OLDER PEOPLE ’ S PERCEPTION OF ACTIVITIES DEVELOPED IN THE HIPERDIA PROGRAMME

This is a qualitative descriptive exploratory study that aims at understanding how older people evaluate HiperDia activities. Four focus groups were organized from November to December 2013. The participants were seniors citizens enrolled in the HiperDia programme of a primary care unit of a city in the northwest of the state of Paraná. Data was analysed through thematic content analysis. The following themes emerged: educational activities are appreciated; participants associate medical consultations and dispensing of medicines to the activities; and weaknesses of the HiperDia sessions. The authors concluded that older people taking part in the educational activities perceive them as a source of information about their own health and an incentive to change their lifestyle. They associate access to medication and doctor’s appointments to the educational activities and this is what motivates them to attend the sessions.


INTRODUCTION
Population ageing is a global reality.In Brazil, data from the 2010 census demonstrates that 11% of the population is in that group. 2 In addition, each year 650,000 new senior citizens are expected to be incorporated into the Brazilian population. 1 The increase in the life expectancy meant an increase in the prevalence of non-communicable diseases (NCDs) 3 , leading cause of death worldwide.Approximately 80% of these occur in low or middle income economies.Most deaths are caused by cardiovascular diseases, cancer, diabetes mellitus and chronic respiratory diseases. 4igh blood pressure and diabetes mellitus are public health issues responsible for acute and chronic complications 5 , such as coronary artery disease, acute myocardial infarction, stroke and kidney disease.The risk factors associated with them are: smoking, physical inactivity, obesity and a family history of cardiovascular disease. 6The effects of the ageing process are felt on the structure and cardiovascular functions 7 which means that that population is biologically and socially vulnerable to comorbidities.
The onset of a chronic disease in older people means that patients should receive information on the diseases' aetiology, course, treatment, possible complications and self-care since it requires the patient's participation in the treatment. 8Given its incurable characteristics, it should be the responsibility of the health team to promote educational activities geared towards self-care and aiming at improving that population quality of life.
In order to achieve such objectives it is necessary to analyse extensively the population cared by the Family Health Strategy (ESF).This programme aims at expanding health services and reviewing educational activities under a dialogic, emancipatory and participatory perspective. 10Users' co-participation in the process of health education leads to the reduction of injuries and a healthier ageing. 11Also, it is possible to meet individual needs, so that such actions fulfil the demands of older people with hypertension and diabetes mellitus. 9n this context, the Brazilian Health Department created the Reorganization Care Programme for Arterial Hypertension and Diabetes Mellitus (PRAHADM).Its objective is to monitor people diagnosed with such conditions through the Registration and Monitoring of People with High Blood Pressure and/ or Diabetes (HiperDia), an essential tool for improving healthcare attention and reducing complications. 13he interventions aimed at those registered at HiperDia consist of educational and healthcare activities carried out in groups and individually.This procedure makes their monitoring extensive given it is a population group in need of specific care.
In addition to the elderly characteristics obtained by the HiperDia monitoring, it is necessary to assess the effectiveness of the actions promoted.Hence, the present study proposes the following question: "Do the HiperDia meetings promote health care, especially amongst the older adults?" Considering the lack of studies that specifically deal with this perspective, the present study aimed at considering how older people evaluate the activities carried out at the Hiper-Dia programme.

MATERIAL AND METHODOLOGY
This is a qualitative descriptive exploratory research whose data was collected through discussions in focus groups.
The study was carried out with older adults registered in the HiperDia programme of a basic health unit (UBS) at a NW city of the state of Paraná.The city has two Family Health Strategy (ESF) teams and about 960 people are registered in the programme; 90% of them are over 60 years old.
People registered in the UBS are invited to attend the meetings every three months.However, about half of them, for different reasons, do not participate.Four meetings are carried out weekly in the health unit; there are two meetings per team.Each group should have at most 20 participants.An important strategy is to keep the same participants in the groups in order to promote social interaction among their members.The next meeting is scheduled at the end of each session.Furthermore, the Family Health Strategy team carries out home visits for patients that cannot get to the health unit.
The programme offers as well as educational activities, blood pressure and weight measurement (height is checked only at the time of inclusion in the group).After the meeting, the participants go through a medical exam so a treatment can be prescribed and medication dispensed by the UBS pharmacy.
Data were collected between November and December 2013 in four HiperDia groups.The inclusion criteria were: to be 60 years or over; to have attended the HiperDia activities for at least six months.The focus groups were carried out after the meetings.The researchers invited the older adults after informing them about the study objectives, type of participation expected and likely duration of the group.
Six to eight individuals participated in the focus groups.The researchers asked them the following questions: What does it mean to you to participate in the HiperDia meetings?;How do the HiperDia meetings affect your life?What are the advantages and disadvantages of participating in these meetings?In addition to that, the authors used a semi-structured research roadmap to collect the participants' social and demographic data, which was filled up shortly after the focus groups.
The interviews were fully transcribed and analysed according to the three phases of thematic content analysis: sorting, categorization and final analysis. 14,15 he following themes emerged: educational activities are valued; medical consultations and dis-Their narratives demonstrated that older people put into practice what they learn and recognize the impact of a new lifestyle in their health: […] I think it's very important.When I started I had very high blood pressure, cholesterol, and was feeling very ill; then I started to participate in the meetings and started taking care of my health.Thanks God now everything is all right: I watch what I eat: wholemeal bread, whole food, a lot of vegetables, and thanks God I'm fine … the advantages are to improve our health and make sure your blood pressure is under control (Group 2).
[…] we try to follow all the recommendations; we try to improve (Group 3) Despite recognizing the importance of the information provided, the participants recognized how difficult such changes are:

