How Is the Active Ageing

How is the Active Ageing? A characterization of a senior population attending a Senior University in Portugal Exploring active ageing determinants in senior students

Joana Mendes* Dália Nogueira** Abstract Objective: to characterize active ageing determinants in a sample of portuguese senior students. Design, sample and setting: a cross-sectional survey was carried on 78 participants, attending a portuguese senior university (SU) in Elvas, Portugal. Measures: Physical activity, alcohol consumption, tobacco, eating habits, medication, housing conditions, falls history, education and literacy, income and work/ retirement situation, measured with the ABUEL - Health and wellbeing questionnaire in individuals between 60 and 84 years old. Results: The data shows a predominantly female sample of mostly “young-olds”, retired, with a level of primary education or above, living in their own homes (with acceptable to good housing conditions), non-smoking, non-drinking, taking a varied and apparently healthy diet, actively engaging in physical activities (physical education and hydrogymnastics), leisure, living comfortably well with their monthly income. Discussion: There was no statistically significant difference in the values between gender, age, educational status, income and tobacco use, although this last one shows a near statistically difference between the male and female population, with a trend towards higher consumption among men. Statistical analysis also seems to indicate a significantly higher percentage of male population ingesting alcohol when compared with the female population, in line with national trends. Other analyses were performed and discussed, generally comparing sample values of alcohol, tobacco and medication consumption with national values. The high percentage of senior students who started regular physical activity after signing to the SU was notable. Conclusions: This sample of senior students seems to be “actively ageing”, keeping an interest in their life style. A larger sample of senior students, other methodologies (inferential tests, other evaluation scales) and different populations (such as those in residential homes, larger community settings) should be used in the future to draw firmer conclusions.

Keywords: Active ageing, older people, senior university, determinants

*Physiotherapist, Escola Superior de Saúde do Alcoitão, Estoril, Portugal. ** Speech Therapist, Escola Superior de Saúde do Alcoitão, Estoril, Portugal. ***This article was redacted according to the Instructions to Authors from the Age and Ageing journal, available on http://www.oxfordjournals.org/our_journals/ageing/for_authors/ ****This article was handed-in has a assessment paper for the module “Trabalho de Projecto”, of the Physiotherapy MSc-1st edition-Ageing Studies, Escola Superior de Saúde de Alcoitão, Estoril, Portugal

1 Background The last decades have been marked by an ageing demographic phenomenon, most prominent in countries with social, economic and health care development. This has forced structural adjustments in the organisation of social support systems and structures (pension, retirement and social security schemes), as well as health and long- term care [1]. The proportion of elderly portuguese population, as a percentage of the total population in 1960 [8%], more than doubled to 16.4% in 2001, representing an increase of 140%, with an updated total dependency rate of 52 (a social measure calculated as the number of persons under age 15 plus persons aged 65 or older per one hundred persons 15 to 64) [2,3] . As a result of different regional dynamics, the distribution of the elderly portuguese population is not territorially homogeneous: the North has the lowest percentage of elderly in the mainland. The largest relative concentration of elderly people can be found in the Alentejo region (Portugal Ageing Index - number of persons 60 years old or over per hundred persons under age 15 - 129; Alentejo Ageing Index: 179), Algarve and followed by the Center region. By contrast, the Autonomous Regions of Azores and Madeira show the lowest levels of the country's ageing [4,2]. Given this rapid increase in the ageing population, it is critical to understand factors that contribute to overall health/ well-being at older ages. The subject of “active ageing” is not a new one in discussion, and several international agencies developed attitudes and policies to face future economic and social challenges due to the world’s demographic change. There have been many studies and theories on ageing, either considering it “usual”/”normal”, “pathological” or, on the other hand “positive”, “successful”, “healthy”, “active”, with cross sectional and longitudinal studies focusing on measuring biological, genetic, physical, social, psychological, cognitive factors or determinants in different settings [5]. Attempting to integrate all views of ageing, the World Health Organization’s (WHO) document “Active Ageing: A Policy Framework”, introduces the three pillars of Active Ageing (AA): health, participation and security, and defines AA as “the process of optimizing these (pillars) to enhance quality of life as people age”. The document also stated that active ageing depends on a variety of influences or “determinants” in individuals, families and nations [6]. Even though these determinants apply to the health status of all ages, their main focus is on elderly health and quality of life: culture and gender (cross-cutting to all people), determinants related to health and social service

