Ageing and conditions for active and healthy living: perceptions of older adults across diverse socio-environmental contexts in a Brazilian municipality

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Despite normative advances, persistent barriers continue to limit the effectiveness of strategies aimed at ensuring the rights of older people. Incorporating participatory approaches that value older adults’ perceptions, expectations and demands is therefore essential, particularly in territories marked by socio-spatial inequalities that shape living conditions and ageing experiences. This study aimed to analyse older adults’ perceptions of the ageing process and the conditions required for a healthy and active life across different socio-environmental contexts in a Brazilian municipality. Methods This qualitative, descriptive and exploratory study was grounded in the Bioecological Theory of Human Development. It was conducted in Santo André, São Paulo, across two contrasting territories: a central urban area and a peripheral area with low urban connectivity. A total of 44 individuals aged 60 years and over participated (mean age 71.0 years, SD 6.4; range 60–85), recruited with support from the Family Health Strategy. Data were collected between 21 and 30 June 2022 using the Nominal Group Technique, including discussion and prioritisation of elements related to ageing and healthy living, as well as perceived barriers and facilitators. Data were transcribed, thematically organised and interpreted in light of the theoretical framework. Results Five themes emerged: (1) body, immediate relationships and well-being; (2) interactions between family, community and services; (3) institutional and social structures; (4) cultural and symbolic values; and (5) temporal and historical dimensions of ageing. Family, autonomy, self-care, spirituality and social support were central across both contexts. Territorial differences were evident: in the urban area, ageing was associated with adaptation and access to services despite structural barriers, whereas in the low-connectivity area, perceptions emphasised functional decline, isolation, limited transport and reduced state presence, alongside strong reliance on family and community networks. Conclusion Perceptions of ageing are shaped by interactions between individual, social, territorial and institutional factors. The findings highlight the need for territorially sensitive, intersectoral actions that address inequalities and promote autonomy, participation and dignity in ageing. Ageing Older people Healthy ageing Public policy Social determinants of health Bioecological theory Territorial inequalities Qualitative research Figures Figure 1 Background Population ageing in Brazil represents a continuous, accelerated, and irreversible process, marked by profound demographic and social transformations. Official projections indicate that by 2030 the number of older adults in Brazil will exceed, in absolute terms, the population of children and adolescents, redefining demands and priorities for both the State and society [ 1 ]. This scenario imposes structural challenges for ensuring dignified living conditions, requiring public policies capable of responding, in an articulated and sustainable manner, to the multiple needs of this age group. Promoting dignified ageing goes beyond increasing life expectancy and requires actions that ensure well-being, autonomy, social participation and inclusion [ 2 , 3 ]. Public policies aimed at older people must therefore adopt a multidimensional perspective, integrating health, social assistance, mobility, culture, leisure, and opportunities for community interaction, while being guided by principles of equity and by recognition of the diversity that characterises ageing trajectories [ 4 ]. Despite normative advances in Brazil, such as the Statute of Older Persons [ 5 ] and the National Policy for Older Persons [ 6 ], obstacles persist that limit their effectiveness. Among these are intersectoral fragmentation, discontinuity of actions, and the gap between legal guidelines and the realities experienced in local territories. In this context, strengthening policies requires not only technical consistency but also participatory processes that value the perceptions, expectations, and demands of older people themselves [ 7 ]. Understanding ageing cannot be restricted to biomedical or socioeconomic indicators. Subjective dimensions, such as self-perceived health, social recognition, sense of belonging, preservation of autonomy, and opportunities for participation, play a decisive role in shaping the experience of ageing and quality of life. Considering these experiences is essential for the development of policies that are more sensitive, human-centred, and adapted to the complexities of different sociocultural contexts [ 3 , 8 – 10 ]. Listening to older people through qualified engagement has increasingly been recognised as a key element for guiding care strategies and social protection policies, enabling responses that are more coherent with their lived experiences, meanings, and concrete needs [ 11 , 12 ]. Recent studies reinforce this perspective. Research by Donatelli et al. [ 13 ], conducted in a central urban area and in a low-connectivity peripheral area in Santo André, São Paulo, Brazil, highlighted the importance of incorporating older adults’ perspectives into social programmes. In light of the Bioecological Theory of Human Development, such perceptions are understood as the result of continuous interactions between individuals and multiple environments, from immediate contexts to broader sociopolitical structures, also incorporating the temporal dimension [ 14 , 15 ]. In addition, the meanings attributed by older people to their experiences constitute a fundamental basis for developing more welcoming and person-centred practices [ 16 ]. This theory significantly expands the analysis of interactions across multiple levels of the social context through the Process–Person–Context–Time (PPCT) model [ 17 ]. Investigating how this population perceives the ageing process therefore represents an essential step for improving strategies aimed at promoting healthy, equitable and diverse ageing. This study aimed to analyse the perceptions of older people regarding the ageing process and the conditions required for a healthy and active life, considering the interaction between the individual, their relationships, their living conditions and their experiences over time within the Brazilian municipal context. Methods This was a qualitative, descriptive, and exploratory study grounded in Bronfenbrenner’s Bioecological Theory of Human Development [ 14 , 15 ]. This framework, originally developed within the field of psychology, can be applied to understand individual perceptions within a systemic context, broadening the analytical perspective on individuals as active agents in processes of coping with adversity and vulnerability [ 18 ]. The study sought to systematise older people’s perceptions regarding the ageing process and the conditions required for an active and healthy life, organising them according to the levels of the microsystem, mesosystem, exosystem, macrosystem and chronosystem. The reality under investigation may be understood as complex, as it reflects a dynamic network of interactions between person, process, time and context [ 14 , 15 , 19 ]. According to Bronfenbrenner, it is necessary to adopt an analytical perspective capable of capturing the complexity of different contextual systems or levels that are in constant interaction with one another [ 19 ]. Unlike the socioecological model, which emphasises the organisation of contexts into levels, the bioecological approach enables understanding of how these levels interact through relational processes over time, highlighting the active role of older people in constructing their ageing experience [ 17 ]. This study forms part of a broader investigation previously published [ 13 ], which aimed to identify the needs and priorities of older adults in a central urban area and in a low-connectivity peripheral area in the municipality of Santo André. Data collection was conducted using the Nominal Group Technique (NGT), a structured methodological approach for group research designed to explore topics and build consensus, allowing participants themselves to collectively identify, organise, and prioritise issues with minimal interference from researchers [ 20 , 21 ]. In the present article, the data produced were reinterpreted in light of the Bioecological Theory of Human Development, with the aim of deepening the understanding of interactions between person, context, processes and time in ageing across different socio-spatial realities. The study was approved by the Research Ethics Committee of Centro Universitário FMABC (approval number 5.292.649). The research was conducted in the municipality of Santo André, located in the Metropolitan Region of São Paulo, Brazil. In 2022, the municipality had an estimated population of 748,919 inhabitants and a demographic profile characterised by population ageing, with approximately 143,717 individuals aged 60 years or older. Santo André has a Municipal Human Development Index (HDI) of 0.815 (2010), classified as very high, reflecting elevated levels of income, education and longevity [ 22 ]. Two territories with contrasting characteristics were selected: A central urban area characterised by a wide availability of public services, facilitated mobility, and high population density. An area isolated due to low urban connectivity, corresponding to the Paranapiacaba and Parque Andreense region, located southeast of the Billings Reservoir. This region is characterised by distance from the central urban area, low population density, environmental restrictions associated with watershed protection, and limited access to public services and transport. Although located within an environmentally preserved area, the region has a history of irregular occupation and population densification, coexisting with structural and institutional limitations that affect access to public policies. The central urban area was designated Group 1 (G1), while the isolated area was designated Group 2 (G2). Participants were individuals aged 60 years or older residing in the selected territories, with independent mobility and able to provide informed consent. Individuals under 60 years of age, non-residents of the selected areas, or those unable to participate fully in the proposed activities were excluded. Participants were randomly identified and invited with the support of community health workers from Family Health Strategy teams in Primary Health Care Units located in the respective territories. Data collection Between 21 and 30 June 2022, two face-to-face groups were conducted, one in each territory, facilitated by researchers from Centro