Sexuality in old age: knowledge/attitude of nurses of Family Health Strategy

ABSTRACT

Objective  To evaluate the knowledge and attitudes of Family Health Strategy nurses regarding sexuality in old age.

Method  Cross-sectional, exploratory, descriptive, quantitative study with nurses of the Family Health Strategy of the city of Sobral-CE. The instruments used were a socio-demographic and professional questionnaire and the Aging Sexual Knowledge and Attitudes Scale, Brazilian version. Data were processed in GraphPad Prism 5^®, and the significance level was set at p<0.05.

Results  The participants were 56 nurses, most of them female, young adults, who reported they were able to provide orientations about sexuality. The mean score in the knowledge dimension was 29.95 (SD=2.21), in a range of 20 to 60; the mean score in the attitude dimension was 27.14 (SD=2.19), in a range of eight to 40. Participants who declared receiving permanent health education and conducting health education on sexuality presented a significantly favorable knowledge, but no statistically significant attitude.

Conclusion  Nurses have adequate knowledge about sexuality in old age, but still present conservative attitudes. Investing in processes of continuing health education can improve the knowledge and practice of nurses.

Older Adult; Sexuality; Aging; Geriatric Nursing; Attitude of Health Professionals; Family Health Strategy

RESUMO

Objetivo  Avaliar o conhecimento e a atitude dos enfermeiros da Estratégia Saúde da Família sobre sexualidade na velhice.

Método  Estudo transversal, exploratório-descritivo, de abordagem quantitativa, com enfermeiros da Estratégia Saúde da Família do município de Sobral-CE. Utilizou-se de questionário sociodemográfico e profissional e da Aging Sexual Knowledge And Attitudes Scale , versão brasileira. Os dados foram processados no GraphPad Prism 5^®, e estabelecido nível de significância p<0,05.

Resultados  Participaram 56 enfermeiros, a maioria do sexo feminino, jovens adultas, que se autodeclaram saber orientar sobre sexualidade. A média dos escores do conhecimento foi de 29,95 (DP=2,21), em uma variação de 20 a 60; já para a atitude, a média foi de 27,14 (DP=2,19) na escala, que varia de oito a 40. Os participantes que declararam receber educação permanente em saúde e realizar educação em saúde sobre sexualidade detêm um conhecimento significativamente favorável, mas não foi encontrada atitude significante.

Conclusão  Os enfermeiros possuem conhecimento adequado sobre a sexualidade na velhice, mas difundem ainda atitudes conservadoras. Investir em processos de educação permanente em saúde pode melhorar o saber e fazer dos enfermeiros.

Idoso; Sexualidade; Envelhecimento; Enfermagem Geriátrica; Atitude do Pessoal de Saúde; Estratégia Saúde da Família

RESUMEN

Objetivo  Evaluar el conocimiento y la actitud de enfermeros de la Estrategia Salud de la Familia acerca de la sexualidad en la vejez.

Método  Estudio transversal, exploratorio y descriptivo, de abordaje cuantitativo, con enfermeros de la Estrategia Salud de la Familia del municipio de Sobral-CE. Se utilizó cuestionario sociodemográfico y profesional y la Aging Sexual Knowledge And Attitudes Scale, versión brasileña. Los datos fueron procesados en el GraphPad Prism 5^®, y fue establecido nivel de significación p<0,05.

Resultados  Participaron 56 enfermeros, la mayoría del sexo femenino, jóvenes adultas, quienes se autodeclararon saber orientar acerca de la sexualidad. El promedio de los scores del conocimiento fue de 29,95 (DP=2,21), en una variación de 20 a 60; ya para la actitud, el promedio fue de 27,14 (DP=2,19) en la escala, que varía de ocho a 40. Los participantes que manifestaron recibir educación permanente en salud y realizar educación sanitaria acerca de la sexualidad detienen un conocimiento significativamente favorable, pero no fue encontrada actitud significativa.

Conclusión  Los enfermeros tienen conocimiento adecuado sobre sexualidad en la vejez, pero todavía difunden actitudes conservadoras. Invertir en procesos de educación permanente en salud puede mejorar el saber y el hacer de los enfermeros.

