Life and health conditions of elderly indigenous Kaingang

Objective: To describe the living conditions and health of the elderly Kaingang in Faxinal indigenous territory in the state of Paraná. Methods: Qualitative study, supported by the ethnographic method was conducted with 28 elderly Kaingang. Data were collected between November 2010 and February 2013, through participant observation, analyzed by means of ethnography. Results: The elderly have specific socio-cultural organization, live in houses built by the government, have electricity and running water. They are physically active, independent, have diet rich in carbohydrates and saturated fats. Often, older people make attempts to meet their health problems within the family before seeking the health service. Conclusion: It is necessary to adopt proposals aimed at improving the living conditions and health of the elderly, considering the cultural specificities of indigenous peoples, may control interventions are more effective, particularly in relation to disease.


INTRODUCTION
The growth of the indigenous population that can be observed nowadays sets challenges to nurses and the multidisciplinary team in health care of the elderly Brazilian native americans.The National Policy of Health Care to Indigenous Peoples (PNASPI) aims at ensuring indigenous peoples the access to integral health care, in the mold of the principles and guidelines of the Unified Health System (SUS), considering the social, cultural, geographic, historical and political diversities as well as the right of these peoples to their culture 1 .Therefore it becomes necessary to learn about life and health conditions of these populations in their various aspects, including their environmental, psychosocial, cultural and economic problems.
With the ever-present aging process in villages, cultural aspects should be taken into consideration, since the culture directly influences the thoughts, decisions and actions, and especially the actions related to the health care 2 .
In spite of investments in public health in the last decades, social and health inequalities still exist among indigenous peoples 3 .The indigenous profile of morbidity identified in the literature is characterized by the low level of education, inadequate housing and sanitation and poor access to health services 4,5 .In Brazil the information about nutritional and eating habits 6,7 , environmental and health conditions 8,9 are little as well as behavioral problems, such as alcoholism 10,11 and the physical activity of the indigenous population 7,12 and most of the times they are carried out with children or adults.
Among the studies that address some elements of the living conditions and health of elderly Brazilian native americans, there is a survey carried out with the indigenous tribe Kaingang which is entitled "social and family dynamics: an ethnographic description of elderly families Kaingang" 13 and the study on the situation of life, health and disease of the indigenous tribe Potiguara 9 .
Under these considerations, the relevance of this study focuses on the socio-cultural and scientific context as knowledge production in order to offer information to health care professionals, especially nurses so that they can strengthen and better evaluate actions to promote improvements in the health of the Kaingang elderlies.Which, therefore, corroborates in planning intervention strategies to improve the living conditions and health of this the population.For this purpose, it has aimed at describing the conditions of life and health of the elderlies from the Kaingang's Indigenous Land in Faxinal -PR, emphasizing health behaviors, existing morbidities, sanitation and drug use.

METHOD
This study has had a descriptive qualitative approach based on methodological framework of ethnography.Ethnography is a research method 14 , which aims at learning about a society or a culture in its totality, understanding it from within, and what the individuals that belong to it feel.
The survey was conducted in the Indigenous land Faxinal de Catanduvas (ILF), in the city of Cândido de Abreu, in the Center-South region of Paraná, where about 600 Indians of the Kaingang ethnicity live, distributed in approximately 120 families.
The elderly were selected from a list of resident population in the ILF provided by the local health unit and the office of the National Foundation for Native Americans (FUNAI) in November 2010.Forty-one seniors were identified.After initiating the contact with possible participants, it was found that six elderly had died and four moved to other ILs, remaining 31 subjects.In addition to these, also, three elderly were excluded once they refused to participate in the study, which left the total of 28 individuals.
Data collection comprised the period of November 2010 to February 2013.Once it's part of the research project "The Knowledge and the Health Care Practice for the families of the elderlies from the Kaingang in the indigenous land in Faxinal -PR", observations began in November 2010, resulting in a total of eleven moments in field, with the permanence of researchers through periods of seven to ten days.In the early moments in field it was possible to establish a relationship between researchers and study participants.It is noteworthy that in each time in field researchers strengthened this relationship by establishing a trust relationship.
The participant's observation was the main research tool, which was developed through home visits recorded in field journal.Through this technique, we were able to observe the daily lives of informants: the situations they face and their behaviors towards them, trying to come close to the interpretations they have before the observed facts.The observations were complemented by semi-structured interviews recorded and transcribed.
It was used for data collection an observation script that addressed three aspects: characterization of the elderly (gender, age, marital status, education, income and individual labor activity), structure of residence (material, existence of bathrooms, number of rooms, electricity, running water and peri-domiciliary), health behaviors (physical activity, eating habits, consumption of alcoholic beverages and tobacco), heath problems reported and use of medications.At times the researchers had help from an Indigenous Health Agent (AIS) as a bilingual interpreter, considering that most of the elderly population speaks their native language, the Kaingang, which belongs to a linguistic branch of the Macro-Jê.These moments comprised the home visits and interviews.
After completing the data collection, the analysis started with the processing the notes from the field journals and we also transcribed the interviews, following the ethnography guidelines 14 .
The study met all the requirements of the National Health Council Resolution 196/96, getting approval from the National Committee of Ethics in Research (CONEP).To preserve the identity of participants, each elderly were coded with numbers preceded the letter I and identified by the letter F for females and M for males, followed by the individual's age.