2 systems (health promotion and disease prevention, curative services, long-term care, mental health services), behavioural determinants (tobacco use, physical activity, healthy eating, oral health, alcohol consumption, medications, iatrogenesis, adherence), determinants related to personal factors (biology and genetics, psychological factors), determinants related to the physical environment (physical environments, safe housing, falls history, clean water, clean air and safe foods), determinants related to the social environment (social support, violence and abuse, education and literacy) and economic determinants (income, social protection, work). The WHO’s Framework (2002) [6] defines “active” as continuing participation in social, economic, cultural, spiritual and civic affairs, and not just the ability to be physically active or to participate in the labour force. The Universities of the Third Age Network Association (Portuguese RUTIS) – a certified public utility institution representing the Portuguese SU – promotes AA through creation and incentive to participation in physical, social and learning activities: with sports, scientific, cultural, leisure and recreational activities, especially created for the senior population, reducing signs and symptoms of old age, whilst improving or maintaining cognitive, physical and social abilities of students [7]. Despite the diversity in opinions, definitions and contributions to the knowledge on AA- aiming at its promotion- there still is not a lot of information on how the elderly live their determinants, on how they age- whether healthily or not, what behaviours related to active ageing they initiate, display and indeed maintain [8,5].

Aim The study aimed to describe and characterize, in a sample of senior students, determinants related with the active ageing, namely: physical activity, alcohol consumption, tobacco, healthy eating, medication, housing conditions, falls history, education and literacy, income and work/ retirement situation. The main research question was: how are senior students ageing, in terms of their active ageing determinants, namely behavioural, social, physical environment and economically?

3 Methods The research was a cross-sectional survey study with a descriptive - exploratory focus. For design outline, population and sample size, please see Appendix 1. After ethical approval, and approval from the City Hall, all participants were given the information sheet and signed the informed consent. Data was collected between 11.05.2011 and 01.06.2011, in the SU of Elvas (Alentejo region-Portugal), with the Portuguese version of the “ABUEL- Health and wellbeing questionnaire in individuals between 60 and 84 years old” (for more details please see Appendix 2) [9]. Because the ABUEL did not include questions about physical activity, another questionnaire, proposed by a certified group of portuguese researchers, was used [10]. The final questionnaire was self- completed; the first 20 questionnaires were assisted by the researcher. The data collected from students was introduced and analysed in the Statistical Package for the Social Sciences (SPSS). Descriptive statistics and frequency distribution were performed. Chi-square tests and Fisher’s tests were used for inferential analysis. Results Characteristics of sample The sample was constituted by 78 participants (mean age of 68 years) - 97.4% were Portuguese, 73.1% female, 62.8% from Elvas- city and surroundings, 35.6% from Évora and Portalegre, 1.6% were from Lisbon, Oporto and Spain. More details of the sample including marital, educational status (ES), working status, housing conditions, income, social support, with “no response” (%), are shown in Appendix 3. AA Determinants On leisure activities (please see Appendix 4 - Figure 1), listening to music (46.2%), taking care of grandchildren (26.9%), being with family (57.7%) and watch television (73.1%) were the most commonly performed activities on a daily basis. Outdoor activities (2.6%), assisting mass/ other religious activities (15.4%) and travelling (3.8%) were activities performed less frequently. On eating habits (please see Appendix 4 - Figure 2), participants ate fruit (85.9%), cereals (71.8%), vegetables (66.7%) and dairy products (80.8%) on a daily basis. Meat and fish are sparsely ingested daily: the first with a 28.2% value, the latter with a 24.4% value. A small percentage of participants (2.6%) did not ingest dairy products. On medications taken daily, medications for pain (34.6%), heart and circulatory conditions (33.3%), depression (24.4%) and sleeping (21.8%) were the ones with higher percentage intake (please see Appendix 4 - Figure 3). Also noteworthy was the

4 medication for anxiety (11.5%), high blood pressure (10.3%) and diabetes (15.4%). Additionally, in our sample, pain, depression, anxiety, allergy, heart medication intake (in percentage terms) were at a level higher than the national values available (with exceptions: the only participant with +85 years did not take pain medication; anxiety medication between 55-64 years old was also at a level lower than the national percentage values). On the other hand, the percentage intake of medication for conditions such as sleeping, asthma, high blood pressure and cholesterol was generally lower, when compared with the percentage intake, at the national level, of medication for the same conditions. One exception to this general finding is the medication for sleep condition for those in the age group 55-64 years old. Diabetes medication values from the sample were very close with those at national level. Due to financial difficulties, about 10.3% of participants stopped taking medication. About present physical activity (please see Appendix 4 - Figure 4), on average, 44.6% of those who practiced regular physical activity did so for two hours/week. Prior to reaching their senior age, participants referred to sports such as running and football. In present physical activities, participants referred to physical education and hydrogymnastics (12.8%) or just hydrogymnastics (28.2%) (please see Appendix 4 - Figure 5). The SU was the main provider of present physical activity (64.1%), followed by other Institutions (9%). Other data on physical activity, as well tobacco and alcohol consumption are outlined on Table 1. Table 1. Physical activity, tobacco, alcohol consumption of senior participants. Sample n=78 Determinant % (Frequency) Physical activity Sedentary life 5.1 (4) Active life 5.1 (4) Regular sports practice 79.5 (62) Never practice regular physical activity before entering the SU 66.7 (52) Tobacco Active smokers 5.1 (4) Never actively smoked 75.6 (59) Stopped smoking >6 months ago 20.5 (16) Alcohol consumption Alcohol drinkers 24.4 (19) Non-alcohol drinkers 75.6 (59) Stopped drinking alcohol >6 months ago 21.8 (17)