Anciano; Sexualidad; Envejecimiento; Enfermería Geriátrica; Actitud del Personal de Salud; Estrategia de Salud Familiar

INTRODUCTION

The production of knowledge about sexuality in old age has increased in the last decade, given the urgent need to know more about this subject in order to improve the quality of life of older adults⁽¹⁾. However, there are still gaps in the way health professionals deal with this issue.

Sexuality is seen as an essential component of human existence that varies according to the social, cultural and religious context. “It is vital to every human being and is related to our needs for pleasure, reproduction, love, and others, which are formed by several biological, psychological, social and cultural factors transmitted from generation to generation”⁽²⁾.

Sexuality transcends the body, the physical contact; it is a combination of pleasures: harmony in the relationship, affection, cultural and social aspects. Sexuality is present in the different life stages of men and women, including young people, adults and older adults, and it must be addressed in different ways at each stage⁽³⁾.

There are still prejudice and myths regarding sexuality in old age. The belief that sexuality is restricted to young people contributes to the idea that sexuality in old age is an unusual and immoral practice⁽³⁾.

The aging process does not preclude older adults from exercising their sexuality. However, older adults are seen by society as asexual beings, who rarely exercise their sexuality. Therefore, health professionals are usually inattentive to this issue, increasing the vulnerability of this population⁽⁴⁾.

The Ministry of Health (MS) reinforces the importance of addressing sexuality in older adults, not only because of population ageing and the increased rate of sexually transmitted infections (STIs) among individuals over 60 years of age, but also because it is a fundamental aspect for the quality of life of these people⁽⁵⁾.

Older adults who can overcome possible aging-related barriers and experience a satisfying sexuality are those who receive sympathetic care from health professionals, who provide information on the events particular to old age and give more attention to doubts and insecurities⁽⁴⁾.

Nursing professionals must be attentive and prepared to provide the necessary support to older adults regarding the intense changes related to their bodies and other biological factors that interfere with sexuality. Health professionals must be free from prejudice, and it is essential that they do not treat this population as degenerating beings. “Therefore, they must create situations that promote self-esteem, speak directly about the subject and respond to all questions, without mincing words or showing embarrassment, helping these patient’s biopsychosocial well-being”⁽⁶⁾.

Based on experiences in the Family Health Strategy (FHS), it is possible to say that these professionals have a central role in promoting the health of older adults. The longitudinal contact with the primary care nurse promotes a strong relationship, based on mutual trust, which can facilitate and stimulate the expression of intimate needs, such as those related to sexuality.

The knowledge and attitudes of nurses in the FHS regarding sexuality in old age is still little explored. Understanding these demands can help in the analysis of actions and behaviors related to the promotion of sexuality of older adults.

This study is considered significant for nursing professionals, because it can stimulate critical reflection about the care they provide to this population, identifying their knowledge and their attitudes regarding the approach to sexuality in old age, and promoting a more comprehensive care.

Thus, the objective of this study is to evaluate the knowledge and attitudes of Family Health Strategy nurses regarding sexuality in old age.

METHOD

TYPE OF STUDY

This is a cross-sectional, exploratory, descriptive, quantitative study.

SCENARIO

The study was conducted between September and October 2016, in the Basic Care Service in the city of Sobral, in the State of Ceará (CE) in Brazil.

The FHS of Sobral is organized in macro areas. The territory is composed of 63 teams, with 21 Basic Health Units (BHUs) in the urban area and 23 BHUs and three annexes in the rural area. A total of 127 nurses work in the FHS, of whom 47 are nurse managers and 80 are nurse practitioners. In the urban area, there are 21 nurse managers and 67 nurse practitioners. In the rural area, there are 39 nurses, of whom 13 are managers.

SELECTION CRITERIA

Inclusion criteria for participation in the study were: nurse practitioners in the FHS, working in the urban area of the city of Sobral-CE, with a minimum of 3 months of professional activity. The exclusion criterion was: nurses who were absent (on medical leave or on vacation) during the study period.