Conditions of life and health of elder Kaingang
Borghi AC, Carreira L

Study Participants: short description
From the Kaingang's seniors participating in the study, 17 were women and 11 were men, aged between 60 and 103 years old.The median was 72.9 years old Among these, 14 were aged between 60-69 years old, six between 70 to 79 years old and eight aged 80 and over.Four were octogenarians, three nonagenarians and one was over one hundred years old.It is observed that the aging process in the indigenous population has occurred similarly to that observed among non-indigenous -predominance of young elderly female.
Among the Kaingang's elderlies, sixteen were married, ten were widows/widowers and two were separate Among these fourteen elderlies lived in numerous families, that is, families consisting of an elderly couple, or just a single one along with their children, married daughters and their respective families.It was also noted that among the elderlies living by themselves, four of them were couples.
Regarding the level of education, the elderlies reported not to be alphabetized in the Portuguese language, but could interact and communicate effectively with the non-Indian population.
Most Kaingang elderlies are retired or receive pensions.We noted that on the payment days they headed to the nearest city to go shopping and food or pay bills.The phrase "My money is to buy food and pay for the purchases," was often reported by the seniors, which allowed us to note that the elderlies were the financial support of their families.Another source of livelihood was the production in the family gardens of food such as corn, beans, manioc.
Two main themes were then identified: How the Kaingang elderly lives and the health of the Kaingang elderly.

How the Kaingang elderly living
The village policy established since the arrival of the Europeans have changed the ancestral forms of spatial organization of the Kaingang people, whose "settlements" were constantly remade in new locations.With the legitimation of this policy, the Kaingang people organized themselves mainly in function of the indigenous post and other non-indigenous locations in the village such health post, school and churches.The main reason for such kind of organization is the fact that the indigenous policy was legitimated through applying welfare strategies such as food distribution, which led the Brazilian native americans to the dependence on welfare resources.
Although there have been changes in the way the Kaingang people were organized within the indigenous land, the permanence of cultural principles, especially with regard to the rules of descent and residence are maintained until the present days.The Kaingangs, like other groups of the linguistic family macro-Jê, are characterized as sociocentric societies that recognize the dualist principles of sociocosmology, presenting a system of halves.Among the Kaingangs, the originating halves of the society are named Kamé and Kairu.The halves system is an articulator of Kaingang's social organization, which, according to the Kaingang tradition, the marriages must be performed between individuals of the opposite halves, that is, Kamé should marry with the Kairu and vice versa.Among the Kaingang, the belonging to one half stems from the paternal descent.
The Kaingan's traditional dualistic principles of sociocosmology operates on a social structure based on the articulation of social units that are territorially localized, formed by intertwined families who divide ceremonial, social, educational, economic and political responsibilities 15 .The literature brings us that the Kaingang's minimum social unit is the family group formed by a nuclear family (parents and children), who are part of larger social units called domestic groups, formed by an elder couple, their sons and single daughters, their married daughters, their son-in-laws and grandchildren 15 .
In the ILF, the composition of the domestic groups follows the characteristics mentioned in the literature 15 , an elderly couple, or just a single elderly, if widow/widower, their single children, married daughters, son-in-laws and grandchildren.The average number of individuals in these groups is six.These groups don't necessarily occupy the same housing, but the same territory.So we could see nineteen domestic groups occupying the same housing and nine in the same territory, that is, the house of the daughters is located next to the house of the parents.
The way domestic groups are organized favors the interaction of individuals from those groups.The speech of I2; F101 is significant at this point: [...] he (the son) cuts the wood to make fire at night [...] they (the children) all live near here [...] we are always together [...] (I2; F101).The support offered by the family, emotional or functional can play a key role in maintaining or even promoting the physical and mental health of the elderly, contributing to healthy aging 13,14 .
Knowing how these indigenous organize themselves and how they interact allows the multidisciplinary team, especially nurses, plan and develop prevention and health promotion of the indigenous elderlies.
The architecture of the indigenous houses follows different patterns, according to the time of their construction.In the 1980s, the government of Paraná built pre-molded houses without rooms, covered by zinc and asbestos.But in 2003, the Paraná Housing Company (COHAB-PR), through the house-building program in indigenous communities, named "House of the Indigenous Family", built new houses in ILF.These houses have 52 m 2 , built in masonry with wooden frames, two bedrooms, living room, kitchen, outside toilet, balcony and roof of ceramic tiles.
In the ILF, most seniors reside in the houses built by the government of Paraná.The older elderlies live in wooden houses without rooms, with dirt floors covered with sheets of asbestos or canvas.This structure allows the maintenance of a bonfire inside, cultural habit preserved by the elderlies.For this reason, it is common that in brick houses seniors build additional houses to heir house.For the Kaingangs the fire has a very important function as it is in it that the food is prepared and the house kept warm on cold days.The smoke released by the combustion of wood is responsible for the conservation of grains such as corn