Universitário FMABC, the Ribeirão Preto Medical School of the University of São Paulo, and the University of Birmingham, UK. The methodological description followed general recommendations for qualitative research, considering the absence of specific EQUATOR Network guidelines for studies based on the Nominal Group Technique. Older participants from each area met on different days and locations. The sessions began with a presentation of the study objectives and a brief discussion about conceptions of ageing. Participants were then divided into subgroups of five to seven individuals. Subgroups discussed, for approximately one hour, predefined topics: Important elements for an active and healthy life; Main perceived barriers; Main facilitators. At the end of each theme, a structured prioritisation process following the NGT methodology was conducted, in which participants individually assigned scores to the listed items. Scores were subsequently summed to determine group priorities, a stage lasting approximately 30–45 minutes per theme. Statements resulting from subgroup discussions were recorded on flipcharts and consolidated into lists. Subsequently, prioritisation was conducted through voting among participants to define the five final priorities for each topic. Discussions were audio recorded solely for documentation purposes and later fully transcribed. Analysis was conducted based on textual transcripts and field notes. The total duration of this stage was approximately three hours. Statements and priorities were analysed through thematic categorisation and interpreted in light of the Bioecological Theory of Human Development. This model allowed participants’ perceptions to be situated at different levels of influence: Microsystem (direct relationships, such as family and health professionals); Mesosystem (interactions between microsystems, such as relationships between family and health services); Exosystem (contexts that influence the individual without direct participation, such as public policies and community networks); Macrosystem (cultural values, social norms, and broader economic and political systems); Chronosystem (changes over time, both individual and sociopolitical). The comparison between G1 and G2 enabled the identification of territorial differences in perceptions of the ageing process and of the conditions that facilitate or hinder healthy and active ageing. Results A total of 44 individuals participated in the study, including 17 residents of the central urban area (G1) and 27 from the area isolated due to low urban connectivity (G2), with a predominance of women in both groups. The mean age of participants was 71.0 years (SD 6.4), ranging from 60 to 85 years,, with most participants being women aged between 65 and 79 years. Incomplete primary education was more frequent in the isolated area, whereas completion of secondary education predominated in the central urban area. Most participants lived with spouses or family members, although some lived alone, particularly women. Following Bronfenbrenner’s bioecological model, five main themes emerged: (1) body, immediate relationships and perceptions of well-being; (2) interactions between family, community and services; (3) perceptions of institutional and social structures in the lives of older people; (4) cultural and symbolic values; and (5) the temporal and historical dimension of ageing. The statements are presented in aggregated form by group (G1 – central urban area; G2 – area isolated due to low urban connectivity), preserving the collective nature of the Nominal Group Technique rather than attributing statements to individual participants. 1. Body, immediate relationships and perceptions of well-being Ageing was described by participants as a process marked by physical, emotional and social changes that require constant adaptation. Many reported bodily limitations, such as loss of strength, memory and mobility: “Age brings weakness and memory loss.” (G1). At the same time, narratives emerged that associated ageing with the accumulation of life experiences and the ability to adapt to restrictions imposed by the body: “It is a phase when some doors close, but others open. You have to learn to live with the possibilities you still have.” (G2). In this sense, physical transformations were understood both as a natural condition of life and as a stimulus for self-care, the adoption of healthy habits and recognition of one’s own limits: “You feel that your body no longer responds as before, but you need to learn to take better care of yourself.” (G1). Family coexistence emerged as a central element for maintaining well-being, providing emotional support, security and a sense of continuity: “Having my family close is what keeps me strong.” (G2). Participants also emphasised the importance of preserving autonomy and having their decisions respected: “What matters is that the family lets us decide what we want and respects our choices” (G2). Despite these positive aspects, barriers were also reported that weaken everyday experiences, including lack of social and community life, scarcity of leisure spaces and architectural barriers that limit mobility and promote isolation. Distinct reflections emerged in each territory, shaping the experience of ageing. In both areas, physical changes and the need for adaptation were recognised; however, in the isolated area there was a stronger perception of inevitable decline, whereas in the central urban area more references were made to adaptation and self-care. 2. Interactions between family, community and services Interactions between close contexts proved to be crucial for well-being. Ageing was understood as the result of integration between personal experiences, family relationships and community networks, highlighting the need for collective and institutional support. Participants’ statements revealed both resources and weaknesses. On the one hand, participation in community groups, educational programmes and collective activities was considered fundamental for strengthening social bonds and promoting active living: “Taking part in older people’s groups and having community activities really helps us not feel alone.” (G2) “Learning and practising manual, mental and occupational activities, exchanging experiences and skills, remaining active through manual, intellectual and voluntary work, maintaining life goals and routines, and participating in educational programmes and social networks.” (G1) “In this specific place (isolated area), nature, breathing fresh air, contact with animals and having gardens and plants improve our lives.” (G2) New demands also emerged, such as digital inclusion, viewed as a pathway to greater autonomy and reduced isolation: “Nowadays everything is done through mobile phones and the internet, and we need to learn.” (G1) “It would be important to have courses and support to learn how to use mobile phones and the internet.” (G2) On the other hand, participants reported barriers that hinder these interactions, including the lack of appropriate leisure spaces, insecurity in public spaces, mobility difficulties and fragile social support networks: “There is a lack of leisure options and places to meet friends here.” (G2) “It is useless to have a doctor if transport does not take us there.” (G2). “There is a lack of guidance and explanation regarding quality health services, prescriptions, examinations and consultations, transport and older people’s rights”. (G1) These findings highlight the importance of articulating family, community and service networks. When strengthened, such articulation promotes intergenerational coexistence, social participation and the development of care networks. When fragile, it reinforces isolation and limits access to dignified ageing conditions. Participants from the central urban area relied more on institutional resources, such as health services and technologies, whereas those in the isolated area placed greater emphasis on affective and environmental networks, such as contact with nature. Issues related to isolation and the need for more adequate transport were emphasised particularly in the isolated area. 3. Perceptions of social and institutional structures in the lives of older people Perceptions of public services and institutional arrangements revealed both facilitating and restrictive factors. Timely access to healthcare, adequate transport and enforcement of older people’s rights were identified as essential conditions for dignity and autonomy. In the isolated area, the absence of support from governmental bodies and services was considered a limiting factor for maintaining an active and healthy life. Participants emphasised the importance of structures and services that had previously been available in the territory, contrasting this with their current perception of abandonment. “Support provided by governmental and non-governmental agencies and other stakeholders (primary and family health units, including community health workers); well-being groups (physical activity, auriculotherapy, crafts); waste collection; family club (NGO); encouragement for the establishment of small businesses; subprefecture structure to assist with building and renovation guidance; education for young and older people.” (G2) “If there were free transport for our caregivers and faster medical care, ageing well would be much easier.” (G2). However, criticisms predominated regarding long waiting times for specialist consultations, weaknesses in primary healthcare, insufficient transport and failures in urban accessibility: “When we need a specialist doctor, we wait months to get an appointment.” (G1) “The law says we have priority, but in practice it is not quite like that.” (G1) “Poor infrastructure without pavements or walkways reduces mobility. Public transport is precarious. Streets lack signage and speed control, and roads are poorly maintained. We have difficulty walking due to reduced vision.” (G2) Urban insecurity, marked by fear of violence and lack of accessibility, emerged as a factor that restricts mobility and social life: “I am afraid to leave the house; violence has increased a lot.” (G2) Thus, this dimension proved to be critical. Participants clearly indicated that when structures and public policies function properly, they facilitate active ageing; when they fail, they reinforce vulnerabilities, increase inequalities and compromise the dignity of older people. Various obstacles were identified, assuming different configurations across the territories. In the central urban area, the most frequently reported problems included long waiting lists and delays for specialist consultations, urban insecurity, and accessibility difficulties. In the isolated area with low urban connectivity, the most common barriers were the distance to services, the scarcity of public transport, and the absence of governmental structures within the territory. Regarding needs, older adults living in the central region advocated for adapted urban infrastructure, accessible transport, digital inclusion, and intergenerational respect. In contrast, those living in the isolated area emphasised the need for a stronger presence of the State in the territory, more locally responsive public policies, and community spaces for social interaction. Despite the differences between the two contexts, the importance of state presence and effective service provision emerged as central to well-being and the preservation of autonomy. 