| 73
Pensar Enfermagem / v.27 n.01 / August 2023
DOI: 10.56732/pensarenf.v27i1.262
Quantitative Original Article
How to cite this article: Cunha F, Pinto MR, Vieira M. Self-care capacity of Portuguese elderly people living
at home. Pensar Enf [Internet]. 2023 Aug; 27(1)76-81. Available from:
https://doi.org/10.56732/pensarenf.v27i1.262
Self-care capacity of Portuguese elderly people
living at home
Abstract
Introduction
This article presents an analysis of the Self-Care Capacity of elderly people
living at home, identifying variables that interfere with it. Aging is a stage of life
in which health needs undergo continuous changes resulting from disease
situations and the aging process, therefore, the implementation of adequate and
effective support for the ability to take care of oneself will contribute to the
promotion of health and well-being.
Objective
To identify variables that interfere with the Self-Care Capacity of elderly people living at
home.
Method
This is a non-experimental, cross-sectional, quantitative descriptive and correlational study,
involving 400 participants who met the inclusion criteria. Assessment of self-care capacity
using the Exercise of Self-Care Agency – ESCA.
Results
Based on the multivariate analysis of variance, the existence of statistically significant
differences was identified in some domains of Self-Care Capacity according to age,
education and self-perception of the elderly person's health status. Overall, positive
correlations were found between age and the domain Initiative and responsibility (3.6%)
and between education and the domain Knowledge and information seeking (5.2%) and
negative correlations between age and the domain Knowledge and information seeking
(3.7%). We also found that elderly people who perceived themselves as unable to take care
of themselves showed lower scores in the Knowledge and information seeking domain
than those who perceived themselves as able to take care of themselves, both when
self-perceived as healthy or as having a pathology (difference in mean scores of -.38 and
-.53, respectively, p<.05).
Conclusion
In view of these data, and given that ageing is a stage of multiple challenges in self-care,
we suggest that nurses should consider multiple strategies for elderly people to access,
understand, interpret and integrate the content of the information that allows them to
take care of themselves.
Keywords
Self-care; Nursing Care; Aging; Elderly People.
Fátima Cunha1
orcid.org/0000-0001-7847-7739
Maria Rosário Pinto2
orcid.org/0000-0001-6786-6069
Margarida Vieira3
orcid.org/0000-0002-9439-2804
1Life Quality Research Center (CIEQV)|
Interdisciplinary Research Center in Health (CIIS);
Higher School of Health – Polytechnic Institute of
Santarém, Santarém, Portugal.
2 Health Sciences Research Unit: Nursing (UICISA-
E)|Nursing Research, Innovation and Development
Center in Lisbon (CIDNUR); Nursing School of
Lisbon, Lisbon, Portugal.
3 Interdisciplinary Research Center in Health (CIIS),
Health Sciences Institute (ICS) - Portuguese Catholic
University, Porto, Portugal.
Corresponding author:
Fátima Cunha
E-mail: fatima.cunha@essaude.ipsantarem.pt
Received: 16.02.2023
Accepted: 03.05.2023
74 | Cunha, F.
Quantitative Original Article
Introduction
In the 21st century, the trend towards population ageing
is notorious, with longevity being one of humanity's
greatest achievements.1 The United Nations2 identifies
the elderly as the age group with the highest growth in
the last 72 years, representing 13.9% of the global
population. The same Body estimates that the world
population aged 60 years or more should double by 2050
and more than triple by 2100, rising from 962 million in
2017 to 3.1 billion in 2100. In Portugal, the aging index
in 2020 would be 167%, with the percentage of people
over 65 being the fourth highest in the European
Union.3
At this stage of life, health needs undergo continuous
changes due to the aging process and/or pathology
situations, interfering or potentially interfering with the
ability of elderly people to take care of themselves, in their
capacity for self-care, a potentiality that is an integral part
of the human being.
According to Orem's Theory,4 self-care is associated
with the performance or practice of activities that
individuals perform for their own benefit to maintain life,
health and well-being, the potential to engage in actions
aimed at caring for themselves, in a close relationship
with the person's autonomy. As the author mentions, in
self-care, the focus is placed on the human power
activated and evidenced by the person when it searches,
judges, make decisions and produce self-care operations.4
The way in which each person performs self-care
activities leads to different levels of self-care ability/deficit
and, consequently, the ability to develop health-
promoting behaviours and healthy ageing.