Conditions of life and health of elder Kaingang
Borghi AC, Carreira L and beans, and meats that are salted and kept hanging near the smoke in a smoking process 13 .
Of the households surveyed, eleven did not have toilets, however, through sanitation initiatives in the ILF in 2003, shared bathrooms were built and made available for groups of four houses.All elderlies whose domicile doesn't have a bathroom related using "bushes" to do their physiologic needs.They also reported the precariousness of the toilets, which always have "broken pipes", broken toilets or are out of use conditions and lack resources for maintenance.
The sanitizing actions taken in ILF, as already mentioned, included improvements in toilets and the construction of sceptic tanks.It is noteworthy that after finding high rates of intestinal parasites through a research in this IL, a treatment with antiparasitic drugs and health education for the local population were conducted, in partnership with the health care service 8 .
As for solid waste (household waste), these were dispersed in environment, such as on the ground, because there is no suitable waste collection system serving this population.The elderlies refer burning and even burying their garbage as a way to get rid of the generated material.Among the indigenous people the waste produced is commonly buried, burned in peridomicile areas or elsewhere in the village 3,9 .At different moments we were able to see the initiative of the nursing staff to guide and educate the natives about the importance of keeping the village clean, free from garbage, to minimize the proliferation of insects and prevent diseases as intestinal parasites.
With regard to drinkable water all the elderlies refer having access to it, however, five households had no tap water.Seniors who didn't have piped water seek it their children's houses, neighbors or taps scattered around the village.The water used by the indigenous people comes from the artesian well, built in 2004, the year the treatment of the water started.Before that the population used the water from the nearest river, which was contaminated 8 .The Indigenous Agent for Sanitation is responsible for the maintenance of the equipment and water treatment.
Regarding the availability of electricity, eighteen households had it.In the four houses that had no electricity, the elderlies used other types of lighting such as candles, oil lamps and the fire itself.

The Kaingang elderly health
In the aging process, the maintaining body activity is fundamental to conserve vital functions in good working o.In this sense, some elderlies point out the subsistence activities, handcrafts and family agriculture, as a prerequisite for the maintenance of their functional capacity.The speech below reflects this idea: I've just arrived from the farm, I walked a lot.Iwent there(thefarm) in search for bamboo to make handcrafts.We always have to walk a lot, move ourselves, becauseit is bad to depend on others for everything.My mother (I8; F82) can not walk anymore, she needs help to take a shower, go to the bathroom, get water.It is very sad to be like this (I7; F62).