Comparing the sample data with national values for tobacco and alcohol determinants, sample values were lower then the values at a national level, though higher for the male gender, in comparison with the female gender.

5 Within sample, tobacco use, in general, show higher consumption in younger individuals with lower income and higher education. Alcohol consumption values show higher consumption for older, higher income participants and those of higher educational qualifications (please see Appendix 5. National population data comparison and sample: tobacco and alcohol consumption (%). In this study chi-square tests were performed to compare the following groups: feminine/ masculine, age <66 years old/ +66 years old, ES below primary education/ ES higher the primary education, income <750€/ income >750€ and alcohol consumption. The Fisher’s test was performed in the same groups for tobacco use (Table 2). Table 2. Tobacco and alcohol consumption related with gender, age, ES, income in sample- Fisher’s and Chi Square results (%).

Actual smokers Actual drinkers Sample (n=78) Sample (n=78) Determinants Yes No Fisher’s test Yes No Chi-square test Gender Feminine (n=57) 1,8% (1) 98,2% (56) P = 0,057∆ 12,3% (7) 87,7% (50) X2 = 16,763 Masculine (n= 21) 14,3% (3) 85,7% (18) 57,1% (12) 42,9% (9) p = 0,000***

Age < 66 years (n=39) 7,7% (3) 92,3% (36) P = 0,615 20,5% (8) 79,5% (31) X2 = 0,626 + 66 years (n=39) 2,6% (1) 97,4 %(38) 28,2% (11) 71,8 %(28) p = 0,429 ES Primary education or first stage 2,5% (1) 97,5% (39) P = 0,352 17,5% (7) 82,5% (33) X2 = 2,096 of basic education (1st cycle) 7,9% (3) 92,1% (35) 31,6% (12) 68,4% (26) p = 0,148 (n=40) More then Primary education (n=38) Income < 750 euros (n=41) 7,3% (3) 92,7% (38) P = 0,617 22,0% (9) 78,0% (32) X2 = 0,272 + 750 euros (n=37) 2,7% (1) 97,3% (36) 27,0% (10) 73,0% (27) p = 0,602 ∆ Statiscally significant p ≤ 0, 05 ***Statiscally significant p ≤ 0,001 On falls history (Table 3), 6.4% of falls occurred indoors, 1.3% in a yard, balcony or patio, 14.1% outdoors or public space, On causes of falls, slippery floor (7.7%), floor in poor condition, dizziness or fainting (5.2%), loose carpeting (1.3%), other non-specified motive (5.1%), slippery floor & loose carpeting (1.3%) were the main causes. Table 3. Details on falls history of senior participants. Sample Determinant n=78 (%) Falls No fall 76.9 history Fall (1, 2, more then 2) 23.1 No consequences 1.3 Physical consequences (with demand hospital services) 3.8 Bone fracture 1.3 Fear of falling (alone) 1.3 Fear of falling (combined with physical consequences) 2.6