Thus, this is an issue which has already been studied in
different contexts, with several studies showing
statistically significant associations between self-care
ability, health promotion behaviours and well-being in
the elderly.5,6,7,8 The relevance of the dimension of
self-care in a health context is also highlighted by the
increasing number of studies providing instruments to
assess the self-care ability of elderly people,9,10 allowing
to objectify their needs associated with the diversity of
events that occur
throughout the course of life, and not only as a direct
result of chronological age,11 and contribute to the
development of interventions that respond to the
individuality of the person's life.
In this line of thought, the most recent world report on
ageing and health presents a social approach to address
this issue,11 highlighting that advanced age does not imply
dependence and that, although most elderly people
coexist with multiple comorbidities, the diversity of their
capacities and needs is not random.
Similarly, Orem's Nursing Self-Care Deficit Theory4
identifies basic conditioning factors that influence self-
care and transcend age (gender, developmental stage,
standard of living, environmental factors, resource
availability and adequacy). However, the available
scientific evidence identifies a small number of studies
reporting the influence of variables such as gender5,12 and
education.5
Thus, the interest in analysing the elderly person's ability
to take care of themselves, contributing to the
maintenance of their health, and identifying how the
socio-demographic variables interfere with the ability for
self-care emerges.
Considering this perspective, in line with the proposal
to recommend a focus on population ageing that
enhances the transformation of health systems in order
to replace curative models by preventive ones, focusing
on the needs of elderly people,11 it is essential to identify
the variables that interfere with elderly people's self-care
skills in order to implement adequate and effective
support for the development of these skills.
Objective
To identify variables that interfere with the Self-Care
Capacity of elderly people living at home.
Method
This is a non-experimental, cross-sectional, quantitative
descriptive and correlational study, with a favourable
opinion from the Ethics Committee of the Regional
Health Administration of Lisbon and Tagus Valley
(Proc.086/CES/INV/2018), developed ensuring the
ethical and legal dimensions underlying studies of this
nature. Sample composed of 400 elderly people residing
in home care settings, recruited in day care centres (6
settings) and nursing consultations (6 Personalised
Health Care Units and 8 Family Health Units), through a
convenience sampling. Data were collected in paper
format and the researcher was present throughout the
process to ensure compliance with the sampling criteria,
namely the cognitive ability to understand the questions,
informed consent and clarification of language included
in the questionnaire and/or reading it, in participants who
could not read or had decreased visual acuity. To
determine the self-perception of health status, the
elderly person could answer considering three levels: a)
Unable to take care of itself, needs help from others; b)
Able to take care of itself despite the pathology and c)
Healthy, able to take care of itself.
The assessment of the self-care ability was performed
through the application of Kearney and Fleischer's13
Exercise of Self-Care Agency – ESCA, revised by Riesch
and Hauck14 and translated, culturally adapted and
validated for the Portuguese population by the authors
of this article, during which a reliability study was
conducted through the analysis of internal consistency
Pensar Enfermagem / v.27 n.01 / agosto 2023 | 75
DOI: 10.56732/pensarenf.v27i1.262
Artigo
using Cronbach's Alpha coefficient and construct validity
through exploratory factor analysis in a sample of 625
elderly people living at home. The resulting instrument
is composed of 29 items (6 less than the original scale),
distributed by 4 domains conceptually congruent with the
original authors and with psychometric characteristics
suitable for use in clinical or research contexts (global
scale α= .871; subscales: Self-concept α= .705, Initiative
and Responsibility α= .843, Knowledge and information
seeking α= .755 and Passivity α= .646).