I still plant some corn, potatoes, there in my garden and also the makecrafts with the bamboos I find. You have to do these things otherwise you will become dependent on others (I5; F62).
The involvement of the elderlies in these activities occur in different ways.Twenty-six elderly participate in the production of crafts, developing various functions, such as seek and prepare the raw material of bamboo (Bambusa Vulgaris), make and sell the pieces.We note that all the family is involved in the manufacture, regardless of age: women and children are responsible for making baskets, while men make hats and sieves.
Among the elderlies, nine of them besides participating in the craft production also worked on family farms, where the hand work includes land preparation, planting and harvesting.In the practice of family farming among the indigenous people, the distribution of activities is carried out according to gender, where men are responsible for the land preparation and planting, and women harvesting, transportation and food preparation 11 .However, some elderlies point out difficulties in the cultivation of food.Sentences as "when the animals don't eat it all, the rain comes and everything rots" were frequently reported.
It is important to mention that the remaining seniors, a total of two, referred not being able to accomplish these activities.In both cases the reason for not doing so is related to physical, auditory and visual limitations.One of the elderlies need help to move around and has auditory and visual deficits, the other one is totally dependent, and has locomotor disability, blindness and deafness.
To seek bamboo and/or work in the fields, the elderlies reported walking long distances.This happens because the bamboo plantation and family gardens are away from the central IL.Participating in these activities is essential to keeping physically active and independent seniors.The literature suggests that perform hand activities, such as handcrafting or carrying out some labor activity after retirement, has a protective effect of the functional capacity by enabling relationships with others 16 .
The difficulties in maintaining subsistence activities, the easy access to urban centers and the earning of wages, caused the changes in their lifestyles.Theses changes may affect the health of the indigenous people in two aspects: the first is related to the decrease in physical activity; the second to the increase of the purchasing power and consumption of processed foods 7,12 .
As a result of the changes in lifestyle, which have already been mentioned, the Brazilian native americans began to consume higher amounts of high-calorie, refined foods, high in sugar and salt, and small quantities of natural and rich in fiber foods such as fruits and vegetables 6 , this way, industrialized foods are now part of the daily diet of the indigenous people 7 .The surveyed seniors referred the consumption of these products, such as sweets, soft drinks and sausages.The speech of the elderly I5; F62 shows the consumption of foods rich in carbohydrates and fats.

Conditions of life and health of elder Kaingang
Borghi AC, Carreira L

Today I made pork forthe lunch. I wentto the store yesterday and bought pork belly. It's good because I can fry it and take the fat to put in the rice, beans and after that the fat salts and smokes (I5; F62).
Yesterday for dinner I ate rice, beans and chicken done on the grill, Today I will have "virado" (beans and manioc flour) (I23, F75).
The basic food of the indigenous elderly consists of cornmeal, grits, beans, meat, especially the back of the chicken and pork, cassava and corn.There is still a lot of fat due to the pork fat used to prepare foods 13 , such aspect was also highlighted among the Kaingang in Rio Grande do Sul 6 .The food habits can influence the health of the indigenous elderlies in various aspects, such as the occurrence of chronic diseases, obesity, malnutrition.
These seniors have a diet based on what is readily available or cultivated, being preserved the use of pork fat as in the times of the their ancestors.In this context, it's observed elderlies whose diet is potentially harmful to health, which is a result of the adaptation of the culture to the changes in recent decades 17 .With such information, the nurse through the nursing consultation, can track the health status of the elderly in order to observe their nutritional status and prevent malnutrition situations, overweight and/or obesity.
During the research we had some difficulties in contacting some elderlies, because they were almost always drunk or arrested due to the consumption of alcoholic drinks.Many times, for the security of the indigenous people, their chief, as the IL authority, arrests these individuals to avoid traffic accidents, since the ILF is next to a highway and it is common the movement of drunk indigenous people.Due to the alcohol consumption is common to hear speeches referring to older women suffer domestic violence.

When he (I6; M68) drinks "pingas" he gets nervous. Once he hit me, andsometimes, I have to leave home. I get afraid of him (I5; F62).
The outbreak of violence fueled by alcohol consumption depicts episodes of physical abuse, often against women 11 .Domestic violence and constant friction between community members due to alcohol abuse are often reported among indigenous peoples and described as a serious social problem 10,11 .
However the aggressions are perceived differently by this people, who believes not having the right to interfere in the relationship of a couple, and help is only offered to the victim and punishment to the perpetrator only in cases where one of the two heads to the community leaders and demands actions.It is worth mentioning that the perpetrators are not only the males and that among the situations that led to the fact that stand out jealousy reports or adultery finding 13 .
Another unhealthy habit is smoking.Seventeen elderlies refer smoking straw cigarettes that are basically composed of a handful of tobacco, wrapped in a corn straw.A study in a Potiguara indigenous community has shown that both young and old people, affirm smoking or having smoked at least once in life 9 .
Among the health problems reported by seniors, respiratory diseases are the main cause of illness of the Kaingang elderlies and may be related to frequent exposure to smoke from stoves and fires of indigenous peoples in their homes.
The old indian likes the fire.Last night I put a cardboardon the floor, threw a cloth over and slept by the fire, it iswarmer.[...]There is a bed, a mattress, but it's nice sleeping on the floor.It is the custom of the Indians (I15; F61).
We have the habit of cooking with the fire made onthe floor.You don't like it, right!The nurse always says that the smokeis bad for health, and that this is why we get sick (I9; M62).
The elderlies recognize that staying near the smoke is harmful to health, but even being aware of the risks they continue to build fires, because in besides providing heat to the environment and the maintenance of the food, it has cultural significance.For the Kaingangs, staying around the fire strengthens the spirit against the diseases.In these circumstances, the nursing professionals advise on the consequences of this practice, but they also consider the cultural relevance of this habit in order to ensure the care but reducing conflicts 17 .
The literature shows that, in addition to respiratory diseases, this habit represents the leading causes of illness among indigenous peoples 4 , It is the main cause of death among some indigenous groups such as the indigenous peoples of Mato Grosso do Sul 5 .
Behaviors and lifestyles influence the health of the elderlies, such as their unhealthy diet, physical inactivity, tobacco and alcoholic drinks usage.These risk factors can partly explain the epidemiologic profile of the non-communicable chronic diseases among the indigenous population 5 such as hypertension that was referred by four elderlies.
Hypertension, though little referred, should get our attention as it indicates changes in the epidemiologic profile, influenced by the behaviors and lifestyles of the Kaingang elderlies.Before this scenario health care professionals, specially the nursing staff, need to create strategies for promoting health and the prevention of complications that come from this morbidity, they need to encourage drug treatment and the adoption of healthier health habits.
Periodic monitoring of patients with hypertension, informing them about the disease and treatment through health education is needed because treatment adherence is a complex process and should be constant because it requires the involvement and active participation of patients in the practice of self-care, so that there is the prevention of complications and health promotion 18 .
In relation to health services, there are dimensions in which seniors have a choice.Often, older people make attempts to take