4. Cultural and symbolic values Cultural values and social representations significantly shaped the experience of ageing. For some participants, old age was seen as a privilege and continuation of life: “Reaching this point is a blessing, a chance to live longer and keep learning.” (G1) For others, however, old age was marked by social devaluation and suffering: “In our society, old people have no value anymore; it seems like we are a burden.” (G1) “There should be more patience and attention towards older people, more help and mutual respect between young and old.” (G2) Cultural and spiritual values also emerged, including faith, patience, solidarity and intergenerational respect, which were considered essential for maintaining dignity in later life: “Having faith in God and practising gratitude.” (G2) “Nurturing spiritual life regardless of one’s faith.” (G1) These symbolic resources function as coping mechanisms in the face of physical and social limitations. At the same time, participants’ narratives revealed structural and cultural inequalities, expressed through references to financial difficulties and lack of social recognition: “Life is harder because we do not have the financial means for everything we need ; we want to live with dignity, not be treated as a burden.” (G1) “ Insufficient pensions reduce quality of life. ” (G2) Thus, the findings suggest that the barriers experienced by older adults extend beyond the individual level, being embedded in broader social structures, shaped by the extent to which rights are realised, and reinforced by exclusionary practices and ageism. 5. Recognition of the temporal and historical dimension Ageing was understood as a dynamic process characterised by gradual losses, adaptations and reinterpretations throughout life. Some participants emphasised physical and social decline associated with the passage of time: “Each year we lose a little, whether in the body or in social life.” (G2) Others highlighted the possibility of adaptation and reinvention despite limitations: “Every year we need to reinvent ourselves and find new ways to live well” (G1) Experiences accumulated throughout life influence routines, forms of care and levels of isolation. In this sense, old age was interpreted not only as a biographical phenomenon but also as a social and historical one. “Acquisition of wisdom and knowledge about life: integrating past, present and future.” (G2) “Changes that we can shape through physical and mental activity.” (G1) This temporal dimension reinforces that ageing is not static; it requires continuous adaptation to bodily transformations, social relationships and historical conditions. The chronosystem therefore highlights the processual nature of ageing and the need to articulate resources and support mechanisms capable of promoting autonomy and healthier lives over time (Fig. 1 ). The integrated analysis of the findings, guided by the bioecological model and presented in Fig. 1 , demonstrates that older adults’ perceptions of the ageing process and the factors influencing an active and healthy life vary according to the socio-spatial contexts in which they live, revealing determinants at the micro-, meso-, exo-, macro-, and chronosystem levels. While participants from the central area associated ageing with the capacity for adaptation, self-care, and access-albeit limited-to health services and urban infrastructure, those living in isolated areas emphasised the burden of physical decline, the importance of family and community networks, and the difficulties imposed by distance, inadequate transport, and the limited availability of public facilities. Protective factors, such as affective bonds, spirituality, and personal care practices, coexisted with structural barriers, including urban insecurity, mobility limitations, social isolation, and weaknesses in the health system. Despite the differences between the territories, both groups highlighted the central role of family and the desire to maintain autonomy as fundamental elements for quality of life in later life. Ensuring this autonomy was associated with the need for integrated public policies that are sensitive to territorial inequalities and to the multiple dimensions shaping the experience of ageing. Discussion The findings of this study reinforce that older adults’ perceptions of ageing and strategies aimed at promoting a healthy life are shaped by multiple factors situated at different levels of Bronfenbrenner’s bioecological model. These perceptions reveal a complex field of tensions in which subjective aspects—such as autonomy, self-care, spirituality, and family support—coexist with structural limitations related to the physical environment, access to services, and territorial inequalities. This duality, observed both in urban territories and in isolated areas, reaffirms that ageing is a dynamic process that requires constant adaptation, resilience, and meaning making, as also highlighted in international studies [ 9 , 10 ]. However, the results allow us to move beyond the subjective dimension, showing that territory acts as a structuring element of the ageing experience. Barata [ 23 ] argues that social inequalities in health are produced by unequal distributions of power, income, infrastructure, and opportunities, resulting in differentiated patterns of illness and longevity. Territory therefore emerges as a concrete expression of these structural inequalities rather than merely a backdrop. This was evident in the difficulties faced by the older population in the isolated area in accessing goods and services within their territory. According to the author, differences in access to services, transport, security, and urban facilities shape socially produced space, organising opportunities and vulnerabilities throughout the life course [ 23 ]. Recent studies have reinforced that health inequalities among older populations cannot be explained solely by individual characteristics or behavioural choices but are deeply intertwined with social and territorial determinants, such as geographical location, access to services, socioeconomic conditions, and infrastructure. For example, Rahemi et al. [ 24 ] demonstrate that differences in the use of health services among older adults are associated with social and geographical factors, including rural or urban residence, education, and income, while Chen et al. [ 25 ] show inequalities in life expectancy among older adults in urban and rural contexts. Furthermore, the World Health Organization (WHO) [ 26 ] highlights that the conditions in which people live, work and age substantially shape health outcomes, indicating that the experience of healthy ageing is influenced by individuals’ territorial position, as reflected in the perceptions of older adults in this study. Participants’ accounts indicated that, while those living in central areas tended to associate ageing with the need to adopt strategies to maintain autonomy, often expressing a more critical and proactive stance, those from low-connectivity areas more frequently linked the ageing experience to limitations imposed by the territory, revealing a degree of acceptance of the difficulties encountered. This contrast highlights how environmental factors shape the subjective experience of ageing. It also suggests that the spaces individuals inhabit may act as mediators between perceived needs, lived experiences and responses to adversity, thereby contributing to the production of intra-urban inequalities [ 27 , 28 ]. The work of Diez Roux and Mair [ 29 ] is also central to interpreting these findings. In discussing “contextual effects”, the authors demonstrate that neighbourhoods and territories influence health independently of individual characteristics through institutional availability, social interactions, collective norms, and environmental exposures. In this sense, even older adults with similar socioeconomic profiles experience ageing differently depending on where they live. Territory therefore produces its own effects on autonomy, social participation, and perceptions of quality of life. Within the microsystem, the centrality of family, faith, community interaction, and everyday self-care practices was evident among participants, consistent with studies showing that social and family support represent one of the most important pillars for subjective well-being and protection against feelings of loneliness and vulnerability [ 30 , 31 , 32 ]. These elements were valued in both the central and isolated areas. However, in isolated areas such ties assume an even more strategic role, partially compensating for the reduced institutional presence of the State [ 33 ]. The mesosystem revealed important differences in the articulation between family, health services, and primary health care units. In central areas, where public facilities are physically closer, older adults reported greater interaction with care systems, although often accompanied by frustration regarding their effectiveness, confirming that physical availability does not necessarily guarantee effective care [ 34 , 35 ]. In the isolated territory, geographical distance and the precariousness of public transport weaken the mesosystemic network, limiting access and increasing dependence on others, which reinforces the structural influence of territory on the organisation of care [ 36 ]. At the exosystem level, perceptions regarding urban infrastructure, transport, public safety, and accessibility emerged prominently. For older adults living in central areas, obstacles such as insecurity, architectural barriers, and delays in services were highlighted; for residents of the isolated area, deficient transport, social isolation, and dependence on others for mobility were the main barriers. The literature emphasises that the perception of accessible, safe, and inclusive environments is directly associated with better quality of life and represents one of the main mediators between active ageing and effective urban policies [ 8 , 37 , 38 ]. In these studies, rural conditions are shown to intensify historical inequalities and limit opportunities for social participation, thereby negatively affecting subjective well-being. The macrosystem revealed the cultural ambivalence that permeates ageing in Brazil. While social discourses often associate