The sample was composed by 56 nurse practitioners from the FHS, who work in the urban area of the city of Sobral-CE.

DATA COLLECTION

The data collection began by contacting the manager of the BHUs, in order to identify the number of professionals in each service and proceed with the individual approach to the possible participants in the interval of their work activities. The participants were oriented about the objectives of the research and signed the Informed Consent Term. After acceptance, the data collection instruments were presented, and the period of 7 days was established for returning the filled questionnaires.

Two printed self-administered instruments were used. The first one was a questionnaire containing socio-demographic and professional information (age, BHU of work,, time since graduation and time working in the FHS, specialization in geriatrics or gerontology, continuing health education (CHE) on health of older adults, nursing consultations addressing sexuality in old age, health education on sexuality with older adults group). The second instruments was the ASKAS – Aging Sexual Attitudes and Knowledge Scale, in its Brazilian version⁽⁷⁾. This scale was created in the United States by White⁽⁸⁾in 1982, with the purpose of measuring knowledge and attitudes about sexuality in old age. The scale was translated, adapted and validated for Brazil by Viana et al^(7,9), who obtained a Cronbach’s alpha of 87 in the attitude dimension 93 in the knowledge dimension, demonstrating a high internal consistency.

“The Brazilian version of ASKAS⁽¹⁰⁾is composed of 20 questions in the knowledge dimension and 8 in the attitudes dimension. In the first part, a low score indicates advanced knowledge about sexuality in old age. The alternatives of the items are: true= 1 point, false= 2 points and I don’t know= 3 points. The scores vary from 20 to 60 points. In the second part of scale, which assesses attitudes, low scores indicate more favorable attitudes regarding the sexuality of the older adult. The second part consists of a 5-point Likert scale (strongly disagree= 1 point; disagree in part = 2 points; neither agree nor disagree= 3 points; agree in part= 4 points and strongly agree = 5 points). The scores vary from 8 to 40”.

DATA ANALYSIS AND TREATMENT

Data was compiled in spreadsheets in Microsoft Excel 2010 and processed in the software Graphpad Prism 5^®. The distribution of the variables Knowledge and Attitude of the ASKAS was analyzed through non-parametric data. For variables with two categories, the T-test was applied, followed by the Mann-Whitney test. When the number of categories was greater than or equal to three (3), the Kruskal-Wallis test was applied. The level of significance was set at p <0.05, and the data were organized into tables and analyzed descriptively, according to specialized literature on the subject.

ETHICAL ASPECTS

The research respected the bioethical principles established by Resolution no. 466/12 of the National Health Council, which regulates research involving human beings. Participants were invited after explaining the purpose of the study and signing the Informed Consent Term. The study was approved by the Research Ethics Committee of the Universidade Estadual Vale do Acaraú, under protocol no. 1.734.988, in September 19^th, 2016.

RESULTS

The sociodemographic and professional characteristics of the participants of the study are shown in Table 1 . There was a considerable number of female nurses, in a proportion of 8.33 women for each man. The mean age of participants was 37.75 years. The time elapsed since the graduation of these professionals was between 3 months and 5 years for 21 (37.50%) of the nurses, while 18 (32.14%) nurses had been graduated for more than 15 years. The majority of the participants, a total of 55 (98.21%) nurses, did not have a specialization in geriatrics or gerontology. However, 33 (58.93%) had participated in continuing education on the subject. A total of 53 (94.60%) nurses reported they were able to provide orientations about sexuality, 34 (60.71%) addressed the subject in the nursing consultations , but only 14 (25.00%) carried out health education actions with groups of older adults.

Table 1
– Socio-demographic and professional profile of nurses in the FHS – Sobral, CE, Brazil, 2016.