Conditions of life and health of elder Kaingang
Borghi AC, Carreira L care of their health problems within the family before seeking the heath care service.It's also part of their prerogatives to decide whether it is a "white people's disease" or a "spiritual disease," and according to each case they can still choose from various healing practices: the "bush medicine", prayers to Kuiã, Kaingang's healer and health care professionals.It is common to seek for the services of healers, although it is a practice that is losing prestige, given the strong criticism received by the "white people".
The use of "bush medicine" is very extended and is highly valued among the elderly, although the function that they fulfill varies depending on the circumstances.They can be considered a better alternative than the industrialized medicines.The speech of I9; M62 is significant at this point: "I always make medicines with bush herbs.My mother taught me how to do them.When I have some little pain, or flu I go into the woods, catch some leaves and make some medicine".In other occasions the homemade remedies are considered complementary to the treatment offered by the health care services: I hurt my arm and went to the hospital, there they took care of the injure and gave memedication.They gave me medication to take and told me not to ruin the injury.I took the medication, but also I got some plans to make home remedy to put on the injury (I5; F62).
The Kaingang elderlies add to their practices some traditional elements and ones from modernity, but also make use of the teachings of their ancestors.However, there was a decrease in the use of traditional medicines due to the scarcity of medicinal herbs such as reported by the elderly: "Nowadays there is almost no bush medicines (I24, M94)".
With the implementation of the Basic Health Unit in the IL and changes in the health profile of these Indians, the use of industrialized drugs available in the health care service are quite accepted by the elderlies.
When I have some pain, or the body is bad I go to the health unit to be assisted, then I pick the medication with the nurse.But when I need to do some treatment I have to go there every day, in order to take the medication (I24; M94).
The other day I asked my daughter to get the medication for me.I had ran out of it and the doctor said I have to take it otherwise I will get weak (I11; F63).
The implementation of the basic health unit and the improvement of health care activities with the creation of specific health subsystem for the indigenous population has facilitated the access to health resources, mainly to drug treatments, that are more and more frequent in indigenous communities 19 .

FINAL CONSIDERATIONS
The research has enabled better understanding of the situation of life and health of the Kaingang elderlies and has pointed some characteristic aspects of this population.Learning about the way of life of the Indians and the representations about the health-disease process are essential points for the work of health care professionals working in the indigenous health care and to accomplish the implementation of the National Policy for Health Care of Indigenous Peoples.
Considering the life and health conditions of the Kaingang elderlies, it is necessary that the multidisciplinary team, among them the nursing, may consider the cultural specificities of the indians.Cultural approaches will allow the understanding of the cultural universe of the Kaingang Indians and their health-related practices, thus making it the interventions for control more effective, especially in relation to diseases.
Not using tools to assess the functional capacity and the detailing of the nutritional aspects of the population studied was a limiting factor in the study.Therefore, it is suggested that further researches should focus on the study of the functional capacity of this population group, as well as their nutritional conditions.It's necessary the reproduction of this study with other ethnic groups in Brazil, in order to know the real conditions of life and health that the indigenous peoples live, taking into consideration their cultural particularities.