old age with wisdom and learning, social and institutional practices still reproduce marginalisation and age-related prejudice. In participants’ narratives, this ambivalence appeared both in the moral valorisation of older adults and in experiences of discrimination and social invisibility, confirming a paradox widely recognised in the literature: negative attitudes towards ageing are strong mediators of the relationship between perceived health and quality of life [ 39 , 40 , 41 ]. The persistence of these contradictions highlights the need for public policies that promote social recognition, combat ageism, and strengthen intergenerational solidarity. At the chronosystem level, participants’ narratives highlighted bodily changes, functional losses, and sociocultural transformations throughout the life course. Recent studies also indicate that positive expectations regarding public policies, pensions, and health services directly influence perceived quality of life and reinforce more constructive attitudes towards ageing [ 33 , 40 ]. Comparisons between territories revealed significant differences. In central areas, ageing was described as a process of active adaptation: taking care of health, seeking information, maintaining autonomy, and accessing services. Narratives reflected a more direct relationship with urban facilities, although often accompanied by frustration regarding their effectiveness. In isolated areas, perceptions were more strongly marked by functional decline and loss, but also by a strong appreciation of family networks, community interaction, and contact with nature. This combination appeared in several accounts, simultaneously revealing vulnerability and affective support. Such contrast reinforces the idea that quality of life in urban contexts tends to be more closely linked to institutional resources, whereas in isolated contexts it relies primarily on affective networks and the physical environment [ 8 , 42 ]. The results also suggest that standardised public policies may be insufficient to address the diversity of ageing experiences. International studies have already indicated that overly homogeneous policies that fail to incorporate the real perceptions and needs of older adults tend to be ineffective in promoting active ageing [ 3 , 35 ]. Participants’ narratives reinforce this gap, particularly when describing territory-specific barriers and different perceptions regarding the presence or absence of the State. Meaningful listening therefore emerges as a central element for improving public policies, as it allows the identification of gaps, expectations, and priorities that often remain invisible in purely quantitative approaches. This study has some limitations. The research was conducted in a specific regional context and included a relatively small sample, which may limit the generalisability of the findings. However, qualitative approaches aim to provide depth of understanding rather than statistical representativeness, and the study offers important insights into how territorial inequalities shape the ageing experience. Finally, the findings reaffirm that quality of life in older age depends on strategies capable of integrating autonomy, social support, accessible environments, active participation, and health care, aligned with the expectations and subjective experiences of older adults themselves. Adopting a bioecological perspective, articulating person, process, context, and time in interaction with the framework of territorial inequalities, not only highlights the complexity surrounding the ageing process but also underscores the need for multisectoral strategies that are sensitive to territorial contexts and structural inequalities shaping the experience of ageing in Brazil. Conclusions This study highlights the heterogeneity of the ageing process, showing that it is shaped by the interplay between individual, social and territorial factors. The findings demonstrate that place of residence plays a key role in structuring opportunities, constraints and responses to ageing, emphasising the importance of context in shaping these experiences. By adopting a bioecological perspective, this study provides a more integrated understanding of how different contextual levels interact within the same municipality. These insights reinforce the need for context-sensitive and territorially informed strategies to promote healthy and active living in older age, and to address persistent intra-urban inequalities. Declarations Ethics approval and consent to participate This study was approved by the Research Ethics Committee of Centro Universitário FMABC (approval no. 5.292.649). All participants provided informed consent prior to participation. All procedures were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments. Competing interests The authors declare that they have no competing interests. Authors’ contributions Conceptualisation and study design: DCD, CG, JD and VBN; Data collection: DCD; Data curation: DCD, CG, JD and EF; Formal analysis: DCD, JF, CG, JD and VBN; Investigation: DCD and VBN; Methodology: DCD, JF, NCJ, CG, JD and VBN; Supervision: CG and JD; Writing – original draft: DCD, JF, CG and VBN; Writing – review and editing: all authors. Funding The data used in this study were generated as part of a previous project supported by the Institute of Global Innovation, University of Birmingham, UK. The current analysis did not receive any specific funding. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Author Contribution Conceptualisation and study design: DCD, CG, JD and VBN; Data collection: DCD; Data curation: DCD, CG, JD and EF; Formal analysis: DCD, JF, CG, JD and VBN; Investigation: DCD and VBN; Methodology: DCD, JF, NCJ, CG, JD and VBN; Supervision: CG and JD; Writing – original draft: DCD, JF, CG and VBN; Writing – review and editing: all authors. Acknowledgement The authors would like to thank Dina Goodman-Palmer, Maria Lisa Odland, Sandra Agyapong-Badu, Natalia da Cruz-Alves, Meire Rosenburg, and Lisa R. Hirschhorn for their contributions to the earlier phases of the research on which this study is based. Data Availability The datasets generated and analysed during the current study are not publicly available due to the qualitative nature of the data and ethical considerations related to participant confidentiality. As the data contain potentially identifiable information, they cannot be shared publicly. De-identified excerpts may be made available from the corresponding author on reasonable request, subject to approval by the relevant ethics committee. References Pan American Health Organization (PAHO). Taking the pulse of the health system’s response to the needs of older persons: situation analysis Brazil. 2022. https://iris.paho.org/handle/10665.2/56876 . Accessed 24 Nov 2025. Marçola AG, Cipolli GC, Donatelli DC, Carneiro Júnior N, Nascimento VB. A look at vulnerability in the older population in health sciences studies: a systematic review. Geriatr Gerontol Aging. 2023;17:e0230021. 10.53886/gga.e0230021 . Dizon L, Wiles J, Peiris-John R. What is meaningful participation for older people? An analysis of aging policies. Gerontologist. 2020;60(3):396–405. 10.1093/geront/gnz060 . World Health Organization (WHO). Integrated care for older people (ICOPE) implementation framework: guidance for systems and services. 2019. https://www.who.int/publications/i/item/9789241515993 . 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Hoboken: Wiley; 2006. pp. 793–828. 10.1002/9780470147658.chpsy0114 . Bronfenbrenner U. Making human beings human: bioecological perspectives on human development. Thousand Oaks: Sage; 2004. Albuquerque DS, Amâncio DAR, Günther IA, Higuchi MIG. Theoretical contributions on ageing from the perspective of person-environment studies. Psicol USP. 2018;29(3):442–50. 10.1590/0103-656420180142 . Navarro JL, Tudge JRH. Technologizing Bronfenbrenner: neo-ecological theory. Curr Psychol. 2022. 10.1007/s12144-022-02738-3 . Silva MAI, Nunes MR, Priotto EMTP, Braga IA, Santos SD. Fatores de proteção para a redução da vulnerabilidade à saúde. Rev Min Enferm. 2015;19(3):653–8. 10.5935/1415-2762.20150050 . Shermack LV, de Paula FV. A teoria bioecológica de Bronfenbrenner como modelo para a análise da gênese e desenvolvimento de políticas públicas educacionais. Rev PPC Políticas Públicas Cidades. 2025;14(6):1–17. Mullen R, Kydd A, Fleming A, McMillan L. A practical guide to the systematic application of nominal group technique. Nurse Res. 2021;29(1):14–20. 10.7748/nr.2021.e1777 . Lee SH, Ten Cate O, Gottlieb M, Horsley T, Shea B, Fournier K, et al. The use of virtual nominal groups in healthcare research: an extended scoping review. PLoS ONE. 2024;19(6):e0302437. Instituto Brasileiro de Geografia e Estatística (IBGE). Santo André. 2025. https://www.ibge.gov.br/cidades-e-estados/sp/santo-andre.html . Accessed 24 Nov 2025. Barata RB. Como e por que as desigualdades sociais fazem mal à saúde. Rio de Janeiro: Editora Fiocruz; 2009. Rahemi Z, Bacsu JR, Shalhout SZ, Sadafipoor MS, Smith ML, Adams SA. Healthcare disparities among older adults: exploring social determinants of health and cognition levels. Geriatr Nurs. 2025;61:614–21. 10.1016/j.gerinurse.2024.12.037 . Chen Y, Fan X, Shen S, Chen Y, Pan Z, Chen Z, et al. Exploring urban-rural inequities in older adults life expectancy: a case study in Zhejiang, China for health equity. Front Public Health. 2025;13:1439857. 10.3389/fpubh.2025.1439857 . World Health Organization (WHO). Social determinants of health. 2025. https://www.who.int/news-room/fact-sheets/detail/social-determinants-of-health . Accessed 24 Nov 2025. Plabb B, Zerbe S. How does the environment affect human ageing? An interdisciplinary review. J Gerontol Geriatr. 2021;69:53–67. 10.36150/2499-6564-420 . Jacobs N, Van Cauwenberg J, Van Dyck D, Veitch J, Teychenne M, Deforche B. Urban environment perceptions and mental well-being in Belgian older adults: differences across neighborhood income levels. Health Promot Int. 2025;40(3):daaf066. 10.1093/heapro/daaf066 . Diez Roux AV, Mair C, Ann. N Y Acad Sci. 2010;1186:125–45. 10.1111/j.1749-6632.2009.05333.x . McMillan SS, King M, Tully MP. How to use the nominal group and Delphi techniques. Int J Clin Pharm. 2016;38(3):655–62. 10.1007/s11096-016-0257-x . Segura A, Cardona D, Segura A, Robledo CA, Muñoz DI. The subjective perception of the happiness of older adult residents in Colombia. Front Med (Lausanne). 2023;10:1055572. 10.3389/fmed.2023.1055572 . Choi Y, Hwang E. Do policy expectations, health, and social support affect the quality of life of older adults? Int Rev Public Adm. 2022;27(4):325–43. 10.1080/12294659.2022.2147410 . Gabriel Z, Bowling A. Quality of life from the perspectives of older people. Ageing Soc. 2004;24(5):675–91. 10.1017/S0144686X03001582 . Zhao L, Yang H. Impact of healthcare accessibility on the quality of life of older adults in China and its age differences. SAGE Open. 2025;15(3). 