INTRODUCTION

The appropriate management of elderly care should emphasize the functional capacity maintenance and/or improvement, including actions to promote healthy and active aging, injuries prevention, health recovery and physical and cognitive rehabilitation¹ .

The Active Aging refers to the process of optimizing health, participation, safety/protection and long life learning opportunities. The aim is to act on these four pillars to improve the aging quality of life and enable aging be a positive experience¹ .

In this conception, the health is understood as the possibility of access to services to meet physical and cognitive needs of the elderly, ensuring the best quality of life, longest healthy life and independence; the participation involves intersectoral actions promotion that provide the integration of people into recreational, cultural, social and spiritual activities; the safety/protection can be achieved through the policies development and programs that favor physical, social and economic aspects; and the long life learning refers to the training of specialized human resources and educational actions for the elderly¹⁾⁽² .

Thus, the day-care center has been described as a promising opportunity for elderly care, based on health promotion, disease prevention, rehabilitation and recovery. It is a formal social support device for the elderly and their families and caregivers, intended for the daytime stay of elderly people with partial dependence to perform activities of daily living and that provides reception, protection and coexistence³ .

The frequency of the person in this service favors the maintenance of family ties, ensures the better quality of life as possible and allows the interpersonal relationships development, the socialization promotion and the functional capacity and autonomy maintenance/improvement⁴ .

However, in Brazil, the profile data of the population attending in the day-care centers and the results in elderly’s physical and mental health are still scarce. Furthermore, there isn’t consensus concern to the day-care centers concept, activities, professional staff, way of works, structure, work processes, evaluation measures and good practices that must be performed in this care model.

Therefore, day-care centers professionals face a challenge in the search for quality services. This attribute refers to the set characteristics that includes professional excellence, resources efficient use and minimum risk to the user, and its evaluation is essential for planning, organizing, conducting and evaluating the activities developed in these services⁵ .

Thus, this research aimed to validate the content of the activities developed in elderly day-care centers, in the health, participation, safety/protection and long life learning dimensions, to subsidize the quality of services evaluation.

METHOD

It was a methodological study, developed in three phases: identification of the activities of elderly’s attention developed in day-care centers; activities selection; and content validation.

The study was conducted in accordance with Resolution number 466/12 of the National Health Council of the Ministry of Health (CNS/MS), registered in the Brazil Platform and approved by the Research Ethics Committee of the São Paulo University, Nursing School (CEP/EE-USP) on October 4^th, 2014, under protocol number 612.317 (CAAE 29147914.0.0000.5392).

The first phase, activities identification, was carried out from a literature review in databases: MEDLINE via PubMed, LILACS and IBECS. The gray literature was searched through Google Scholar, the WHO website and government websites.

The search strategy and descriptors used in MEDLINE were: ("Day Care"[MeSH]) AND "Health Services for the Aged"[MeSH] and (("Aged"[MeSH]) AND "Community Health Services"[MeSH]) AND "Day Care"[MeSH]. In this database, the search was carried out through two different strategies, with broad literature results. When the two strategies were associated, the search did not result in production destined to the object of this research. In the databases LILACS and IBECS, it was used the subject descriptor DeCS "day care". The gray literature search was conducted using the following words: “day-care center for the elderly”, “community health services”, “day care”, “geriatric day care”, “adult day services” and “day care units”.

The second phase, of activities selection, took place through the categorization of those that were identified in the literature review, according to the health, participation, safety/protection and long life learning dimensions, giving rise to the material to be validated¹ .

The content validation of the activities developed in geriatric day-care centers, corresponding to the third phase of the study, was based on the four pillars of active aging, considering the scope of care¹ . This validation was carried out by nine specialists, using the Delphi technique⁶ . The first contact with the professionals to explain the study goals and method was carried out by phone, e-mail or in person, followed by the sending of: an invitation letter, the validation material and the filling instructions, in the most convenient way for the specialist - in person or by electronic means. At that time, it was agreed the deadline of 30 days for the material to be returned.