6 Discussion The main objective of this research was to collect and analyse data of a senior portuguese population on some of its active ageing determinants, according to the WHO (2002). The findings from this sample of senior students (representing about 36% of seniors attending the SU) state a mostly female, “young-olds”, retired (not working), educated at the level of primary education or above, living in their own homes or renting (with acceptable to good housing conditions), taking a varied and apparently healthy diet, actively engaging in leisure, family and social activities. These senior citizens are actually engaged in healthy life styles: behavioural (non-smoking and drinking), physical (practicing physical activity), social (feeling socially supported by family and friends), living well enough with their monthly income - from pension retirement or other (thou half say feeling worried about it). Either from the “inside” and from “outside” this sample of seniors looks homogeneous in the three “pillars” of AA (health, participation and security), and though the objective of this study was not outlining a testable model of active ageing (like Depp & Jeste (2006) and Peel, McClure & Bartlett (2005) revised) [13, 14], many determinants, and their values, become extremely relevant for the knowledge on active ageing. In general, for the two behavioural determinants tobacco and alcohol, these seniors present lower consumption values (in percentage terms), in comparison with national ones, probably due to national health campaigns or perhaps due to explicit medical advice because of mild illness. For the physical activity determinant, a similar comparison between national and sample values would have been relevant, but the National Health Survey [12] values appear inadequate for statistical analysis. Data from the Observatório Nacional de Actividade Física (2011) [17], reveals that inactivity in persons aged 65 years or more rises to over half the population (55% men and 72% women). According to the same institutional source, these results are similar to those observed in the United States, and are a sign that interventions to promote physical activity should be increased in the elderly, particularly in women, since only 28% of women in this age group are considered sufficiently active. Our senior students showed desirable values of physical activity practice, been a success case in physical activity promotion. There was no statistically significant difference between gender, age, educational status, income and tobacco use intra sample, though tobacco values reveal a near statistically difference between the male and female population, with a trend towards higher

7 consumption among men. Between senior students, there was no statistically significant difference between values, over the physical activity determinant. Other data comparison seems to indicate a significantly higher percentage of male population ingesting alcohol when compared with the female population, similarly to national trends [18]. In the leisure values, the low values of participation in religious activities, given the gender, age, and the common belief in catholic religious education of the Portuguese population, were noteworthy. Not popular were also outdoor activities, probably due to weather conditions of the region (cold winters and hot summers), health conditions, and non-existing outdoor exercise routine. Participants did not have a fall history, and where altogether healthy, taking pain, anxiety and heart medications on a regular basis; also noteworthy was the intake of depression medication. The lower intake of high blood pressure and cholesterol medication might be associated with several factors, namely regular physical activity, but the data collected and sample size of the study were insufficient to corroborate this. On past and present physical activity, the number of participants engaging in a regular physical activity was noteworthy, having increased for more then half after signing to the SU hydrogymnastics and physical education activities, underpinning the contribution of this SU in the promotion of this important behavioural determinant. Fear of falling is concurrent with international studies that show, among community- dwelling older people over 64 years of age, 28-35% fall rate each year. Of those who are 70 years and older, approximately 32%-42% fall each year [16]. Our results show a slightly inferior number, related with age and sample characteristics. Due the various definitions and interpretations of human ageing process, it is difficult to find in the literature similar studies on the active ageing determinants by the WHO (2002) [6]. There are several studies prior to the introduction of this more comprehensive concept, with concepts on successful ageing, positive ageing or healthy ageing, exploring factors identical to the WHO’s determinants. There are, of course, national statistics on population: health, living conditions, income, etc. that are used in this study for general comparison. Recently, a study by Molina (2010) in Chile, investigated social, psychological, biophysical components of active ageing [15], with similar findings in formal education, good housing conditions, non-smoking, non-alcoholic, high social support perception. Results between studies differ in present work situation- our senior citizens showed

8 very low levels of participation in the labour market in comparison; constant physical activity throughout life- a large percentage of our participants started regular physical activity only after signing in the SU; income- our participants received considerably less, though none mentioned receiving help from family or friends. Despite invaluable data collection, the study had limitations worthy of consideration: the sample size did not reach representativeness and there was no random selection, a convenience sample of senior students was studied. In the future, a larger sample of senior students from this Senior University and others should be studied (in Portugal there are approximately 170 Senior Universities, with 25,000 students and 13,000 teachers [7]). Also, it would be worth studying the same determinants in a community-setting and in a residential home, to compare results and outline firmer conclusions on active ageing determinants behaviour. This study methodology could be enriched taking a qualitative perspective in some matters, by doing a mental or psychological evaluation of participants, as well as investigating student’s points of view on their active ageing, and whether they feel participation in the SU activities makes them “active agers”. Future studies could research reasons and implications of engaging in regular physical exercise and particular benefits felt by seniors. Research could provide a deeper understanding of which determinants and interactions influence healthy and active life styles. Other line of research could be to study a commonly accepted definition that determines to what extent people, in a given context and/or population, are ageing positively, like Fernandez- Ballesteros, whose study supported a multidimensional concept of positive ageing: health, cognition, activity, positive emotions, and physical fitness are the major factors for aging well [18]. The findings might have a clinical relevance, namely for health promotion policies in the Alentejo rural region of Portugal, concerting efforts between the Health Center (medical, nursing, physiotherapist) and the City Hall (local Government), creating pathways and communication between organizations, to better reach elderly populations (community or via SU), and improve their ageing. In a wider setting and framework of a multidisciplinary support for the ageing community, the physiotherapist could be consulted on matters of physical activity, proving guidance and advice.