Medical consultations and dispensation of medication are associated to the educational activities
The participants were aware of the importance of such activities in their lives and said they liked to attend them because then they were visited by a physician, got prescription drugs and, when necessary, laboratory exams were arranged.This generates more information about their health status:

[…] I think it's good, because if it weren't for these meetings, we'd had no blood test. Now the doctor often asks us such tests. I know what's going on, and before I didn't (Group 1). […] it's important because I know what's going on with me. I come here every three months, so every three months I get to know how things are; get to know what to do, get to hear what's going on (Group 3).
[…] I think it's a great thing to come here every three months; we get to know how we are (Group 4).

RESULTS
Twenty-four individuals participated in the study, wherein seventeen were female.Of these, thirteen were married, eight were widowers and two separated/divorced; one participant was single.Their age group was between 60 and 78 years old; 20 were retired; their level of schooling ranged from illiterate to complete secondary education.
Data analysis identified the following themes: Educational activities are valued The participants valued the educational activities carried out during the meetings of the HiperDia, because of the information received:

[…] during the meetings they explain things we should know, things we need: what to eat … nutrition guidance, exercises … We are learning things we don't know; they guide us because there are things we don't know and then you come here and tell us. I eat more lettuce, more chicory; I put them in the blender and take them (Group 1). […] We talk with those who know better: nurses, psychologists, we get to know things to have a better life … It's very good because it guides us about physical exercises. For me it's great! (Group 4) […] It is indispensable to me. It's good because we learn a lot; I eat more fruit, less salt, less fat, this is what we get. It's all there; what you can and what you can't eat (Group 2).
The fact that educational activities expand older adult's knowledge and enable changes in their habits that were maintained for lack of information was also highlighted:

[…] It's fine to do what is good for you, for your health, because we often do wrong things without knowing it. Then with the advice given to us here, if you follow them it is excellent, very good … Because we get to know things we didn't know: what you should eat, things like that. It's for our own sake… (Group 3)
They emphasized also the supply of medication by the UBS pharmacy: […] It's good for your health because you need to come, you get the medicines … And I think it's good, it's every three months, but there is no lack of medicines.We are well-looked after; thank God! (Group 1) […] It does make a difference, especially the appointments for the medicines; that is the most important!(Group 2)

[…] I come here, get advised, get the right medicine; the doctor is very patient with me. Whatever they can do for us is an improvement. Not leaving us without the medicine in the unit… sooner or later you may need it. (Group 3)
In conclusion, the participants linked the consultations, the information about their health status and the dispensing of medicines to their participation in the HiperDia meetings.

Limitations of the development of the HiperDia meetings
Although being pleased with the meetings, the participants identified problems with their development, such as time and unpunctuality:

[…] I think they should start earlier in the day, because of the sun (Group 4). […] I think they had to be more punctual. Some people have jobs, I don't, but many people do. They schedule a meeting for say one o'clock and it doesn't start till half past (Group 1).
They emphasized the lack of a few touches that could give better welcoming, promote the feeling of well-being and interaction among the participants, as well as the language used by health professionals:

[…] they could give us a cup of tea (Group 1). […] I couldn't understand anything, because I'm deaf. I can hardly hear. I have hearing aids, but that isn't even working for me. Although I got very little, I liked the meeting. (Group 3).
The research subjects also missed an individualized approach that could take into account their specific needs: "[…] I think we should be given more attention, they should talk to us, and ask things; everything here is done in a hurry.They need to give more guidance, talk more" (Group 4).