In order to compose the specialists group, we have established the following criteria: professionals and/or researchers with experience working in day-care center or with knowledge in the themes: aging, elderly care activities, instruments validation, services quality and evaluation, and health promotion and disease prevention.

The experts received a questionnaire and each one delivered their individual judgment, aiming at the content analysis. After the judges return the material, the data was organized in a spreadsheet, and the answers analysis, to verify the consensus index (CI), which in this study was established in ≥ 80%⁷ .

The validation instrument was built based on the one developed for validation of the activities performed by the nursing team in Material and Sterilization Centers (CME)⁸ . This choice was made due to the methodological similarity of the present study and the one conducted to validate the activities in CME.

The questionnaire used in this study had two parts. The first one with the variables for the specialists characterization, namely: age, sex, work place, institution legal nature, position occupied and occupation time, work area, graduation and graduation time, last academic degree and area.

The second part consisted of validation content items and was composed of a table describing the dimensions - health, participation, safety/protection and long life learning, the corresponding activities and their descriptions.

Subsequently, assertions were made that allowed affirmative or negative responses, as well as spaces destined to the possible specialists comments and/or suggestions. The judges were also expected to analyze each activity and its descriptions regarding: definition, inclusion and/or exclusion of descriptions and whether the set of descriptions represented actions aimed at that activity to elderly’s care in day-care centers. We asked the experts to consider whether the set of activities contemplated each dimension and whether to include another activity or not.

For the health dimension, the activities were food and nutrition and hygiene and comfort; for participation, mental capacity optimization, socio-cultural activities, acceptance and monitoring and spiritual support; for the safety/protection dimension, accessibility and mobility; and for the long life learning, socio-educational activities.

The activities and their descriptions were represented by letters and numbers, and the letters corresponded to the initial of each dimension (Health - H, Participation - P, Safety/Protection - SP and Long Life Learning - L) and the numbers corresponded to the order of presentation in the text.

The evaluation of dimensions, activities and descriptions was carried out through four attributes: relevance (it is significant for the elderly’s quality of care in day-care centers); clarity (the expressions are objective and intelligible); pertinence (reproduces what is advocated for health promotion and prevention of aggravations in the ​​aging area); and simplicity (it expresses a single idea, without possibilities of other interpretations).

The data were stored in a spreadsheet and analyzed by descriptive statistics, in absolute and relative frequencies and in measures of central tendency. The concordance analysis among the judges who composed the committee was calculated by the Consensus Index (CI), represented by the ratio between the number of concurrent experts and the total number of specialists, multiplied by one hundred⁹ .

RESULTS

The specialists group was composed of nine professionals, all female, with five (55%) nurses, two (22%) gerontologists, one (11%) social scientist and one (11%) nutritionist. Among them, three (33%) had experience in day-care centers.

The age ranged from 28 to 66 years, with an average of 40,2 years (dp±10,1) and a median of 42,5 years. As for training time, the mean was 15,3 years (dp±11,2) and the median was 12 years, with a minimum of 3 and a maximum of 29 years. The average time in the current position was 4,1 years (dp±2,6) and the median was 3 years, ranging from 1 to 8 years.

Most of the specialists (55%) worked in a public institution, holding the position of professor (33%) and worked in the area of ​​teaching/research (33%), with the predominance of specialists with stricto senso postgraduate (44,4%), followed by those with specialization lato senso (33,3%).

In the experts’ consensus analysis regarding the definition of activities in each of the dimensions, the value obtained was ≥ 80% in all activities, and the lowest values ​​were 88%. The simplicity attribute obtained 100% agreement regarding the definition in all activities. The definitions of activities food and nutrition, socio-cultural activities and socio-educational activities had 100% consensus for the four attributes evaluated.