Variable	N	%
Gender
Female	50	89.29
Male	6	10.71
Age (years)
23 – 28	14	25.00
29 – 34	15	26.79
35 – 40	7	12.50
41 – 46	5	8.93
47 – 52	5	8.93
53 – 58	7	12.50
59 – 64	2	3.57
65 – 70	1	1.79
Time working in the FHS
≤1 – 5 years	29	51.79
6 – 10 years	9	16.07
11 – 15 years	6	10.71
>15 years	12	21.43
Specialization degree in geriatrics or gerontology
Yes	1	1.79
No	55	98.21
Other academic titles
None	13	23.21
Specialization	43	76.79
Received CHE on Older Adult’s Health
Yes	23	41.07
No	33	58.93
Addresses the subject of sexuality with older adults in the nursing consultation
Yes	34	60.71
No	22	39.29
Can provide orientations to the older adults when they talk/ask about sexuality
Yes	53	94.64
No	3	5.36
Carries out health education actions regarding sexuality with groups of older adults
Yes	14	25.00
No	42	75.00

• Note: (N=56).

In the knowledge dimension of ASKAS, it was possible to observe greater difficulty in the statements 6, 8, 15 and 18. In statement number 6, “Most older females are sexually unresponsive”, 51.79% of professionals said it was true, 33.93% said it was false, and 14.29% did not know. In statement 8, “Basically, changes with advanced age (65+) in sexuality involve a slowing of response time rather than a reduction of interest in sex”, 58.93% answered true, 17.86% false, and 23.21% did not know. In statement 15, which addresses the subject of masturbation, “Excessive masturbation may bring about an early onset of mental confusion and dementia in people over 65 years”, 8.93% believed it was true, 62.50% false, and 28.57% did not know. In statement 18, which addresses the issue of sexual impotence, “Impotence in men over 65 can be effectively treated and cured”, 55.36% answered true, 33.93 % false, and 10.71% did not know.

Regarding nurses’ attitudes about sexuality in old age, the presence of negative attitudes was mainly observed in items 23 and 26. Item 23 addresses the interest in sexuality, “The interest in sexuality of people over 65 inevitably disappears”: 46.43% totally disagreed, 35.93% disagreed in part, 3.57% neither agreed nor disagreed, 16.07% agreed in part, and none totally agreed. Item 26 addresses attitudes towards masturbation, “Masturbation is an acceptable sexual activity for men over 65 years 7.14% totally disagreed, 8.93% disagreed in part, 16.07% neither agreed nor disagreed, 28.57% agreed in part, and 39.29% totally agreed.

The data in Table 2 present the statistically significant associations between Knowledge and Attitudes regarding sexuality in old age (ASKAS) and some professional characteristics of the study participants. The mean values of the ASKAS scores were 29.95 (SD=2.21) for knowledge and 27.14 (SD=2.19) for attitude.

Table 2
– Scores of knowledge and attitude in the ASKAS, according to professional variables of the nurses in the study – Sobral, CE, Brazil, 2016.

Variables	Knowledge	p-value	Attitude	p-value
Time working
≤1 – 5 years	29.67 ± 3.60	0.878	27.08 ± 4.32	0.352
6 – 10 years	29.80 ± 5.07		27.40 ± 1.07
11 – 15 years	30.00 ± 5.32		26.42 ± 1.61
>15 years	30.90 ± 4.45		27.91 ± 3.30
Specialization degree
No	28.15 ± 2.94	0.196	25.85 ± 5.61	0.516
Yes	30.02 ± 4.32		27.58 ± 2.17
Received continuing education on Older Adult’s Health
No	30.45 ± 4.07	0.031*	27.45 ± 1.73	0.729
Yes	28.61 ± 4.22		27.22 ± 5.23
Addresses sexuality in the nursing consultations
No	30.82 ± 4.42	0.100	27.27 ± 1.66	0.513
Yes	29.09 ± 3.88		27.12 ± 4.07
Carries out health education actions regarding sexuality with groups of older adults
No	30.45 ± 4.54	0.027*	27.38 ± 3.72	0.208
Yes	27.43 ± 1.65		27.07 ± 1.20
ASKAS (population studies)
p-value (0.0038)*	29.77 ± 4.15		27.18 ± 3.32
ASKAS (population studied per territory)
p-value (0.0003)*	29.95 ± 2.21		27.14 ± 2.19

• In the values expressed as mean ± SD, the Kruskal-Wallis test was used for the variable (time working) and the Mann-Whitney test for the variables time working, specialization, continuing education, addresses sexuality, carries out activities, knowledge versus attitude per nurse and knowledge versus attitude per territory, *level of significance p < 0.05.