DISCUSSION
A profile analysis demonstrated the similarity between the research subjects' sociodemographic characteristics (sex, level of education and income) with those of other studies. 16,17he educational activities developed in the HiperDia aim at changing habits, however, other aspects also deserve the attention of the healthcare team, such as adherence to treatment and health education.The objective of such interventions is to inform and guide this population and their families about diseases and their consequences. 18Participants' narratives confirm that older people appreciate the advice received, and are pleased with the meetings.
In the participants' opinion, information given during the activities had a positive impact on their health encouraging them to change old habits.This is an important aspect, because lack of information may lead to non-adherence to treatment. 16owever, some of the study subjects revealed that, despite the information received, they had trouble to put it into practice.Therefore, interventions of the healthcare team are essential in order to encourage self-care attitudes. 9ealth professionals are able to perform both individual and/or group clinical and educational interventions, i.e. in a manner that fulfils the users' real needs. 13It is necessary to rethink how to awaken the interest and give autonomy to change the habits of older patients with a chronic disease, especially hypertension and diabetes mellitus.
Group activities are important as a means to socialization and exchange of experiences.Such type of activity needs to be implemented within this perspective.Consequently, it is essential to give people time to speak, request information, exchange experiences and have their doubts clarified.Some of the narratives describe a very different context characterized by the transmitting and receiving of information which is not effective enough to promote such changes.Thus, it can be said that educational actions still consider learners as repositories of information: there is no exchange of knowledge between professionals and users, making it difficult for the latter to become active in the care process. 18ctive listening of the reasons that hinder changes and information about what others do to overcome these difficulties is possible through the exchange of experiences.This is probably a more appropriate way to achieve such goal is.
The HiperDia sessions were recognized as facilitators: patients receive information, their health status is assessed and prescriptions are renewed.Hence, according to them, the ac-appreciated the medical consultations and prescriptions and, especially, the supply of medicines.
The limitations of the activities were: inadequate or inexistent welcoming services, the language used and the lack of attention to individual needs.
It appears that, despite being well-established programmes with positive outcomes, the ESF and the HiperDia need improvements.
Understanding the users' point of view could enable health professionals to achieve some of the Unified Health System principles (universality, equality and comprehensiveness) and to practice the precepts of humanization of care.
Treatment and prevention of chronic diseases, such as hypertension and diabetes mellitus, have specific issues.The management of both diseases depends not only on qualification, guidance and monitoring, but also on the users' and their families' lifestyles.
The present study revealed older people's perceptions of the activities developed in the HiperDia sessions.Their limitations are related to their being developed in only one basic health unit with two ESF teams.Despite reflecting a local context, the results may reproduce the context of the Brazilian health services and more specifically, primary health care services.
Further studies focussing on the performance of ESF teams and the HiperDia programme are needed.By identifying the real needs of individuals and the problems of the health system, a better health care delivery will be possible and the life of those that depend on the public health system will be improved.tivities are closely linked to faster scheduling of medical appointments and exams, the dispensing of enough medicines to last for three months.
In Brazil, not all people diagnosed with high blood pressure or diabetes mellitus are registered in the Unified Health System not having, therefore, regular access to medications. 12Another study in the same municipality revealed that lack of medications was a frequent complaint of those registered in the programme. 19he importance given by older adults to the medicines corroborates a study which shows that, according to this population, medication is as important as food.The supply of medication was to some of them the main reason to their participating in the HiperDia meetings.
The association between medication and food raises the question of whether those patients are adequately informed about the importance of all the activities that make up the Hi-perDia programme, including blood pressure and weight measurement, medical consultation, prescription of drugs and supply of prescribed medications.
From their narratives it is clear that the educational activities are valued but need to be more effective.This was also the case in a study in which participants pointed out the need for more information about the disease and its treatment.This can be achieved through the support of a health team. 16Nursing actions, such as promotion of health and preventive care are often irregular due to the lack of integration between health professionals and a heavy workload.Most of their working hours are dedicated to administrative duties and, consequently, they lack the time for educational actions. 20nother study carried out with elderly patients with hypertension found that health professionals need to develop strategies specifically addressed to those with a chronic disease 17 .The study participants resented the lack of attention to their demands, of a welcoming service and of bonding with the health professionals.
In this context, nurses play a very important role, given that they are responsible for the implementation of educational activities in different contexts, such as the meetings of the HiperDia; control of blood pressure and, since diabetes mellitus requires significant participation of the patient, the adoption of self-care actions.Thus, the information provided in educational activities can be a strong allied to therapeutic treatment. 9

CONCLUSION
The participants of the HiperDia programme promoted by the ESF teams were satisfied with it; they recognized the importance of the advice received and the motivation to change habits, as well as the information about their own health.Significantly, the researchers observed that the individuals greatly pensation of medication are associated to the educational activities; limitations in the development of the HiperDia meetings.The study followed the recommendations of the National Health Council Resolution 466/2012.It was authorized by the Centre for Continuing Health Education of the Maringá Health Department and approved by the Research Ethics Committee of the State University of Maringá (protocol No 494.163/2013).All participants signed two copies of the Term of Free and Informed Consent.