Data analysis was performed using the IBM SPSS
Statistics Base, version 27.0. Descriptive statistics
(measures of central tendency and measures of
dispersion) were used to characterise the sample. For the
multivariate analysis of variance, the assumptions of
independence of observations and homogeneity of
variance/covariance were duly checked. We used Pillai's
Trace due to its robustness to modest violations of
normality and Wilks' Lambda whenever homogeneity was
verified, which is in line with Marôco's
recommendations.15
Results
As regards the sample's characteristics, the sample was
mostly composed of elderly females (68.5%), aged
between 65 and 97 years old (M = 75.52 years old; SD =
7.16). Regarding education, the majority had primary
education (61.3%), followed by those who had attended
or concluded Secondary Education (27.3%). With less
representation, those who had higher education (7.2%)
and those who never attended school (4.3%). Most
elderly people reported being able to perform their usual
self-care activities despite the pathology (55%), 33.5%
reported perceiving themselves as healthy and only
11.5% reported a self-perception of inability to perform
usual self-care activities, requiring the help of others.
As results of this study, it was found that gender does
not interfere with Self-Care Capacity, since the data
from the multivariate analysis of variance revealed no
statistically significant differences [Wilks´ Lambda =
.988, F (4, 395) = 1.23, p = .297, ηp2 = .012, (1-β) =
.386]. Univariate tests also failed to identify any
statistically significant differences.
With regard to age, Pearson's correlation coefficient analysis
identified a positive correlation of low magnitude with
the dimension Initiative and responsibility (r = .191, p<
.01), and a negative correlation, also of low magnitude,
between age and Knowledge and information seeking
(r = .193, p< .01) (see Table 1). It was also identified
that the greater the age of the elderly person, the greater
the Initiative and Responsibility and the lower the
Knowledge and search for information.
Table 1 - Pearson's correlation coefficients between participants' age and the ESCA measures
Age of participants
Pearson correlation coefficient (r)
.036
.191**
-.005
-.193**
.031
*p < .05 **p < .01
With regard to the influence of the level of education, the
multivariate analysis of variance showed an influence of
the level of education on self-care ability, since a
statistically significant overall effect was observed [Pillai
Trace= .150, F(12, 1185)= 5.18, p< .001, ηp2= .050, (1-β)>
.999].This effect is due to the existence of differences at
the level of the dimensions Knowledge and
information seeking
(magnitude corresponding
ηp2=
5.2%),
Self-concept
(ηp2= 2.6%) and Initiative and
responsibility (ηp2= 2.0%)(see Table 2).
76 | Cunha, F.
Quantitative Original Article
Table 2 - Mean scores and standard according to the deviations of the ESCA participants' education level: Univariate tests
(F), magnitude of experimental effect (r;p2 ) and power of investigation (1-β)
Education level
Did not attend
school
(n= 17)
Primary
education (n=
245)
Secondary
Education
(n= 109)
Higher
education
(n= 29)
Total
(N= 400)
M
DP
M
DP
M
DP
M
DP
M
DP
F
(3, 396)
ηp2
1-β
ESCA (global)
3.14
.56
3.20
.45
3.20
.50
3.12
.40
3.19
.46
Initiative and responsibility
3.50
.56
3.36
.56
3.25
.59
3.13
.51
3.32
.57
2.76*
.020
.666
Self-concept
3.49
.65
3.63
.37
3.56
.42
3.41
.40
3.59
.40
3.46*
.026
.774
Knowledge and
information seeking
2.33
1.23
2.84
.89
3.14
.69
3.21
.49
2.93
.86
7.20**
.052
.983
Passivity (inverted)
2.58
.93
2.50
.81
2.58
.98
2.52
.71
2.52
.86
.25
.002
.098
* p < .05 **p < .01
The Games-Howell tests indicated statistically significant
differences in Self-concept, exclusively in the mean scores
between elderly people with Primary Education and those
with Higher Education (mean score difference of .22, p<
.05). In terms of Knowledge and information seeking,
statistically significant differences were found between
elderly people who did not attend school or have Primary
Education and those with Higher Education (difference in
mean scores of .88 and .36, respectively, p<.05), as well
as between participants with Primary and Secondary
Education (difference of -.30, p<.01). In addition to these
aspects, we found that elderly people who did not attend
school had low levels of Knowledge and information
seeking (M=2.33; SD=1.23). We also identified a
progressive increase in the values obtained with
increasing education level (primary education M= 2.84;
SD=.89; secondary education M=3.14; SD=0.69 and
higher education M=3.21; SD=0.49) (see Table 2).