10.1177/21582440251356051 . Rony MKK, Parvin MR, Wahiduzzaman M, Akter K, Ullah M. Challenges and advancements in the health-related quality of life of older people. Adv Public Health. 2024. 10.1155/2024/8839631 . Liu L, Li J, Tang Y, Chen C, Yu C, Li X, et al. The impact of life events on health-related quality of life in rural older adults: the moderating role of social support. Front Public Health. 2025;13:1587104. 10.3389/fpubh.2025.1587104 . Gobbens RJJ, van Assen MALM. Associations of environmental factors with quality of life in older adults. Gerontologist. 2018;58(1):101–10. 10.1093/geront/gnx051 . Stephens C, Szabó Á, Allen J, Alpass F. Livable environments and the quality of life of older people: an ecological perspective. Gerontologist. 2019;59(4):675–85. 10.1093/geront/gny043 . Bužgová R, Kozáková R, Bobčíková K. Predictors of attitudes towards aging in elderly living in community care. BMC Geriatr. 2024;24:266. 10.1186/s12877-024-04840-6 . Liu C, Gao Y, Jia Z, Zhao L. Association of public sports space perception with health-related quality of life in middle-aged and older adults: evidence from a survey in Shandong, China. Behav Sci (Basel). 2023;13(9):736. 10.3390/bs13090736 . Low G, Molzahn AE, Schopflocher D. Attitudes to aging mediate the relationship between older peoples’ subjective health and quality of life in 20 countries. Health Qual Life Outcomes. 2013;11:146. 10.1186/1477-7525-11-146 . Vanleerberghe P, De Witte N, Claes C, Schalock RL, Verté D. The quality of life of older people aging in place: a literature review. Qual Life Res. 2017;26(11):2899–907. 10.1007/s11136-017-1651-0 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 10 May, 2026 Reviewers invited by journal 08 May, 2026 Editor assigned by journal 08 May, 2026 Editor invited by journal 07 May, 2026 Submission checks completed at journal 07 May, 2026 First submitted to journal 06 May, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9499933","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":637711918,"identity":"be691008-5688-4dda-b17d-1d54d86aaa4b","order_by":0,"name":"Danyela Casadei Donatelli","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYDCCAyCiAMKWYDCwYWBgh3AS8GsxgGtJY2BgJk0Lw2HCWviOnz0m8cHATp6///DDGx8Kzif2MzMwfviYw5Bn3oBdi+SZvDTJGQbJhjNupBlbzjC4nTizmYFZcuY2hmKZA9i1GBzIMZPmMWBOYLjBAGLcTtxwmIGNmXcbQ+IMHA4zOP/GTPqPQX2C/Pnj34CMc0RouQG0hcHgcALYOqClhLVI3nhjbNljcNxw442cYiAj2XhmM2Mz0C8SxRK4Qux8juGNHxXV8nLnj2+88eOPnWw/e/PBDx+32eTh0gIELOhyjA0M4DjCDZg/4JMdBaNgFIyCUcAAAFwZWbLHPJDqAAAAAElFTkSuQmCC","orcid":"","institution":"Centro Universitário FMABC","correspondingAuthor":true,"prefix":"","firstName":"Danyela","middleName":"Casadei","lastName":"Donatelli","suffix":""},{"id":637711921,"identity":"9ad6cfd0-4d6c-42a1-80d0-153327b04953","order_by":1,"name":"Juliana Franceschini","email":"","orcid":"","institution":"ProAR Foundation","correspondingAuthor":false,"prefix":"","firstName":"Juliana","middleName":"","lastName":"Franceschini","suffix":""},{"id":637711926,"identity":"a83ce0a4-d707-41cb-82b0-6f64120646b7","order_by":2,"name":"Nivaldo Carneiro Jr","email":"","orcid":"","institution":"Centro Universitário FMABC","correspondingAuthor":false,"prefix":"","firstName":"Nivaldo","middleName":"","lastName":"Carneiro","suffix":"Jr"},{"id":637711931,"identity":"71090845-c2b4-49cc-90ef-827e4d6288a0","order_by":3,"name":"Carolyn Greig","email":"","orcid":"","institution":"University of Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Carolyn","middleName":"","lastName":"Greig","suffix":""},{"id":637711933,"identity":"4dcde013-f501-468e-8d99-98ee24bd098d","order_by":4,"name":"Justine Davies","email":"","orcid":"","institution":"University of Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Justine","middleName":"","lastName":"Davies","suffix":""},{"id":637711934,"identity":"81b74d5c-fce3-4894-9cc2-5595b8772b15","order_by":5,"name":"Eduardo Ferriolli","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Eduardo","middleName":"","lastName":"Ferriolli","suffix":""},{"id":637711935,"identity":"f0b1c556-c1d1-4188-b3d8-fe20b145060d","order_by":6,"name":"Vania Barbosa Nascimento","email":"","orcid":"","institution":"Centro Universitário FMABC","correspondingAuthor":false,"prefix":"","firstName":"Vania","middleName":"Barbosa","lastName":"Nascimento","suffix":""}],"badges":[],"createdAt":"2026-04-22 19:39:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9499933/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9499933/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109436468,"identity":"bf9410ab-bf32-47c8-99e4-ba00b935d7c8","added_by":"auto","created_at":"2026-05-18 06:19:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":295612,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrative diagram of older adults’ perceptions of the ageing process across interconnected environmental levels, based on Bronfenbrenner’s Bioecological Theory of Human Development.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9499933/v1/15c07ebf9d6a59b89533f489.png"},{"id":109799638,"identity":"64e24c72-8fa7-4a41-ad6e-3d8d3e8c6628","added_by":"auto","created_at":"2026-05-22 15:32:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":489707,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9499933/v1/1bcf3e10-d1f7-4032-a0ee-528637a1e4d1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ageing and conditions for active and healthy living: perceptions of older adults across diverse socio-environmental contexts in a Brazilian municipality","fulltext":[{"header":"Background","content":"\u003cp\u003ePopulation ageing in Brazil represents a continuous, accelerated, and irreversible process, marked by profound demographic and social transformations. Official projections indicate that by 2030 the number of older adults in Brazil will exceed, in absolute terms, the population of children and adolescents, redefining demands and priorities for both the State and society [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This scenario imposes structural challenges for ensuring dignified living conditions, requiring public policies capable of responding, in an articulated and sustainable manner, to the multiple needs of this age group.\u003c/p\u003e \u003cp\u003ePromoting dignified ageing goes beyond increasing life expectancy and requires actions that ensure well-being, autonomy, social participation and inclusion [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Public policies aimed at older people must therefore adopt a multidimensional perspective, integrating health, social assistance, mobility, culture, leisure, and opportunities for community interaction, while being guided by principles of equity and by recognition of the diversity that characterises ageing trajectories [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite normative advances in Brazil, such as the Statute of Older Persons [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and the National Policy for Older Persons [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], obstacles persist that limit their effectiveness. Among these are intersectoral fragmentation, discontinuity of actions, and the gap between legal guidelines and the realities experienced in local territories. In this context, strengthening policies requires not only technical consistency but also participatory processes that value the perceptions, expectations, and demands of older people themselves [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnderstanding ageing cannot be restricted to biomedical or socioeconomic indicators. Subjective dimensions, such as self-perceived health, social recognition, sense of belonging, preservation of autonomy, and opportunities for participation, play a decisive role in shaping the experience of ageing and quality of life. Considering these experiences is essential for the development of policies that are more sensitive, human-centred, and adapted to the complexities of different sociocultural contexts [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eListening to older people through qualified engagement has increasingly been recognised as a key element for guiding care strategies and social protection policies, enabling responses that are more coherent with their lived experiences, meanings, and concrete needs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Recent studies reinforce this perspective. Research by Donatelli et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], conducted in a central urban area and in a low-connectivity peripheral area in Santo Andr\u0026eacute;, S\u0026atilde;o Paulo, Brazil, highlighted the importance of incorporating older adults\u0026rsquo; perspectives into social programmes.\u003c/p\u003e \u003cp\u003eIn light of the Bioecological Theory of Human Development, such perceptions are understood as the result of continuous interactions between individuals and multiple environments, from immediate contexts to broader sociopolitical structures, also incorporating the temporal dimension [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In addition, the meanings attributed by older people to their experiences constitute a fundamental basis for developing more welcoming and person-centred practices [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This theory significantly expands the analysis of interactions across multiple levels of the social context through the Process\u0026ndash;Person\u0026ndash;Context\u0026ndash;Time (PPCT) model [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Investigating how this population perceives the ageing process therefore represents an essential step for improving strategies aimed at promoting healthy, equitable and diverse ageing.\u003c/p\u003e \u003cp\u003eThis study aimed to analyse the perceptions of older people regarding the ageing process and the conditions required for a healthy and active life, considering the interaction between the individual, their relationships, their living conditions and their experiences over time within the Brazilian municipal context.