Background and current state of the subject

The increase in life expectancy and the low birth rates in many countries are causing an accelerated growth in the percentage of older people ^(1,2). According to the World Health Organization (WHO), between 2000 and 2050, the proportion of the planet's inhabitants over 60 years of age will double from 11% to 22% ^(1,2). Aging implies physical, psychological or social changes, which together with changes in lifestyle, mean that a longer life expectancy is not accompanied by a better quality of life ^(1,2). Currently there are different ways of measuring the state of health of people; the “proven health”, the “observed health” and the “perception of health”, which is referred to by the people themselves, based on their knowledge, beliefs and personal expectations ⁽³⁾. Today, the perception of health is considered a simple, but very complete measure to assess health, being a valid, relevant, unique and invaluable indicator of a person's global health status ⁽³⁾.

It has been shown that self-perception of health is a good predictor of quality of life, well-being, and health; in addition, in adults, it is an important predictor of life expectancy, morbidity and mortality, and the use of healthcare services^(4,5). As a reflection of all this, various experts and organizations such as the WHO recommend including it as a health indicator in studies and surveys ^(1,3,4).

There is wide evidence in the scientific literature about the relationship between self-perception of health with a wide range of demographic, health, socioeconomic, psychosocial factors, etc. ^(3,4,5,6,7). Married people, with higher levels of education, with a higher economic status, with an optimal family/social relationship and without comorbidities tend to report good self-assessed health ^(3,5,6,7), on the contrary, it has been seen that when suffering from chronic diseases or disability, the reported perception of health tends to be lower ^{(3,5,6,7,8,9)}.

On the other hand, it is of special interest to mention the association found by several authors between perceived health and eating habits, exercise or the Body Mass Index (BMI), observing that obesity, a deficient diet or physical inactivity are associated with a worse self-perceived state of health ^(4,5,6,7,8).

Bearing in mind that the perception of health is a multidimensional concept, various instruments have been designed for its evaluation ^(8,9,10), with the Short-Form 36 Health Survey (SF-36) being one of the most widely used validated instruments. in Spain based on its good psychometric properties, being quite useful for evaluating the self-perception of health in the elderly in Primary Care ^(8,9,10).

It is well established that a balanced diet is a key element to achieve healthy aging ^(8,11), today it is known that the Mediterranean Diet (MD) is the prototype of a healthy diet: it is varied, balanced and moderate ^(4,8,11).

Several studies have evaluated the association between MD and health status, highlighting among them the PREDIMED-1 trial, concluding that MD is associated with reduced mortality, longer life expectancy, and better quality of life ⁽¹²⁾. however, it has been observed that its adherence among the elderly population is decreasing, favoring the development of non infectious diseases (NIDs) ^(11,12,13). Given the MD-health binomial, various tests have been published to assess its adherence, such as the MEDAS-17, a test based on another already validated 14-item test (PREDIMED-1) used in the PREDIMED-PLUS trial. This version adds 3 items that reflect the caloric restriction to be applied to the MD to lose weight ⁽¹³⁾.

Together with MD, Physical Activity (PA) has shown benefits among the elderly population: it increases their life expectancy, reduces their mortality, maintains their physical functioning, translating into a good perception of health ^(8,11,12). Despite the evidence in favor of PA, various organizations, such as the WHO, report alarming rates of sedentary lifestyle among the geriatric Spanish population ^(11,12). Due to its relevance, there are several scales to measure the level of PA in older adults, with the Rapid Assessment of Physical Activity (RAPA) being one of the most widely used due to its proven high sensitivity, reliability, and specificity ⁽¹⁴⁾. Sarcopenia, defined as the loss of muscle mass and strength, is a significant phenomenon of old age, due to the high impact it has on quality of life ^(15,16). Due to its repercussions, it is essential to make an early diagnosis. In this context, it is worth noting the Rapid Screening tool for Sarcopenia (SARC-F), a test applied in studies for its detection due to its high reliability of 80% ^(15,16).

During old age, "good health" is synonymous of autonomy, which is an essential component of quality of life ^(1,2). However, inexorably as age advances, there is a certain decline in the functional state that entails several consequences, among which the reduction of the self-perception of health stands out, as a reflection of this, various authors document that the perception of health of the elderly with functional losses is deficient ^(3,5,16). The functional capacity can be evaluated through the degree of autonomy that the person possesses to carry out a series of Basic Activities of Daily Living (BADL), the current bibliography exposes various tools, being the Barthel Index (BI) a widely validated scale used in Spain, especially in Geriatrics ⁽¹⁷⁾.

Justification and objectives

Older adults are a population group with a progressive demographic weight and with considerable importance in terms of health politics, due to the high amount of resources they require for their care ^(1,2). Specifically, the loss of their autonomy, the decline in their health due to changes in their lifestyle (sedentary lifestyle, Westernization of their diet) ^(11,12) and the decline in their perception of health, are factors strongly linked to an increase in healthcare expenses ^(11,12).

