 0.6, root mean square error of approximation (RMSEA) ≤ 0.05, P - Root Mean Error of Approximation (PCLOSE) ≥ 0.05 and expected cross-validation index (MECVI); the lower the value, the better.¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014. The relative normed fit index (RNFI) was calculated to assess the quality of the global structural model (Step 2). RNFI > 0.80 is an indicator of good fit and significant trajectories with P < 0.05.¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014.

The quality of the local adjustment was identified based on the values of factor loadings (λ > 0.3)³⁰30. Laros JA. O uso da análise fatorial: Algumas diretrizes para pesquisadores. In: Pasquali L, editor. Análise Fatorial para pesquisadores. Brasília-DF: LabPAM Saber e Tecnologia; 2012. p. 141-60. and individual reliability (R² ≥ 0.25).¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014. Modification indices greater than 11 (P < 0.001) were used to refine the models, and the measurement errors that led to considerable improvement in the adjustment of the models were correlated.¹⁰10. Marôco J. Análise de equações estruturais: Fundamentos teóricos, software e aplicações. Lisboa: ReportNumber; 2014.

Validity, reliability, and rigor

The instruments used in this study were validated in Brazil. The interviewers collected data from health professionals who underwent training and had qualifications in approaches to ethical research issues. Field supervisors reviewed the interviews to analyze the consistency and completeness of the questionnaire. This study was conducted using a representative sample of older people living in an urban area of a Brazilian municipality.

Ethical considerations

The project was approved by the Human Research Ethics Committee by Universidade Federal do Triângulo Mineiro, on May 9, 2017 (CAAE:65885617.8.0000.5154). The interviews were conducted after obtaining consent from the participants and the participants signing the Free and Informed Consent Form.

RESULTS

There was a predominance of female older people (66.9%), those aged 70–80 years (41.4%), those with 1–5 years of education (52.4%) and partners (42.8%), those who lived accompanied by other people (81.1%), and those with an individual monthly income of 1–3 minimum wages (85.8%) (Table 1).

Table 1 shows the sociodemographic and economic characteristics of older people living the health microregion.

In the QoL assessment, most older people classified it as good (58.7%), followed by not bad/not good (22.3%), very good (13.5%), poor (4.5%), and very poor (1.0%). In the QoL assessment using the WHOQOL-BREF, the highest mean score was for the social relationships (70.12 ± 15.43) domain, and the smallest one was for the physical (64.41 ± 17.15) domain (Table 2).

The facet of the WHOQOL-OLD that presented the highest mean score for QoL was death and dying (75.43 ± 26.73), and the lowest score was in the social participation facet (67.29 ± 16.29) (Table 2).

Table 2 shows the QoL scores measured using the WHOQOL-BREF and WHOQOL-OLD for older people living in a healthy microregion.

The structural model, which demonstrates the effect of active aging on the self-assessment of QoL of older people, showed a good quality of adjustment (χ2/gl = 3.63, P < 0.001; GFI = 0.93, CFI = 0.91, TLI = 0.90, PGFI = 0.72, PCFI = 0.76, RMSEA = 0.05, PCLOSE = 0.130, MECVI = 1.11, and RNFI = 0.94) (Figure 1).

Most items had a standardized factor loading (λ > 0.3) and adequate individual reliability (R² ≥ 0.25) (Table 3).

Table 3 shows the standardized factor loadings and individual reliability of the observed variables that comprise the structural model of the effect of active aging on the self-assessment of QoL in older people living in a health microregion.

It was found that acting aging, the second-order factor, explained 50% of the variation in self-assessment of QoL and had a direct and positive effect on this outcome (λ = 0.70; P < 0.001), showing that the more people actively aged, the better their self-assessment of QoL; that is, an increase in one active aging unit implies an increase of 0.70 in the self-assessment of QoL (Figure 1).

DISCUSSION

In the current study, most older people self-assessed their QoL to be good. It was also found that the highest mean QoL scores were for the domain of social relationships and facet of death and dying, while the lowest was for physical relationships and social participation. Furthermore, a global structural model was proposed to measure the effect of active aging on the self-assessment of QoL in older people living in the urban area of a health microregion in Minas Gerais. Active aging was found to have a direct positive effect on these outcomes.