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a qualitative, descriptive, and exploratory study grounded in Bronfenbrenner\u0026rsquo;s Bioecological Theory of Human Development [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This framework, originally developed within the field of psychology, can be applied to understand individual perceptions within a systemic context, broadening the analytical perspective on individuals as active agents in processes of coping with adversity and vulnerability [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study sought to systematise older people\u0026rsquo;s perceptions regarding the ageing process and the conditions required for an active and healthy life, organising them according to the levels of the microsystem, mesosystem, exosystem, macrosystem and chronosystem. The reality under investigation may be understood as complex, as it reflects a dynamic network of interactions between person, process, time and context [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. According to Bronfenbrenner, it is necessary to adopt an analytical perspective capable of capturing the complexity of different contextual systems or levels that are in constant interaction with one another [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Unlike the socioecological model, which emphasises the organisation of contexts into levels, the bioecological approach enables understanding of how these levels interact through relational processes over time, highlighting the active role of older people in constructing their ageing experience [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study forms part of a broader investigation previously published [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which aimed to identify the needs and priorities of older adults in a central urban area and in a low-connectivity peripheral area in the municipality of Santo Andr\u0026eacute;. Data collection was conducted using the Nominal Group Technique (NGT), a structured methodological approach for group research designed to explore topics and build consensus, allowing participants themselves to collectively identify, organise, and prioritise issues with minimal interference from researchers [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In the present article, the data produced were reinterpreted in light of the Bioecological Theory of Human Development, with the aim of deepening the understanding of interactions between person, context, processes and time in ageing across different socio-spatial realities.\u003c/p\u003e \u003cp\u003e The study was approved by the Research Ethics Committee of Centro Universit\u0026aacute;rio FMABC (approval number 5.292.649).\u003c/p\u003e \u003cp\u003eThe research was conducted in the municipality of Santo Andr\u0026eacute;, located in the Metropolitan Region of S\u0026atilde;o Paulo, Brazil. In 2022, the municipality had an estimated population of 748,919 inhabitants and a demographic profile characterised by population ageing, with approximately 143,717 individuals aged 60 years or older. Santo Andr\u0026eacute; has a Municipal Human Development Index (HDI) of 0.815 (2010), classified as very high, reflecting elevated levels of income, education and longevity [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Two territories with contrasting characteristics were selected:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eA central urban area characterised by a wide availability of public services, facilitated mobility, and high population density.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAn area isolated due to low urban connectivity, corresponding to the Paranapiacaba and Parque Andreense region, located southeast of the Billings Reservoir. This region is characterised by distance from the central urban area, low population density, environmental restrictions associated with watershed protection, and limited access to public services and transport. Although located within an environmentally preserved area, the region has a history of irregular occupation and population densification, coexisting with structural and institutional limitations that affect access to public policies.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe central urban area was designated Group 1 (G1), while the isolated area was designated Group 2 (G2).\u003c/p\u003e \u003cp\u003e Participants were individuals aged 60 years or older residing in the selected territories, with independent mobility and able to provide informed consent. Individuals under 60 years of age, non-residents of the selected areas, or those unable to participate fully in the proposed activities were excluded.\u003c/p\u003e \u003cp\u003eParticipants were randomly identified and invited with the support of community health workers from Family Health Strategy teams in Primary Health Care Units located in the respective territories.\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eBetween 21 and 30 June 2022, two face-to-face groups were conducted, one in each territory, facilitated by researchers from Centro Universit\u0026aacute;rio FMABC, the Ribeir\u0026atilde;o Preto Medical School of the University of S\u0026atilde;o Paulo, and the University of Birmingham, UK. The methodological description followed general recommendations for qualitative research, considering the absence of specific EQUATOR Network guidelines for studies based on the Nominal Group Technique.\u003c/p\u003e \u003cp\u003eOlder participants from each area met on different days and locations. The sessions began with a presentation of the study objectives and a brief discussion about conceptions of ageing. Participants were then divided into subgroups of five to seven individuals. Subgroups discussed, for approximately one hour, predefined topics:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eImportant elements for an active and healthy life;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMain perceived barriers;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMain facilitators.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAt the end of each theme, a structured prioritisation process following the NGT methodology was conducted, in which participants individually assigned scores to the listed items. Scores were subsequently summed to determine group priorities, a stage lasting approximately 30\u0026ndash;45 minutes per theme.\u003c/p\u003e \u003cp\u003eStatements resulting from subgroup discussions were recorded on flipcharts and consolidated into lists. Subsequently, prioritisation was conducted through voting among participants to define the five final priorities for each topic. Discussions were audio recorded solely for documentation purposes and later fully transcribed. Analysis was conducted based on textual transcripts and field notes. The total duration of this stage was approximately three hours.\u003c/p\u003e \u003cp\u003eStatements and priorities were analysed through thematic categorisation and interpreted in light of the Bioecological Theory of Human Development. This model allowed participants\u0026rsquo; perceptions to be situated at different levels of influence:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMicrosystem (direct relationships, such as family and health professionals);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMesosystem (interactions between microsystems, such as relationships between family and health services);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExosystem (contexts that influence the individual without direct participation, such as public policies and community networks);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMacrosystem (cultural values, social norms, and broader economic and political systems);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eChronosystem (changes over time, both individual and sociopolitical).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe comparison between G1 and G2 enabled the identification of territorial differences in perceptions of the ageing process and of the conditions that facilitate or hinder healthy and active ageing.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 44 individuals participated in the study, including 17 residents of the central urban area (G1) and 27 from the area isolated due to low urban connectivity (G2), with a predominance of women in both groups. The mean age of participants was 71.0 years (SD 6.4), ranging from 60 to 85 years,, with most participants being women aged between 65 and 79 years. Incomplete primary education was more frequent in the isolated area, whereas completion of secondary education predominated in the central urban area. Most participants lived with spouses or family members, although some lived alone, particularly women.\u003c/p\u003e \u003cp\u003eFollowing Bronfenbrenner\u0026rsquo;s bioecological model, five main themes emerged: (1) body, immediate relationships and perceptions of well-being; (2) interactions between family, community and services; (3) perceptions of institutional and social structures in the lives of older people; (4) cultural and symbolic values; and (5) the temporal and historical dimension of ageing. The statements are presented in aggregated form by group (G1 \u0026ndash; central urban area; G2 \u0026ndash; area isolated due to low urban connectivity), preserving the collective nature of the Nominal Group Technique rather than attributing statements to individual participants.\u003c/p\u003e \u003cp\u003e1. Body, immediate relationships and perceptions of well-being\u003c/p\u003e \u003cp\u003eAgeing was described by participants as a process marked by physical, emotional and social changes that require constant adaptation. Many reported bodily limitations, such as loss of strength, memory and mobility:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Age brings weakness and memory loss.\u0026rdquo;\u003c/em\u003e (G1).\u003c/p\u003e \u003cp\u003eAt the same time, narratives emerged that associated ageing with the accumulation of life experiences and the ability to adapt to restrictions imposed by the body:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is a phase when some doors close, but others open. You have to learn to live with the possibilities you still have.\u0026rdquo;\u003c/em\u003e (G2).\u003c/p\u003e \u003cp\u003eIn this sense, physical transformations were understood both as a natural condition of life and as a stimulus for self-care, the adoption of healthy habits and recognition of one\u0026rsquo;s own limits:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You feel that your body no longer responds as before, but you need to learn to take better care of yourself.\u0026rdquo;\u003c/em\u003e (G1).\u003c/p\u003e \u003cp\u003eFamily coexistence emerged as a central element for maintaining well-being, providing emotional support, security and a sense of continuity:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Having my family close is what keeps me strong.\u0026rdquo;\u003c/em\u003e (G2).\u003c/p\u003e \u003cp\u003eParticipants also emphasised the importance of preserving autonomy and having their decisions respected:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;What matters is that the family lets us decide what we want and respects our choices\u0026rdquo;\u003c/em\u003e (G2).\u003c/p\u003e \u003cp\u003eDespite these positive aspects, barriers were also reported that weaken everyday experiences, including lack of social and community life, scarcity of leisure spaces and architectural barriers that limit mobility and promote isolation.