Consequently, the evaluation of the self-perception of the health of the elderly acquires an important relevance, both from the clinical point of view and from the healthcare management point of view, being of help for the health professionals of the Primary Care (PC), since the knowing the perceived health of the elderly in PC will highlight their health needs and preferences, serving as support in order to plan healthcare services^(18,19). Likewise, knowing the factors positively or negatively linked to their self-perception of health could be an excellent starting point for designing appropriate strategies in this group, from tactical planning (programs) to strategic planning (health plans) ^(7,10).

Several authors have investigated the factors associated with the perception of health in the elderly, finding family/social relationships, general health, finances, housing or functional status to be highlighted ^(6,7), however , there are few articles in which their relationship with adherence to MD, sarcopenia or PA level has been measured ⁽¹⁵⁾, consequently it has been decided to include them in this study to show their effects on the perception of health, in such a way that we try to contribute to fill the gap in the literature on the drivers of perceived poor and/or good health among older adults in PC.

Reviewing various works on perceived health, it has been observed that the majority agree in evaluating it using the SF-36, for this reason we have applied it, on the other hand, 4 validated scales have been added: IB, RAPA, SARC-F and MEDAS-17^{( 9,12,14)}, to investigate more deeply into the factors linked to perceived health among the elderly, not having evidence of any previous study in which they have been applied.

The main reason that has prompted us to develop our study at the Calaceite Health Center is that to our knowledge there are no studies on self-perceived health in older adults studied at the center, nor in the Alcañiz Health Sector, nor in Aragon, in addition, there are few studies on this subject in our country: Spain. Lastly, to report that this study can serve as a precedent for future lines of research, since it will measure the impact of variables little studied up to now on the self-perception of health, an aspect that is essential to design plans to improve it later on.

The aim of this study was to find out the self-perceived state of health, adherence to the MD, the level of PA, the degree of autonomy for BADL and the probability of suffering from sarcopenia, in a sample of adults aged 65 or over in a rural Primary Care (PC) healthcare center, by completing a self-administered, online, anonymous and voluntary questionnaire, in addition to evaluating the existing relationship, if any, between the different variables collected.

Type of study, setting and target population

This is a cross-sectional descriptive observational study. The center object of the work has been the Health Center (HC) of Calaceite, HC that belongs to the Health Sector of Alcañiz, a sector made up of 12 Basic Health Zones (BHZ). The target population of the study has been the population of the BHZ of Calaceite, made up of 2946 inhabitants (data extracted from the register of the National Institute of Statistics).

Study population, sample size and selection criteria

The sample size was calculated starting from 916 inhabitants (study population), which is the population aged 65 or over in the BHZ of Calaceite, data consulted in the BDU of the Government of Aragon, with 195 subjects being the representative sample.

Type of sampling and recruitment strategy

The type of sampling chosen was consecutive, so that all patients aged 65 or over who attended a nursing and/or medical consultation and/or demanded home care appointments in the months of recruitment were invited to participate. In order to encourage participation, informative posters of the study were placed by the HC.

Study variables

Several variables with a proven association with the perception of health were included in the study ^(5,6,7,8). The variables were collected through an "ad hoc" questionnaire, which included 5 validated scales: MEDAS-17, RAPA, IB, SARC-F and the SF-36. 37 variables were collected, grouped into 7 categories: 3 sociodemographic variables (age, gender and educational level), 6 socio-family support variables (marital status, income sufficiency, type of coexistence, period of time alone, primary care of a dependent person and weekly time dedicated to leisure), 10 clinical variables (weight, height, Body Mass Index/BMI, tobacco use, alcohol, polypharmacy, number of drugs consumed per day, taking psychotropic drugs, number of chronic diseases and consumption consultations), 3 variables linked to COVID-19 (COVID-19 infection, fear of coronavirus-19 and difficulty sleeping due to concern about suffering from COVID-19, evaluated using the Fear of Covid-19 Scale/FCV-19S or scale of fear of Covid-19), 2 lifestyle variables (adherence to the DM: evaluated using the MEDAS-17 and the PA level: measured through the RAPA), 2 functional capacity variables (autonomy for ADL measured with the IB and risk of suffering from sarcopenia through the SARC-F), health perception variables: evaluated using the Spanish version of the SF-36, its 36 items analyzed the 8 dimensions of perceived health, which are detailed later on ^(8,9).

Instruments used for data collection

The methodological tool used to achieve the formulated objectives has been a self-administered online, anonymous and voluntary questionnaire, designed with Google Forms. The data obtained was transferred to an Excel database, sent to Jamovi for statistical analysis. The questionnaire was made up of 4 blocks: a first block dealt with sociodemographic, clinical, socio-family support and COVID-19-related variables, a second block to collect data on lifestyle, made up of the MEDAS-17 and RAPA ^(4,13,14,19), a third block to collect information on functional capacity, made up of the IB and the SARC-F (16)(17)(18)(19) and a fourth block to collect information on the perception of health, made up of the validated questionnaire SF-36 ^{(8,9,10,20,21,22)}.