Data related to the QoL self-assessment, verified in the current study, were obtained from older people living in the city of Uberaba (MG), in which the majority (51.1%) rated their QoL as good.³¹31. Molina NPFM, Tavares DMS, Haas VJ, Rodrigues LR. Religiousity, spirituality and quality of life of elderly according to structural equation modeling. Texto Contexto - Enferm. 2020;29:e20180468. http://dx.doi.org/10.1590/1980-265X-TCE-2018-0468.
https://doi.org/10.1590/1980-265X-TCE-20... However, different results were identified among older people from other cities in the same state as those in the research in question, as a higher percentage classified QoL as regular (54%)³²32. Silva JG, Caldeira CG, Cruz GECP, Carvalho LED. Envelhecimento ativo, qualidade de vida e cognição de idosos: um estudo transversal em uma cidade de Minas Gerais. REAS. 2020;12(1):e1796. https://doi.org/10.25248/reas.e1796.2020.
https://doi.org/10.25248/reas.e1796.2020... and poor (41.3%).⁶6. Sousa AAD, Martins AMEBL, Silveira MF et al. Quality of life and functional disability among elderly enrolled in the family health strategy. ABCS Health Sci. 2018;43(1):14-24. https://doi.org/10.7322/abcshs.v43i1.986.
https://doi.org/10.7322/abcshs.v43i1.986... Such differences may be related to ethnic and cultural differences, as these can interfere with subjective measures self-reported by the older people, such as QoL.³³33. Assari S, Smith J, Bazargan M. Health-related quality of life of economically disadvantaged African American older adults: age and gender differences. Int J Environ Res Public Health. 2019;16(9):1522. PMID: 31036795; https://doi.org/10.3390/ijerph16091522.
https://doi.org/10.3390/ijerph16091522...

In the current study, higher mean scores were observed for the domain of social relationships, similar to studies conducted among older people in the community in Brazil³¹31. Molina NPFM, Tavares DMS, Haas VJ, Rodrigues LR. Religiousity, spirituality and quality of life of elderly according to structural equation modeling. Texto Contexto - Enferm. 2020;29:e20180468. http://dx.doi.org/10.1590/1980-265X-TCE-2018-0468.
https://doi.org/10.1590/1980-265X-TCE-20... ,³⁴34. dos Santos Junior AG, Casais TR, Arantes WS, et al. Avaliação da qualidade de vida em idosos de um centro de convivência. R Enferm Cent O Min. 2019;9:e3053. https://doi.org/10.19175/recom.v9i0.3053,
https://doi.org/10.19175/recom.v9i0.3053... and Greece.³⁵35. Papathanasiou IV, Rammogianni A, Papagiannis D, et al. Frailty and Quality of Life Among Community-Dwelling Older Adults. Cureus. 2021;13(2):e13049. PMID: 33680593; https://doi.org/10.7759/cureus.13049.
https://doi.org/10.7759/cureus.13049... A varying result was shown in a survey in the Netherlands among people aged ≥ 50 years, in which this domain had the lowest QoL scores.³⁶36. Gobbens RJ, Remmen R. The effects of sociodemographic factors on quality of life among people aged 50 years or older are not unequivocal: comparing SF-12, WHOQOL-BREF, and WHOQOL-OLD. Clin Interv Aging. 2019;14:231-9. PMID: 30787599; https://doi.org/10.2147/CIA.S189560.
https://doi.org/10.2147/CIA.S189560... Positive personal relationships associated with an active social life contribute to the prevention of social isolation, reflecting the physical and mental health status of older people and, consequently, their QoL.³⁷37. Brito TRP, Nunes DP, Duarte YAO, Lebrão ML. Redes sociais e funcionalidade em pessoas idosas: evidências do estudo Saúde, Bem-Estar e Envelhecimento (SABE). Rev Bras Epidemiol. 2018;21 (Suppl 02):e180003. https://doi.org/10.1590/1980-549720180003.supl.2.
https://doi.org/10.1590/1980-54972018000... In this context, approaches that make it possible to integrate the family and components of the social network into care are resources that should be valued and used as they add to the QoL of older people.³⁸38. Aragão EIS, Campos RM, Portugal FB, et al. Social Support patterns in Primary Health Care: differences between having physical diseases or mental disorders. Cien Saude Colet. 2018;23(7):2339-50. PMID: 30020386; https://doi.org/10.1590/1413-81232018237.21012016.
https://doi.org/10.1590/1413-81232018237...