\u003c/p\u003e \u003cp\u003eDistinct reflections emerged in each territory, shaping the experience of ageing. In both areas, physical changes and the need for adaptation were recognised; however, in the isolated area there was a stronger perception of inevitable decline, whereas in the central urban area more references were made to adaptation and self-care.\u003c/p\u003e \u003cp\u003e2. Interactions between family, community and services\u003c/p\u003e \u003cp\u003eInteractions between close contexts proved to be crucial for well-being. Ageing was understood as the result of integration between personal experiences, family relationships and community networks, highlighting the need for collective and institutional support.\u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; statements revealed both resources and weaknesses. On the one hand, participation in community groups, educational programmes and collective activities was considered fundamental for strengthening social bonds and promoting active living:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Taking part in older people\u0026rsquo;s groups and having community activities really helps us not feel alone.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Learning and practising manual, mental and occupational activities, exchanging experiences and skills, remaining active through manual, intellectual and voluntary work, maintaining life goals and routines, and participating in educational programmes and social networks.\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In this specific place (isolated area), nature, breathing fresh air, contact with animals and having gardens and plants improve our lives.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003eNew demands also emerged, such as digital inclusion, viewed as a pathway to greater autonomy and reduced isolation:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Nowadays everything is done through mobile phones and the internet, and we need to learn.\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It would be important to have courses and support to learn how to use mobile phones and the internet.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003eOn the other hand, participants reported barriers that hinder these interactions, including the lack of appropriate leisure spaces, insecurity in public spaces, mobility difficulties and fragile social support networks:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is a lack of leisure options and places to meet friends here.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is useless to have a doctor if transport does not take us there.\u0026rdquo;\u003c/em\u003e (G2).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is a lack of guidance and explanation regarding quality health services, prescriptions, examinations and consultations, transport and older people\u0026rsquo;s rights\u0026rdquo;. (G1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThese findings highlight the importance of articulating family, community and service networks. When strengthened, such articulation promotes intergenerational coexistence, social participation and the development of care networks. When fragile, it reinforces isolation and limits access to dignified ageing conditions.\u003c/p\u003e \u003cp\u003eParticipants from the central urban area relied more on institutional resources, such as health services and technologies, whereas those in the isolated area placed greater emphasis on affective and environmental networks, such as contact with nature. Issues related to isolation and the need for more adequate transport were emphasised particularly in the isolated area.\u003c/p\u003e \u003cp\u003e3. Perceptions of social and institutional structures in the lives of older people\u003c/p\u003e \u003cp\u003ePerceptions of public services and institutional arrangements revealed both facilitating and restrictive factors. Timely access to healthcare, adequate transport and enforcement of older people\u0026rsquo;s rights were identified as essential conditions for dignity and autonomy. In the isolated area, the absence of support from governmental bodies and services was considered a limiting factor for maintaining an active and healthy life. Participants emphasised the importance of structures and services that had previously been available in the territory, contrasting this with their current perception of abandonment.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Support provided by governmental and non-governmental agencies and other stakeholders (primary and family health units, including community health workers); well-being groups (physical activity, auriculotherapy, crafts); waste collection; family club (NGO); encouragement for the establishment of small businesses; subprefecture structure to assist with building and renovation guidance; education for young and older people.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If there were free transport for our caregivers and faster medical care, ageing well would be much easier.\u0026rdquo;\u003c/em\u003e (G2).\u003c/p\u003e \u003cp\u003eHowever, criticisms predominated regarding long waiting times for specialist consultations, weaknesses in primary healthcare, insufficient transport and failures in urban accessibility:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When we need a specialist doctor, we wait months to get an appointment.\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The law says we have priority, but in practice it is not quite like that.\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Poor infrastructure without pavements or walkways reduces mobility. Public transport is precarious. Streets lack signage and speed control, and roads are poorly maintained. We have difficulty walking due to reduced vision.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003eUrban insecurity, marked by fear of violence and lack of accessibility, emerged as a factor that restricts mobility and social life:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I am afraid to leave the house; violence has increased a lot.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003eThus, this dimension proved to be critical. Participants clearly indicated that when structures and public policies function properly, they facilitate active ageing; when they fail, they reinforce vulnerabilities, increase inequalities and compromise the dignity of older people.\u003c/p\u003e \u003cp\u003eVarious obstacles were identified, assuming different configurations across the territories. In the central urban area, the most frequently reported problems included long waiting lists and delays for specialist consultations, urban insecurity, and accessibility difficulties. In the isolated area with low urban connectivity, the most common barriers were the distance to services, the scarcity of public transport, and the absence of governmental structures within the territory.\u003c/p\u003e \u003cp\u003eRegarding needs, older adults living in the central region advocated for adapted urban infrastructure, accessible transport, digital inclusion, and intergenerational respect. In contrast, those living in the isolated area emphasised the need for a stronger presence of the State in the territory, more locally responsive public policies, and community spaces for social interaction. Despite the differences between the two contexts, the importance of state presence and effective service provision emerged as central to well-being and the preservation of autonomy.\u003c/p\u003e \u003cp\u003e4. Cultural and symbolic values\u003c/p\u003e \u003cp\u003eCultural values and social representations significantly shaped the experience of ageing. For some participants, old age was seen as a privilege and continuation of life:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Reaching this point is a blessing, a chance to live longer and keep learning.\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003eFor others, however, old age was marked by social devaluation and suffering:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In our society, old people have no value anymore; it seems like we are a burden.\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There should be more patience and attention towards older people, more help and mutual respect between young and old.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003eCultural and spiritual values also emerged, including faith, patience, solidarity and intergenerational respect, which were considered essential for maintaining dignity in later life:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Having faith in God and practising gratitude.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Nurturing spiritual life regardless of one\u0026rsquo;s faith.\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003eThese symbolic resources function as coping mechanisms in the face of physical and social limitations. At the same time, participants\u0026rsquo; narratives revealed structural and cultural inequalities, expressed through references to financial difficulties and lack of social recognition:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Life is harder because we do not have the financial means for everything we need\u003c/em\u003e; \u003cem\u003ewe want to live with dignity, not be treated as a burden.\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eInsufficient pensions reduce quality of life.\u003c/em\u003e\u0026rdquo; (G2)\u003c/p\u003e \u003cp\u003eThus, the findings suggest that the barriers experienced by older adults extend beyond the individual level, being embedded in broader social structures, shaped by the extent to which rights are realised, and reinforced by exclusionary practices and ageism.\u003c/p\u003e \u003cp\u003e5. Recognition of the temporal and historical dimension\u003c/p\u003e \u003cp\u003eAgeing was understood as a dynamic process characterised by gradual losses, adaptations and reinterpretations throughout life.\u003c/p\u003e \u003cp\u003eSome participants emphasised physical and social decline associated with the passage of time:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Each year we lose a little, whether in the body or in social life.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003eOthers highlighted the possibility of adaptation and reinvention despite limitations:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Every year we need to reinvent ourselves and find new ways to live well\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003eExperiences accumulated throughout life influence routines, forms of care and levels of isolation. In this sense, old age was interpreted not only as a biographical phenomenon but also as a social and historical one.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Acquisition of wisdom and knowledge about life: integrating past, present and future.