9 Conclusions This research intended to give an important contribution to the knowledge on the “Active Ageing” field of study and concept, with the characterization of behavioural, social, economical, physical determinants in senior students. In general, this sample of senior citizens appears to be living quite actively and healthily, with overall conditions to do so (social, housing, income), keeping interest in various leisure activities, and most importantly keeping themselves fit, choosing to practice regular physical activity. The SU are places where opportunities to learn and teach are offered to senior students, also promoting interaction between generations. This was clearly verified in our findings, especially in the physical activity, where thanks to the SU, hydrogymnastics and physical education had an enormous participation and adherence. Our major challenge, as health professionals, is not only to help these senior citizens to maintain their activity level as much as they can, for as long as they can, but also to recruit and raise new senior citizens who are not engaged in this “active way of life” to become so.

Key points  Knowledge on active ageing behaviours and determinants in rural Portugal is scarce;  This study has characterized a sample of senior students in their active ageing determinants, according to the WHO (2002);  Results show some serious healthy behaviours in the students, with regular physical activity, diet, leisure, keeping a “general interest” in life;  Implications for health promotion policies are discussed, in order to maintain these healthy behaviours in seniors, and recruit others, explaining benefits for their ageing process.

Acknowledgements The authors would like to thank all participants of the study, the teachers at the SU, the assistants at the Municipal Pool and the working staff at the City Hall.

10 References 1. United Nations. Current Status of the Social Situation, Well-Being, Participation in Development and Rights of Older Persons Worldwide. New York: UN, Department of Economic and Social Affairs, 2010. 2. Instituto Nacional de Estatística Statistics Portugal. Censos 2011 – Resultados Provisórios. XV Recenseamento geral da população V Recenseamento geral da habitação, 2011 3. United Nations. World Population Ageing 1950-2050. Annex I Definition of the indicators of population ageing. New York: UN, Department of Economic and Social Affairs Population Division, 2002. 4. Carrilho MJ, Patrício L. The Demographic Changes in Portugal. Revista de Estudos Demográficos 2010; 48: 101-148. 5. Hutchison T, Morrison P, Mikhailovich K. A review of the literature on active ageing. University of Canberra. Australia, 2006. 6. World Health Organization. Active Ageing. A Policy Framework. Geneva: WHO, 2002. 7. Jacob L. Como eles ousaram regressar às aulas. Voz das Misericórdias. October, 2008. 8. Kroes N. Commission Recommendation of 11th July 2011 on the research joint programming initiative ‘More years, better lives — the potential and challenges of demographic change’ (2011/413/EU). Official Journal of the European Union, 2011. 9. Faculdade de Medicina da Universidade do Porto. Serviço de Higiene e Epidemiologia. ABUEL- Questionário sobre saúde e bem estar nos indivíduos entre os 60 e os 84 anos de idade (Questionnaire on Health and Well-being of People between 60 and 84 Years), 2009. 10. Canhão H, Fonseca JE, Viana MQ. Questionário para identificação de factores de risco de osteoporose. Acta Reum Port 2004; 29: 63-9. 11. Statistics Portugal. Population Ageing in Portugal: Recent demographic and socio- economic situation of older persons. Serviço de Estudos sobre a População do Departamento de Estatísticas Censitárias e da População. Portugal, 2002. 12. Statistics Portugal. National Health Survey 2005/2006. 2009. 13. Depp CA, Jeste DV. Definitions and Predictors of Successful Aging: A Comprehensive Review of Larger Quantitative Studies. Am J Geriatr Psychiatry 2006; 14: 6 –20.

11 14. Peel NM, McClure RJ, Bartlett HP. Behavioral Determinants of Healthy Aging. Am J Prev Med 2005; 28: 298–304. 15. Molina MB. Predictores psicosociales del envejecimiento activo: evidencias en una muestra de personas adultas mayores. Anales en Gerontología 2010; 6: 11-29. 16. Yoshida S. A Global Report on Falls Prevention Epidemiology of Falls. Ageing and Life Course Family and Community Health. World Health Organization, (n.d.). 17. Observatório Nacional de Actividade Física. Livro Verde da Aptidão Física. Instituto do Desporto de Portugal, I.P. 2011. 18. Fernández-Ballesteros R, Casinello MDZ, Bravo MDL et al. Envejecimiento con éxito: criterios y predictores. Psicothema 2010; 22, 641-647.