A lower score in the physical domain may indicate a more significant impact on daily activities; dependence on drugs or treatments and work capacity are aspects evaluated in this domain.³3. Fleck MP, Louzada S, Xavier M, et al. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref” [Application of the Portuguese version of the abbreviated instrument of quality life WHOQOL-bref]. Rev Saude Publica. 2000;34(2):178-83. PMID: 10881154; https://doi.org/10.1590/S0034-89102000000200012.
https://doi.org/10.1590/S0034-8910200000... Similar data were found in other studies in Brazil,³³33. Assari S, Smith J, Bazargan M. Health-related quality of life of economically disadvantaged African American older adults: age and gender differences. Int J Environ Res Public Health. 2019;16(9):1522. PMID: 31036795; https://doi.org/10.3390/ijerph16091522.
https://doi.org/10.3390/ijerph16091522... ,³⁹39. Bombardelli C, Rosa LHT, Keller KD, et al. Quality of life of elderly people living in a municipality with rural characteristics in the countryside of Rio Grande do Sul, Brazil. Rev Bras Geriatr Gerontol. 2017;20(1):85-90. https://dx.doi.org/10.1590/1981-22562017020.160082.
https://doi.org/10.1590/1981-22562017020... Poland,⁸8. Talarska D, Tobis S, Kotkowiak M, et al. Determinants of quality of life and the need for support for the elderly with good physical and mental functioning. Med Sci Monit. 2018;24:1604-13. PMID: 29551764; https://doi.org/10.12659/msm.907032.
https://doi.org/10.12659/msm.907032... and Greece.³⁵35. Papathanasiou IV, Rammogianni A, Papagiannis D, et al. Frailty and Quality of Life Among Community-Dwelling Older Adults. Cureus. 2021;13(2):e13049. PMID: 33680593; https://doi.org/10.7759/cureus.13049.
https://doi.org/10.7759/cureus.13049... This finding highlights the importance of reevaluating the impact of physical health on the QoL of older people, with a view to establishing actions that favor self-care and maintenance of functionality and independence during aging.

The highest average scores in death and dying, verified in the research on screen, align with the findings among older people in Brazilians³⁴34. dos Santos Junior AG, Casais TR, Arantes WS, et al. Avaliação da qualidade de vida em idosos de um centro de convivência. R Enferm Cent O Min. 2019;9:e3053. https://doi.org/10.19175/recom.v9i0.3053,
https://doi.org/10.19175/recom.v9i0.3053... ,⁴⁰40. Costa IP, Bezerra VP, Pontes MLF, et al. Qualidade de vida de idosos e sua relação com o trabalho. Rev Gaúcha Enferm. 2018;39:e2017-0213. https://doi.org/10.1590/1983-1447.2018.2017-0213.
https://doi.org/10.1590/1983-1447.2018.2... and differ from studies conducted in the Netherlands, in which this facet was among those with the worst evaluations.³⁷37. Brito TRP, Nunes DP, Duarte YAO, Lebrão ML. Redes sociais e funcionalidade em pessoas idosas: evidências do estudo Saúde, Bem-Estar e Envelhecimento (SABE). Rev Bras Epidemiol. 2018;21 (Suppl 02):e180003. https://doi.org/10.1590/1980-549720180003.supl.2.
https://doi.org/10.1590/1980-54972018000... Such data suggest that these individuals are facing, in a good way, concerns and fears related to the end of life, which are items evaluated in this facet.³3. Fleck MP, Louzada S, Xavier M, et al. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref” [Application of the Portuguese version of the abbreviated instrument of quality life WHOQOL-bref]. Rev Saude Publica. 2000;34(2):178-83. PMID: 10881154; https://doi.org/10.1590/S0034-89102000000200012.
https://doi.org/10.1590/S0034-8910200000...