In the health dimension, of the total 32 descriptions, only four (12,5%) had CI lower than 80%. In the food and nutrition activity, all the descriptions reached 100% agreement for the relevance and pertinence attributes; among the nine existing descriptions, six (H1.3, H1.4, H1.5, H1.6, H1.7 and H1.8) presented 100% consensus among the experts regarding relevance, clarity, pertinence and simplicity. The worst percentages involved activities H1.1 (77%) and H1.9 (66%), in attributes clarity and simplicity.

In the hygiene and comfort activity, there was a 100% consensus for relevance and simplicity. The descriptions H2.4 to H2.14 showed 100% agreement for the four attributes analyzed. Two descriptions (H2.18 and H2.21) obtained a CI of 77%, close to the estimated, in the relevance attribute.

In the participation dimension, of the total 35 propositions, 33 (94,2%) reached consensus ≥ 80%. The worst results (77%) were verified in the activities acceptance and monitoring (P3.1) and spiritual support (P4.2 and P4.3), in the attributes clarity and simplicity.

In the activity mental capacity optimization, 100% of the descriptions obtained CI ≥ 80%. The lowest CI (88%) was verified in item P1.2, in the attribute relevance.

In the descriptions of socio-cultural activities, the lowest consensus value (88%) was obtained in items P2.1, P2.2, P2.3, P2.7 and P2.9 for clarity and simplicity. For the relevance and pertinence attributes, there was 100% consensus for all descriptions.

The agreement between the judges regarding relevance was also 100% for all descriptions of acceptance and monitoring activity. In this activity, the majority (68,8%) of the descriptions (P3.3 to P3.7 and P3.11 to P3.16) reached a consensus of 100% in the four aspects analyzed. Only the description P3.1 didn’t reach the estimated consensus for clarity and simplicity (77%).

For the descriptions of the spiritual support activity, the highest CI was 88%. The agreement percentage for the descriptions P4.2 and P4.3 was 77%, also in the clarity and simplicity aspects.

In the safety/protection dimension, of the total descriptions related to the accessibility and mobility activity, two (22,2%) (SP1.5 and SP1.6) didn’t reach a consensus ≥ 80%, the first being in clarity and simplicity attributes (77 %) and the second in the clarity attribute (77%).

In the long life learning dimension, in terms of relevance and pertinence, the agreement among the judges was 100% for all descriptions of socio-educational activities. The lowest CI observed were 88% in items L1.5 and L1.6, in clarity and simplicity aspects. The other four descriptions reached 100% consensus on the four attributes. Thus, in this dimension, all the descriptions obtained the established CI.

In the health dimension, for 88% of the specialists, the descriptions contained in food and nutrition and hygiene and comfort represented these activities as a whole. For the participation dimension, this percentage was 100% for activities mental capacity optimization and socio-cultural activities, and 88% for activities acceptance and monitoring and spiritual support. In the safety/protection dimension, 88% of the judges mentioned that the proposed descriptions comprised, as a whole, the activity accessibility and mobility, and in the long life learning dimension, this percentage was 100% for socio-educational activities.

Regarding the need to include or exclude descriptions in each of the activities, the answers indicated that in the health dimension, 44% of the judges would include descriptions in the food and nutrition activity and 23% in the hygiene and comfort activity; 23% would exclude some description in food and nutrition activity and 44% in hygiene and comfort. In the participation dimension, the percentages for descriptions inclusion were 44% for acceptance and monitoring, 33% for spiritual support and 23% for mental capacity optimization and for socio-cultural activities. In this dimension, the acceptance and monitoring activity received the highest percentage of opinions to exclude some description (55%), followed by spiritual support (33%). For the other activities, the percentage was 12%.

The accessibility and mobility activity, from the safety/protection dimension, was the one which most of the experts pointed out the need to include descriptions (77%). As for the exclusion, the percentage was 12%. In the long life learning dimension, the percentages for descriptions inclusion and exclusion for socio-educational activities were 33% and 12%.