Regarding the influence of Self-perception of health status
on Self-Care Capacity, the results of the multivariate
analysis revealed a statistically significant overall effect, with
a magnitude for the multivariate test in the order of 6.5%
[Pillai trace = .130, F(8, 790)= 6.84, p< .001, ηp2= .065, (1-
β)>.999].
The Games-Howell tests allowed identifying higher scores
at the Self-concept level in healthy elderly people,
compared to those who perceived themselves as unable
to take care of themselves (mean score difference of .25,
p<.05). Elderly people who perceived themselves as able
to take care of themselves despite their pathology also
showed higher scores compared to those who perceived
themselves as unable to take care of themselves, needing
support from others (mean score difference of .31, p<.01).
With regard to the Knowledge and information search
factor, elderly people whose self-perception is of inability
to care for themselves, showed lower scores than those
who perceive themselves as able to care for themselves
despite the pathology and those who perceive themselves
as healthy (difference in mean scores of -.38 and -.53,
respectively, p<.05).
In the Passivity (inverted) dimension, elderly people self-
perceived as healthy indicated greater activity compared to
those who perceived themselves as unable to take care of
themselves and to those who said they perceived
themselves as able to take care of themselves despite
pathology (difference in mean scores of .56 and .23,
respectively, p< .05) (see table 3).
Table 3 - Mean scores and standard deviations of the ESCA as a function of the variable Self-perception of health
status: univariate tests (F), magnitude of the experimental effect (ηp2) and power of the investigation (1-β)
Self-perception of health status
Unable to look after
themselves, need help
from others
(n = 46)
Ability to take care of
oneself despite the
pathology
(n = 220)
Healthy, able to
care for itself
(n = 134)
Total
(N = 400)
M
DP
M
DP
M
DP
M
DP
F
(2, 397)
ηp2
1-β
ESCA (global)
2.95
.44
3.21
.44
3.25
.49
3.19
.46
Initiative and responsibility
3.22
.59
3.35
.55
3.32
.60
3.32
.57
1.02
.005
.228
Self-concept
3.34
.53
3.65
.34
3.58
.42
3.59
.40
11.63***
.055
.994
Knowledge and
information seeking
2.54
.88
2.92
.86
3.07
.80
2.93
.86
6.78**
.033
.918
Passivity (inverted)
2.16
.70
2.49
.85
2.71
.87
2.52
.86
8.00**
.039
.955
* p < .05 **p < .01
Pensar Enfermagem / v.27 n.01 / agosto 2023 | 77
DOI: 10.56732/pensarenf.v27i1.262
Artigo
Discussion
When identifying variables that interfere with the Self-
Care Capacity of elderly people living at home, we found
no statistically significant gender differences, which is in
line with the results identified in Turkish elderly people5
and Chinese elderly people.12
In relation to age, Initiative and responsibility tends to
increase with age, whereas the opposite is true for
Knowledge and information search. These results may be
related to the intentionality assigned by the elderly person
to search for information, since, according to Orem,4,16
concern for oneself, motivation and hierarchy of values
are key aspects to engage in self-care actions. On the
other hand, since perception, memory and learning skills
are considered to be essential for self-care actions,16 the
biological losses which become progressive with age may
be the basis for lower levels in the Knowledge and
information search domain at older ages.
We also identify an influence of the education level in the
domains Self-concept, Initiative and Responsibility, as well
as in the Knowledge and Information-seeking domain.