The lowest scores obtained on the social participation facet corroborate the investigation among older people in the community in Brazil.⁴⁰40. Costa IP, Bezerra VP, Pontes MLF, et al. Qualidade de vida de idosos e sua relação com o trabalho. Rev Gaúcha Enferm. 2018;39:e2017-0213. https://doi.org/10.1590/1983-1447.2018.2017-0213.
https://doi.org/10.1590/1983-1447.2018.2... It is possible that the lowest scores on the social participation facet in the current study were due to the worse assessment of the physical domain because these QoL items may be associated, as shown in a previous study.⁴¹41. Bastos MAMSC, Monteiro JMMP, Faria CMGM, et al. Participation in community intervention programs and quality of life: findings from a multicenter study in Portugal. Rev Bras Geriatr Gerontol. 2020;23(6):e190017. https://doi.org/10.1590/1981-22562020023.190017.
https://doi.org/10.1590/1981-22562020023... Reducing older people’s social participation is a relevant aspect to consider. Generally, it is multifactorial and includes access to income and socialization difficulties, including physical aspects, which health services must monitor to improve decision-making capacity and life satisfaction.¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6... ,⁴²42. Envelhecimento ativo: um marco político em resposta à revolução da longevidade. 1a ed. Rio de Janeiro: Centro Internacional de Longevidade Brasil; 2015. Available from: https://longevidade.ind.br/publicacao/envelhecimento-ativo-um-marco-politico-em-resposta-a-revolucao-da-longevidade/. Accessed in 2023 (May 31).
https://longevidade.ind.br/publicacao/en...

Although the promotion of active aging is considered the main action to face the challenges caused by the demographic aging process and to improve or maintain the QoL of older people,¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6... ,⁴²42. Envelhecimento ativo: um marco político em resposta à revolução da longevidade. 1a ed. Rio de Janeiro: Centro Internacional de Longevidade Brasil; 2015. Available from: https://longevidade.ind.br/publicacao/envelhecimento-ativo-um-marco-politico-em-resposta-a-revolucao-da-longevidade/. Accessed in 2023 (May 31).
https://longevidade.ind.br/publicacao/en... there are critical gaps in the scientific literature regarding structural models that operationalize the concept of active aging in a broad and multidimensional approach. A survey developed with an older Spanish population stands out, in which an active aging model was developed based on the WHO proposal. However, the analyzed outcome variable was satisfaction with life, whose association was direct and positive.⁴³43. Marsillas S, De Donder L, Kardol T, et al. Does active ageing contribute to life satisfaction for older people? Testing a new model of active ageing. Eur J Ageing. 2017;14(3);295-310. PMID: 28936139; https://doi.org/10.1007/s10433-017-0413-8.
https://doi.org/10.1007/s10433-017-0413-...

Studies on the association between active aging and QoL have evaluated the association between some variables that make up the determinants of active aging and QoL.⁶6. Sousa AAD, Martins AMEBL, Silveira MF et al. Quality of life and functional disability among elderly enrolled in the family health strategy. ABCS Health Sci. 2018;43(1):14-24. https://doi.org/10.7322/abcshs.v43i1.986.
https://doi.org/10.7322/abcshs.v43i1.986... –⁹9. Toselli S, Campa F, Spiga F, et al. The association between body composition and quality of life among elderly Italians. Endocrine. 2020;68(2):279-86. PMID: 31893349; https://doi.org/10.1007/s12020-019-02174-7.
https://doi.org/10.1007/s12020-019-02174... A study of community-dwelling older people in Spain using structural equation modeling found that the availability of social support was positively associated with QoL. It was also identified that perception of health and satisfaction with life were the two main variables for understanding QoL, regardless of the age variable, which did not affect the model.⁴⁴44. León LP, Mangin JPL, Ballesteros S. Psychosocial Determinants of Quality of Life and Active Aging. A structural equation model. Int J Environ Res Public Health. 2020;17(17):6023. PMID: 32824975; https://doi.org/10.3390/ijerph17176023.
https://doi.org/10.3390/ijerph17176023... However, the active aging model was tested from a psychosocial perspective, including four latent variables (depression, explicit memory, perceived QoL, and social resources). Furthermore, a selected sample of healthy older people was included, after excluding those with functional dependence, no education, visual and mental problems, cognitive alterations, or other criteria.⁴⁴44. León LP, Mangin JPL, Ballesteros S. Psychosocial Determinants of Quality of Life and Active Aging. A structural equation model. Int J Environ Res Public Health. 2020;17(17):6023. PMID: 32824975; https://doi.org/10.3390/ijerph17176023.
https://doi.org/10.3390/ijerph17176023...