When analyzing whether the activities with their descriptions represented, in their whole, the dimension in which they were, the judges positively opined for the four dimensions, being 88% for the health and safety/protection dimensions, 77% for participation and 100% for long life learning.

Thus, when questioned about the need to include activities in the four dimensions, 77% of specialists would not do so in the health dimension and 100% in participation and long life learning. In the safety/protection dimension, 55% of judges would include some activity.

Within the four dimensions, eight activities were described, of which 100% reached the CI established for the four attributes, relevance, clarity, pertinence and simplicity.

The total of items described, considering the eight activities, was 82. Of these, 100% reached the CI established in the relevance attribute, 91,4% (N=75) in the clarity, 97,5% (N=80) in the pertinence and 92,6% (N=76) in simplicity.

Most of the specialists suggestions and comments for the eight activities were to improve the descriptions’ clarity and simplicity.

Regarding the activities definition, in the health dimension there were two suggestions to include functional capacity and frailty activities and continuous use medications. In the participation dimension, there was a suggestion to change the mental capacity optimization activity for handling and cognitive stimulation and reallocate this to the health dimension. One judge suggested modifying the acceptance and monitoring for social-assistance activities and one suggest excluding monitoring. There was also a suggestion to exclude the spiritual support activity and one to put it into the health dimension. In the safety/protection dimension, a specialist commented on redefining the accessibility and mobility activity for accessibility and control of falls risk factors. In the long life learning dimension, the suggestion was to name the activities as educational, rather than socio-educational.

The specialists evaluation and their suggestions/comments allowed the activities and their descriptors readjustment, with the incorporation of the knowledge shared by the judges, and it wasn’t necessary the return of the instrument for a new evaluation.

The validated content allowed the construction of an instrument to subsidize the evaluation of the day-care centers quality, which is structured in four dimensions: health, participation, safety/protection and long life learning. Each dimension has activities with descriptions, totaling ten activities and 102 descriptions. The tables listed from I to IV indicate the activities evaluated and validated by the specialists for each dimensions.

DISCUSSION

The elderly monitoring in the day-care center is an important feature to maximize their functionality and maintain their skills. In countries such as Portugal, Spain, Sweden, Japan, Denmark, Finland, Ireland, the Netherlands, the United Kingdom, Canada and Norway, day-care centers belong to integrated and long-term care networks, aimed to providing health care and social support, recovery, autonomy promotion and the community services provision¹⁰ .

The day-care centers provide family assistance and care for the frail elderly as an alternative to institutionalization, through multiprofessional care, and avoid elderly exposure to risk situations, such as: accidents and violence at home, depression, sedentary lifestyle and social isolation² .

In this study, the specialists participation was essential to better adapt and improve the activities and to point out pertinence involving the dimensions, activities and descriptions. The judges' training, experience and different areas contributed to enrich their judgments, seeking the best quality of validated content.

The specialists comments and suggestions were aimed at identifying more appropriate terms/words to the daily practice of day-care centers, allowing both public and private institutions to use this tool as a reference in their services, and handled by professionals with different backgrounds. Therefore, items considered unclear, non-pertinent or difficult to understand, as suggested by the judges committee were eliminated or replaced.

In the active aging perspective, validated activities in the health dimension - food and nutrition, hygiene and comfort, functional capacity and frailty, continuous use medications and handling and cognitive stimulation - indicated the importance of relating physical, mental and social health, since all three are interrelated and their adequate and timely management minimize losses and benefits the elderly in preserving autonomy, functionality and quality of life¹ .

Considering the importance of acting in elderly support to perform the basic activities of daily living, studies have shown that the prevalence of elderly people who needed some assistance with food and nutrition was 1,5% and in hygiene and comfort, 6,9% of them presented difficulties with bathing¹¹⁾⁽¹² .