Overall, we found that a progressive increase in education
level is associated with an increase in the level of
Knowledge and information seeking. These results are
in line with the findings of other studies which reveal: a
low level of education accompanies an insufficient
knowledge about the pathology and treatment12,17 and a
lower capacity to engage in self-care actions.5
Although it is important to mobilize the dimension of
skills development throughout life, in reality, elderly
people with low education may have greater difficulty in
accessing information related to their health and health
care, as well as, less ability to understand and manage
information that allows them to make decisions related to
their health. Although a vast amount of information may
be available to the public from different formats and
sources of information, many people may have
difficulty interpreting and applying it, which may
contribute to greater complexity when putting good
health practices in place, despite the information made
available.18 Another factor that may be associated to this
problem is the low degree of health literacy of the
elderly population in Portugal, which may condition the
ability to obtain and apply relevant health
information19,20,24 or the management of pathology
situations.20,21,24
When this situation is associated with the self-perception
of inability to care for oneself, lower levels of self-
concept are found, which may be related to the impact of
dependence on the person's identity. Some authors state
that certain pathology situations in which the person
loses control over its own routines cause profound
changes in self-concept.22,23
In view of these results, which are relevant for
understanding care planning strategies and are aligned
with the guidelines of the Orem Mode,l4,16 as well as the
reasoning structure proposed by the author, we suggest
the development of interventions that allow for a follow-
up leading to the integration of information in the
person's self-care, by mobilizing the guidance inherent to
the support and education system for self-care proposed
by the author.3,16
Conclusions
As nurses, we should consider multiple strategies so
that people are able to access, understand, interpret
and integrate the content of the information that allows
them to take care of themselves, given that, in elderly
people, with lower levels of education and with the
perception of being unable to take care of themselves,
lower scores were found in the Knowledge and
information search domain.
In situations of disability, the promotion of self-concept
also emerges as one of the relevant dimensions for self-
care capacity. So this should be a dimension to be
included in care planning.
Considering that this study only includes elderly people
living at home, further studies including hospitalisation
settings of different types are suggested. An analysis of
other variables based on the basic conditioning factors
set out by Dorothea Orem4 in her Nursing Self-Care
Deficit Theory would contribute to a broader
understanding of the issue.
Authors’ contributions
FC: Study conception and design; Data collection; Data
analysis and interpretation; Statistical analysis; Manuscript
writing.
MRP: Collaboration in statistical analysis; Writing of the
manuscript.
MV: Conception and design of the study; Data analysis and
interpretation.
Conflicts of interest
The Authors declares that there is no conflict of interest’.
Funding
Financing: The English translation of this work was
financed by national funds, through FCT – Foundation for
Science and Technology, I.P., under the project nº
UID/CED/04748/2020 (CIEQV).
References
1. Galvão A, Pereira F, Silva A. Promoção do autocuidado
no envelhecimento gratificante. In: Galvão A. Literacia
em Saúde e Autocuidados: Evidências que Projetam a
Prática Clínica. Algés: Euromédice; 2021. p. 211-221.
2. Nações Unidas. Centro regional de informação para a
Europa Ocidental – Envelhecimento [Internet]. ONU;
2023 [cited 2023 April 23] Available from:
https://unric.org/pt/envelhecimento/
78 | Cunha, F.
Quantitative Original Article
3. Instituto Nacional Estatística. Estimativas de
População residente em Portugal. 2020. INE; 2021.
4. Orem D. Nursing: concepts of practice. 6ª edition. St.
Louis: Mosby; 2001. 385.
5. Yanardağ MZ, Özer Ö, Özmen S. Investigating Self-
Care Agency and Well-Being of Elderly People. Soc
Work Public Health [internet]. 2021 May 19;36(4):496-
508. doi: 10.1080/19371918.2021.1915908.
6. Du M, Kong H, Ran L, Ran Y, Bai L, Du Y, Guan H,
Dong Y, Zhao Y. Associations among health-
promoting lifestyle, self-care agency and health-related
quality of life in Bai older adults with hypertension in
Yunnan China. BMC Geriatr. 2022 Dec 7:22(1):942.
doi: 10.1186/s12877-022-03608-0
7. Liu Y, Xue L, Xue H, Hou P. Health literacy, self-care
agency, health status and social support among elderly
Chinese nursing home residents. Health Education
Journal [Internet]. 2018. 77(3): 303-311. Available
from: https://doi.org/10.1177/0017896917739777
8. Tanimura C, Matsumoto H, Yoshimura J, Tokushima
Y, Yamamoto Y, Fujihara Y, Miyoshi M, Hagino H. A
Path Model Analysis of the Causal Relationship
between Self-care Agency and Healthy Behavior in
Community-dwelling Older People from the GAINA
Study. Yonago Acta Med. 2019 Mar 28:62(1):137-145.