Noteworthy, the active aging approach proposed by the WHO includes all people who are aging, including those who are frail, physically disabled, and require care; its main objective is to maintain or improve QoL.¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6... The interest in studying the relationship between active aging and QoL assumes an increasingly essential role in society because of the aging population worldwide.⁴⁵45. World Health Organization. World Population Prospects 2019. Volume II: Demographic Profiles. New York: United Nations; 2019. Available from: https://www.un.org/development/desa/pd/news/world-population-prospects-2019-0. Accessed in 2023 (May 31).
https://www.un.org/development/desa/pd/n... The way each elderly person faces and experiences the human aging process is also determined by the subjective assessment of their QoL, making it one of the main factors to be considered when analyzing the living conditions of the older population.⁴4. Ferreira LK, Meireles JFF, Ferreira MEC. Evaluation of lifestyle and quality of life in the elderly: a literature review. Rev Bras Geriatr Gerontol. 2018;21(5):616-27. https://doi.org/10.1590/1981-22562018021.180028.
https://doi.org/10.1590/1981-22562018021...

Active aging and QoL are considered complementary concepts because QoL is believed to influence how individuals experience the aging process. The ability to remain active during this process is considered a determinant of QoL, whether in maintaining autonomy and independence, which contributes to performing daily tasks, or conducting social activities such as participating in groups and developing voluntary work.⁴²42. Envelhecimento ativo: um marco político em resposta à revolução da longevidade. 1a ed. Rio de Janeiro: Centro Internacional de Longevidade Brasil; 2015. Available from: https://longevidade.ind.br/publicacao/envelhecimento-ativo-um-marco-politico-em-resposta-a-revolucao-da-longevidade/. Accessed in 2023 (May 31).
https://longevidade.ind.br/publicacao/en...

Therefore, given the current state of scientific knowledge, it appears that the findings of this study innovate by showing a direct and positive effect of the global structural model of active aging on the self-assessment of QoL in a representative sample of older people in the community, supporting discussions of a global public health policy to deal with the challenges of the aging population.¹1. World Health Organization. Active ageing: a policy framework. Geneva: WHO; 2002. Available from: https://apps.who.int/iris/handle/10665/67215. Accessed in 2023 (April 13).
https://apps.who.int/iris/handle/10665/6... Furthermore, the results offer elements to study in the field of gerontology that can provide information that helps in developing and improving its practice, specifically in health care for the older population, to promote active aging and QoL.

This study has a limitation in that it excluded older people with severe cognitive impairment, which may have favored a healthier sample. However, the possibility of selection bias was minimized, as all eligible older individuals were interviewed. Moreover, as a limitation, the non-inclusion of variables related to culture and sex can act as barriers or facilitators in the active aging process and interfere with subjective measures such as self-assessment of QoL. It is suggested that multicenter studies and national surveys should be conducted with representative samples of the older population in different Brazilian states, including the variables of culture and sex, to improve health care for the elderly and their QoL.

CONCLUSION

In the self-assessment of QoL, most older adults classified their QoL as good. The highest mean scores were for the social relationships domain and the facets of death and dying, whereas the lowest scores were for physical relationships and social participation. Active aging had a direct and positive effect on the self-assessment of QoL, indicating that the more people actively aged, the better their self-assessment of QoL. Therefore, investigations into the determinants of active aging among older people in the community are relevant to establishing follow-up actions in health services. Additionally, primary care nurses had the most contact with older people. Therefore, identifying these aspects helps reflect actions to promote active aging, considering their effect on the QoL of this age group.

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