Statistic analysis

For the analysis and processing of the data collected in the study, the Excel and Jamovi programs have been used. A descriptive analysis of the data has been carried out: the qualitative variables have been presented through the frequency distribution of the percentages of each category. Quantitative variables were explored using the Kolmogorov-Smirnov conformity test (goodness-of-fit test for a normal distribution) and indicators of central tendency (mean and median) and indicators of dispersion (standard deviation and percentiles) have been given. The association between the self-perception of health and the variables studied has been investigated using hypothesis contrast tests, with comparison of proportions when both variables were qualitative (Chi square, Fisher's exact test), with comparisons of means when one of the variables was qualitative. was quantitative (Student's t test, ANOVA, and if they did not follow a normal distribution, the Mann-Whitney U test or the Kruskall-Wallis test was used) and by bivariate correlations (Pearson's correlation coefficient) when both variables were quantitative . The effects have been considered significant if p<0.05, and the p values have been bilateral. In the case of multiple comparisons of proportions, the Bonferroni correction has been applied to the p-value.

Ethical-legal considerations

Ethical approval of the study was granted by the Research Ethics Committee of the Autonomous Community of Aragon (CEICA) reflected in its act no. 06/2022. In the initial phase of this study, the principal investigator requested written authorization from the coordinators of the Calaceite HC to be able to apply it to the center's patients. In compliance with Law 41/2002, of November 14th, basic regulation of the patient, informed consent was requested from all recruited patients, In addition, in accordance with the provisions of Organic Law 3/2018, of December 5th, Protection of Personal Data and Guarantee of Digital Rights and according to the General Data Protection Regulation, of April 27th, 2016, the names of the participants are not mentioned in the study, or any identifying data ensuring their confidentiality.

Descriptive analysis: sociodemographic, socio-family support, clinical variables, linked to COVID-19, lifestyle and functional capacity

Descriptive analysis: perception of the health of the sample

Table 1: Mean SF-36 score of the sample globally and by gender. 

^{% p. upper limit:}Percentage with maximum score.

^{% p. lower limit:}Percentage with minimum score.

^SD:Standard Deviation.

^IQR: interquartile range.

^PSC:Physical Summary Component.

^MCS:Mental Component Summary.

Table 2 shows that as age increases, the mean score decreases in all subscales as observed in the reference population, with some exceptions, with the greatest decrease in the FF and RF subscales and the lowest in SF and MCS. (22,23). In the FF subscale, the difference between the older and younger age groups was 57.9 points in males and 55.6 in females. In the RF subscale, the differences were also important: 29.2 and 40.6 points in men and women, respectively. However, it was in the SM subscale that the smallest differences were seen, the difference between the oldest and youngest groups was 5.8 points in women, with a 1-point increase being observed even in men. Note that a difference of 5 points in any subscale is considered clinically and socially relevant. The mean scores of the men and women participating in this study in the 8 subscales of the SF-36, in TS and in the summary components were lower than those observed in the reference population, with exceptions that are detailed in bold, being more frequent in women (PF, PR, BP, SF and PCS) than in men (BP, SF and MCS) ^(21,22).

Table 2: Distribution of SF-36 scores of the sample by age and gender. 

The PCS grouped the dimensions PF, PR, BP, GH and the MCS grouped the V, SF, ER and MH ^(9,21)

Results of associations with self-perception of health

Graphs 1, 2, 3 and 4 show a better perception of health in subjects with high adherence, active, independent and with a low risk of sarcopenia

Gráfico XXXII. Salud autopercibida en los sujetos con baja adherencia a la DM y con alta adherencia a la DM. 

Gráfico XXXIV. Salud autopercibida en los sujetos con independencia y con dependencia total para realizar las ABVD. 

Gráfico XXXV. Salud autopercibida en los sujetos con baja probabilidad de sarcopenia y con alta probabilidad. 

Gráfico XXXV. Salud autopercibida en los sujetos con baja probabilidad de sarcopenia y con alta probabilidad. 

Table 3: Relationship between adherence to the MD and the level of PA. 

Table 4: Relationship between sarcopenia and autonomy for BADL. 

Limitations, strengths, suggestions, future lines and practical implications

The main limitation of the aforementioned study is that, based on its cross-sectional design, it does not allow cause-effect relationships to be established, and the sample was made up of geriatric subjects from a HC, so its results cannot be extrapolated. However, it was not designed to be extrapolated, but to study the influence of variables on the perception of health not investigated so far by other authors. In relation to its strengths, it should be noted that validated scales were used to collect the data, allowing the results to be interpreted properly and to be able to compare with other investigations. Based on the repercussions of a low perception of health in the elderly, our results may be a good starting point to try: "add life to their years, instead of years to their lives."