Nurses who reported that they had received continuing health education and carried out education actions on sexuality with groups of older adults had a level of knowledge that was significantly more favorable to the sexuality of the older adults, but with no significance in attitude.

DISCUSSION

The results found in this study regarding the socio-demographic and professional variables of the FHS nurses corroborate evidence from other investigations with this professional profile⁽¹¹⁾. A predominance of females was observed, reinforcing the prevalence of this public in the area of nursing⁽¹²⁾.

Regarding the age of the nurses in the study, there is a higher number of young adults (26.79%), which is similar to another study⁽¹³⁾. Younger professionals are more likely to keep up with the current revolution in the subject of sexuality in old age and, therefore, may adopt knowledge and attitudes more favorable to the sexuality of older adults. However, a limiting factor to guide the actions of their professional practice would be the shorter time of training.

It was noticed that the majority of the nurses (76.79%) had a lato sensu graduation. Their continuity of studies shows commitment and interest in acquiring and updating knowledge, as well as the easy and diverse options of professional qualification in present time⁽¹⁴⁾. However, there were only few (1.79%) professionals with specialization in geriatrics or gerontology, and none with master or doctorate degree. Another study concluded that there is a need to further study this topic, since Geriatrics/Gerontology is still little seen and studied in Brazil⁽¹⁵⁾. Given the population ageing, there is a need to include this discipline in undergraduate and graduate courses, as well as to strengthen the study of this subject in research groups, so that future health workers are duly qualified to provide care for this public⁽¹⁶⁾.

Most of the nurses (94.64%) reported being able to orient an older adult with questions about their sexuality, and 60.71% said to approach the subject in their nursing consultations. This demonstrates that these professionals have security and mastery over the subject, which makes them more comfortable to apply their knowledge to their practices, favoring the empowerment of older adults regarding their sexuality and contributing to self-perception of risk and the need to adopt safe behaviors.

On the other hand, it was verified that 75% of the nurses did not carry out health education activities on sexuality with groups of older adults. In this sense, health professionals must find innovative practices to address this subject, such as the active learning methodology, which can help the individual to become more critical and reflexive in solving problems and strengthen knowledge through experiences⁽¹⁷⁾. An intervention study with a group of older adults showed that the level of knowledge, attitude and practice about sexuality in old age is still deficient, and that the use of health education in a collective way contributed to a positive change in the perception of the older adults about their aging process and sexuality⁽¹⁸⁾.

In this study, the individuals presented a mean score of 29.95 in the knowledge dimension of the ASKAS Brazilian version, which varies from 20 to 60. According to researchers that used the ASKAS in its Dutch version, this way of scoring favors a clearer and more unequivocal perception of the real knowledge possessed by the participants⁽¹⁹⁾.

Thus, the data indicates that the FHS nurses who participated in this study have a good knowledge about sexuality in old age. An international study that investigated the knowledge and attitude of the nursing staff of a long-term institution for the elderly showed limited knowledge⁽¹⁹⁾. A national study carried out with university students from the area of health in the state of Minas Gerais evaluated the knowledge of future health professionals about sexuality in old age and found a mean score of 29.9 for nursing students⁽²⁰⁾, a result similar to that of investigation.

In statements 6 and 8 of the ASKAS, which the majority of participants answered incorrectly – 51.79% and 58.93%, respectively –, the answers may be influenced by cultural aspects that still carry the myth that older adults have no interest in sex, corroborating what the media disseminates about sexuality by associating it only to “young bodies”⁽²¹⁾. Studies with older adults address the issue of their slower response in sexuality, a common change in old age^(5,12). However, slow response is not associated with reduction of interest in sex, as sex and pleasure may be as enjoyable as in youth.