Regarding the functional capacity and frailty activity, the World Health Organization indicated that the possibility of maintaining functional capacity allows the well-being of aging and, according to the National Policy of Elderly Person Health, the main problem that can affect people aged 60 years or over is loss of functional capacity¹³⁾⁽¹⁴ . Thus, we highlight the need for services such as the day-care center, intended to intervene in maintaining or improving the functional capacity of fragile or frail elderly individuals⁴ .

In Brazil, the continuous use medications is present in 72,3% of the elderly in the South, 67,6% in the Northeast and 81,1% in the Southeast^15)(16)(17 . Therefore, professionals who work with the elderly should pay attention to practices such as polypharmacy, self-medication and the use of inappropriate medications, promoting awareness of the rational use of these substances¹⁸ .

The handling and cognitive stimulation are associated with greater autonomy and reduced risk of cognitive decline, dementia and depressive symptoms¹⁹⁾⁽²⁰ . This activity in the day-care center is an important factor, considering that the presence of cognitive decline is associated with greater difficulty in performing the instrumental activities of daily living²¹ .

In relation to the participation dimension, the activities described - socio-cultural activities, acceptance and monitoring and spiritual/religious support - allow social, cultural, recreational and spiritual engagement, which awakens in the elderly the self-esteem, emotional balance, citizenship exercise, strengthening of ties, autonomy and social protagonism¹⁾⁽²² .

The elderly participation in socio-cultural activities has a positive impact on mortality, functional capacity, cognition and well-being²³ . The acceptance and monitoring allow the elderly integration in the service and the evaluation of the answers of the day-care center to their needs¹⁰⁾⁽²⁴ . The spiritual/religious support is significant for the best satisfaction with life, health and ability to carry out the productive and instrumental activities of daily life²⁵ .

When considering the safety/protection dimension, we emphasize that the environment should be safe and friendly to the elderly, adjusted to their limitations and preferences, allowing a sense of control, self-efficacy, autonomy and self-esteem. Friendly environments favor independence and reduce apathy, lack of interest, a sense of incompetence and health complaints²⁶ .

The day-care center is a service that favors accessibility and mobility, emphasizing that the elderly attending this model of care have a reduction of falls risk²⁷ .

In the education dimension, the educational activities are an opportunity for updating and acquiring new knowledge that enables learning in relation to different aspects of life, such as motivation for change, sense of competence and improvement in communication with others, and contribute to the understanding of the aging process²⁸ .

In this way, day-care centers play an important role in promoting autonomy and in representing opportunities for active aging²⁹ . Therefore, the development of new day-care center units in Brazil is recommended, since the elderly frequency in these places avoids isolation, sadness and depression and allows the experience of an active aging³⁰ .

CONCLUSIONS

The accomplishment of this study evidenced the literature scarcity about the activities developed in the day-care centers for the elderly, as well as the management and care models implemented in these equipments. Thus, we consider that the systematization of activities in the four dimensions constitutes an initial step, in order to overcome the innumerable challenges that involve the management and assistance aspects in this context, based on active aging.

In addition, it was possible to verify that the day-care center privileges aspects of the elderly person's quality of life, preventing family disintegration, is a resource that supports health promotion, prevention of injuries and improvement of functionality, as well as providing autonomy of the elderly and social interaction.

We believe that the final product of this research can be used both in public and private day-care centers in Brazil and contribute to structuring elements to evaluate the quality of these services, supporting the planning of activities, the organization of the service and decision making by the managers. However, we indicate as limitations of the proposal the facts that the day-care center isn’t yet a consolidated modality in our country and that not all existing services have Active Aging as a reference framework, which may make it difficult to use the instrument.

Also, we emphasize the need for new investigations, in order to implement the instrument validated in the daily services and involve the management components that can measure the quality in the day-care centers. In this sense, we propose the pursuit of research aiming at the construction and validation of structure, process and result indicators, so that the Donabedian model can be used in the evaluation of the quality of the day-care centers.