doi: 10.33160/yam.2019.03.019
9. Alhambra-Borrás T, Durá-Ferrandis E, Garcés-Ferrer
J, Sánchez-García J. The Appraisal of Self-Care Agency
Scale - Revised (ASA-R): Adaptation and Validation in
a Sample of Spanish Older Adults. Span J Psychol. 2017
Oct 23:20: E48. doi: 10.1017/sjp.2017.52
10. Guo L, Zauszniewski JA, Ding X, Zhang L, Gao H,
Guo Q, Liu K. The Appraisal of Self-Care Agency
Scale-Revised (ASAS-R): Reliability and Validity
Among Older Chinese People. West J Nurs Res. 2017
Nov 39(11):1459-1476. doi:
10.1177/0193945916672821
11. OMS (2015). Relatório mundial de envelhecimento e
saúde. Resumo, OMS
12. Hu J, Gruber KJ, Liu H, Zhao H, Garcia AA. Diabetes
knowledge among older adults with diabetes in Beijing,
China. J Clin Nurs [internet]. 2013 Jan;22(1-2):51-60.
doi: 10.1111/j.1365-2702.2012.04273.
13. Kearney BY, Fleischer BJ. Development of an
instrument to measure exercise of self-care agency. Res
Nurs Health [internet]. 1979 Mar;2(1):25-34. doi:
10.1002/nur.4770020105.
14. Riesch SK, Hauck MR. The exercise of self-care agency:
an analysis of construct and discriminant validity. Res
Nurs Health [internet]. 1988 Aug;11(4):245-55. doi:
10.1002/nur.4770110406
15. Marôco, J. Análise de equações estruturais:
Fundamentos teóricos, msoftware e aplicações. Pêro
Pinheiro: ReportNumber; 2014. 1013.
16. Taylor S, Renpenning K. Self-care science, nursing
theory, and evidence-based practice. Springer
publishing company. New York; 2011. 256.
17. Borba AK, Arruda IK, Marques AP, Leal MC, Diniz
AD. Knowledge and attitude about diabetes self-care of
older adults in primary health care. Cien Saude Colet
[internet]. 2019 Jan;24(1):125-136. doi: 10.1590/1413-
81232018241.35052016
18. Carvalho C, Santos P, Pereira J. Literacia em saúde.
Volume I. Porto: Escola Superior de Saúde do Porto.
Politécnico do Porto. 2020. 23.
19. Serrão C, Veiga S, Ribeiro G. Literacia em saúde: um
desafio na e para a terceira idade. Projeto de literacia em
saúde. Portugal: Tipografia Lessa; 2014. 77.
20. Luyckx K, Rassart J, Aujoulat I, Goubert L, Weets I.
Self-esteem and illness self-concept in emerging adults
with Type 1 diabetes: Long-term associations with
problem areas in diabetes. J Health Psychol
[internet].2016 Apr;21(4):540-9, doi:
10.1177/1359105314531467.
21. Jacobs RJ, Ownby RL, Acevedo A, Waldrop-Valverde
D. A qualitative study examining health literacy and
chronic illness self-management in Hispanic and non-
Hispanic older adults. J Multidiscip Healthc [internet].
2017 Apr [cited 2022 Feb 19]; 20:10:167-177. Available
from: https://doi.org/10.2147/JMDH.S135370
22. Medina, D. Literacia em Saúde: Um estudo sobre a
população idosa portuguesa. [dissertation on the
internet]. Lisboa (Portugal): Faculdade de Ciências
Humanas e Sociais da Universidade Fernando Pessoa;
2019 [cited 2023 jan 23]. 70 p. Available
from: http://hdl.handle.net/10284/7456
23. Townsend, A., Wyke, S., Hunt, K. Self-managing and
Managing Self: Practical and Moral Dilemmas in
Accounts of Living with Chronic Illness, Chronic Illn.
2006 Sep;2(3):185-94. doi:
10.1177/17423953060020031301.
24. Arriaga MT, Santos B, Silva A, Mata F, Chaves N,
Freitas G. Plano de Ação para a literacia em saúde 2019-
2021. Lisboa, Ministério da Saúde-Direção-Geral da
Saúde; 2018. 26.