It was observed that 28.75% of the nurses did not know how to respond to statement 15, which addresses masturbation. That is, a significant portion of the participants do not recognize masturbation as a health maintenance practice, as also revealed in a study conducted in the Federal District – Brasília - using ASKAS with older adults with STIs at a health service⁽²¹⁾.

The nurses in this study had a mean score of 27.14 in the attitude dimension of the ASKAS Brazilian version, which ranges from 8 to 40. However, there was no statistical association between the socio-demographic and professional profile and the attitude of these professionals. This is reinforced in an international study that found a discrepancy between knowledge and attitude: the greater the knowledge about sexuality, the less liberal the attitude on the subject⁽¹⁷⁾.

These data allow us to state that the attitude of nurses regarding the sexuality of older adults should be improved, since these professionals still have conservative attitudes about the subject. In this sense, a study⁽²²⁾that aimed “to analyze how the nursing team acts in issues concerning the sexuality of older adults revealed that representations of sexuality are within the discourse of professionals, who try to censor and control others”. Moreover, the difficulty in approaching the topic of sexuality due to embarrassment or because of personal beliefs demonstrates gaps in academic and professional training.

Literature shows that nursing care for older adults in the FHS is restricted to activities related to routine medications, vaccination and risk/violence, with no individual consultations to address the doubts of these patients about sexuality⁽²³⁾.

In view of the above, nursing training processes regarding sexuality in old age need to combine theory and practice, valuing the social and cultural aspects of the population assisted, which would be of fundamental value for a health care with higher quality.

An important discovery of this study was the statistical significance of Continuing Health Education (CHE) and of health education actions on sexuality with groups of older adults, which presented p-values lower than 0.05. The findings reveal that nurses who participated in continuing education and carried out health education actions addressing the theme of sexuality are those with the best score in the knowledge dimension.

“Thus, CHE is essential because it contributes to training and, consequently, strengthens the Unified Health System (SUS) and the continuous development of workers and health institutions, contributes to the management of health systems and, in addition, enhances health policies such as reception, humanization and extended clinical practice”⁽²⁴⁾.

A study carried out in Santa Catarina with nurses from the FHS addressed the issue of older adult care and showed that these professionals should extend their view to the other needs of these patients, among which is sexuality⁽²⁵⁾. Therefore, CHE actions can contribute to transform existing challenges and meet the new demands in a natural process of care of older adults.

CHE practices bring benefits to health professionals by providing improvement, knowledge, competence and updates on various topics, according to a study carried out with nurses from the FHS in the city of Sobral⁽²⁶⁾.

Despite the challenge posed by new concepts and new practices regarding sexuality in old age, investment in CHE processes is probably the safest alternative for helping professionals to adopt favorable and flexible knowledge/attitudes on issues related to promotion of the sexual health of older adults.

The limitations of the study were its scenario restricted to one city and its small sample size. Thus, new research should be conducted to broaden the sample and the scenario and contribute to the discussion of the issue in Nursing, considering that nurses should provide care for older adults taking into account all human needs, among which is sexuality. In addition, the complexities of the different contexts experienced by FHS nurses in primary care indicate the need for studies that may advance in the analysis of other realities.

CONCLUSION

The study demonstrated that the majority of the nurses have knowledge about sexuality in old age but still present conservative attitudes about it. Therefore, it is necessary to emphasize the way professionals perceive, conceptualize, and add fear, prejudice, shame and false ideologies on the subject. These issues should be seen as barriers and should generate health education processes in the collective spaces present in the Family Health Strategy, such as the chatting circles and groups.

The results of this study also show the importance and necessity of implementing continuing education strategies within the scope of the Family Health Strategy, with the objective of improving the knowledge and practice of nurses, since those who participated in continuing education and who conducted health education on sexuality with groups of older adults obtained better scores, with statistical significance, in the knowledge dimension of the ASKAS. Thus, the results of this study may help developing policy guidelines of continuing education focused on promoting the health of older adults.

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Publication Dates

• Publication in this collection
  29 July 2019
• Date of issue
  2019

History

• Received
  26 May 2018
• Accepted
  26 Nov 2018