\u0026rdquo;\u003c/em\u003e (G2)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Changes that we can shape through physical and mental activity.\u0026rdquo;\u003c/em\u003e (G1)\u003c/p\u003e \u003cp\u003eThis temporal dimension reinforces that ageing is not static; it requires continuous adaptation to bodily transformations, social relationships and historical conditions. The chronosystem therefore highlights the processual nature of ageing and the need to articulate resources and support mechanisms capable of promoting autonomy and healthier lives over time (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe integrated analysis of the findings, guided by the bioecological model and presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, demonstrates that older adults\u0026rsquo; perceptions of the ageing process and the factors influencing an active and healthy life vary according to the socio-spatial contexts in which they live, revealing determinants at the micro-, meso-, exo-, macro-, and chronosystem levels. While participants from the central area associated ageing with the capacity for adaptation, self-care, and access-albeit limited-to health services and urban infrastructure, those living in isolated areas emphasised the burden of physical decline, the importance of family and community networks, and the difficulties imposed by distance, inadequate transport, and the limited availability of public facilities. Protective factors, such as affective bonds, spirituality, and personal care practices, coexisted with structural barriers, including urban insecurity, mobility limitations, social isolation, and weaknesses in the health system. Despite the differences between the territories, both groups highlighted the central role of family and the desire to maintain autonomy as fundamental elements for quality of life in later life. Ensuring this autonomy was associated with the need for integrated public policies that are sensitive to territorial inequalities and to the multiple dimensions shaping the experience of ageing.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study reinforce that older adults\u0026rsquo; perceptions of ageing and strategies aimed at promoting a healthy life are shaped by multiple factors situated at different levels of Bronfenbrenner\u0026rsquo;s bioecological model. These perceptions reveal a complex field of tensions in which subjective aspects\u0026mdash;such as autonomy, self-care, spirituality, and family support\u0026mdash;coexist with structural limitations related to the physical environment, access to services, and territorial inequalities. This duality, observed both in urban territories and in isolated areas, reaffirms that ageing is a dynamic process that requires constant adaptation, resilience, and meaning making, as also highlighted in international studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, the results allow us to move beyond the subjective dimension, showing that territory acts as a structuring element of the ageing experience. Barata [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] argues that social inequalities in health are produced by unequal distributions of power, income, infrastructure, and opportunities, resulting in differentiated patterns of illness and longevity. Territory therefore emerges as a concrete expression of these structural inequalities rather than merely a backdrop. This was evident in the difficulties faced by the older population in the isolated area in accessing goods and services within their territory. According to the author, differences in access to services, transport, security, and urban facilities shape socially produced space, organising opportunities and vulnerabilities throughout the life course [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent studies have reinforced that health inequalities among older populations cannot be explained solely by individual characteristics or behavioural choices but are deeply intertwined with social and territorial determinants, such as geographical location, access to services, socioeconomic conditions, and infrastructure. For example, Rahemi et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] demonstrate that differences in the use of health services among older adults are associated with social and geographical factors, including rural or urban residence, education, and income, while Chen et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] show inequalities in life expectancy among older adults in urban and rural contexts. Furthermore, the World Health Organization (WHO) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] highlights that the conditions in which people live, work and age substantially shape health outcomes, indicating that the experience of healthy ageing is influenced by individuals\u0026rsquo; territorial position, as reflected in the perceptions of older adults in this study.\u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; accounts indicated that, while those living in central areas tended to associate ageing with the need to adopt strategies to maintain autonomy, often expressing a more critical and proactive stance, those from low-connectivity areas more frequently linked the ageing experience to limitations imposed by the territory, revealing a degree of acceptance of the difficulties encountered. This contrast highlights how environmental factors shape the subjective experience of ageing. It also suggests that the spaces individuals inhabit may act as mediators between perceived needs, lived experiences and responses to adversity, thereby contributing to the production of intra-urban inequalities [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe work of Diez Roux and Mair [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] is also central to interpreting these findings. In discussing \u0026ldquo;contextual effects\u0026rdquo;, the authors demonstrate that neighbourhoods and territories influence health independently of individual characteristics through institutional availability, social interactions, collective norms, and environmental exposures. In this sense, even older adults with similar socioeconomic profiles experience ageing differently depending on where they live. Territory therefore produces its own effects on autonomy, social participation, and perceptions of quality of life.\u003c/p\u003e \u003cp\u003eWithin the microsystem, the centrality of family, faith, community interaction, and everyday self-care practices was evident among participants, consistent with studies showing that social and family support represent one of the most important pillars for subjective well-being and protection against feelings of loneliness and vulnerability [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These elements were valued in both the central and isolated areas. However, in isolated areas such ties assume an even more strategic role, partially compensating for the reduced institutional presence of the State [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe mesosystem revealed important differences in the articulation between family, health services, and primary health care units. In central areas, where public facilities are physically closer, older adults reported greater interaction with care systems, although often accompanied by frustration regarding their effectiveness, confirming that physical availability does not necessarily guarantee effective care [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In the isolated territory, geographical distance and the precariousness of public transport weaken the mesosystemic network, limiting access and increasing dependence on others, which reinforces the structural influence of territory on the organisation of care [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the exosystem level, perceptions regarding urban infrastructure, transport, public safety, and accessibility emerged prominently. For older adults living in central areas, obstacles such as insecurity, architectural barriers, and delays in services were highlighted; for residents of the isolated area, deficient transport, social isolation, and dependence on others for mobility were the main barriers. The literature emphasises that the perception of accessible, safe, and inclusive environments is directly associated with better quality of life and represents one of the main mediators between active ageing and effective urban policies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In these studies, rural conditions are shown to intensify historical inequalities and limit opportunities for social participation, thereby negatively affecting subjective well-being.\u003c/p\u003e \u003cp\u003eThe macrosystem revealed the cultural ambivalence that permeates ageing in Brazil. While social discourses often associate old age with wisdom and learning, social and institutional practices still reproduce marginalisation and age-related prejudice. In participants\u0026rsquo; narratives, this ambivalence appeared both in the moral valorisation of older adults and in experiences of discrimination and social invisibility, confirming a paradox widely recognised in the literature: negative attitudes towards ageing are strong mediators of the relationship between perceived health and quality of life [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The persistence of these contradictions highlights the need for public policies that promote social recognition, combat ageism, and strengthen intergenerational solidarity.\u003c/p\u003e \u003cp\u003eAt the chronosystem level, participants\u0026rsquo; narratives highlighted bodily changes, functional losses, and sociocultural transformations throughout the life course. Recent studies also indicate that positive expectations regarding public policies, pensions, and health services directly influence perceived quality of life and reinforce more constructive attitudes towards ageing [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eComparisons between territories revealed significant differences. In central areas, ageing was described as a process of active adaptation: taking care of health, seeking information, maintaining autonomy, and accessing services. Narratives reflected a more direct relationship with urban facilities, although often accompanied by frustration regarding their effectiveness. In isolated areas, perceptions were more strongly marked by functional decline and loss, but also by a strong appreciation of family networks, community interaction, and contact with nature. This combination appeared in several accounts, simultaneously revealing vulnerability and affective support. Such contrast reinforces the idea that quality of life in urban contexts tends to be more closely linked to institutional resources, whereas in isolated contexts it relies primarily on affective networks and the physical environment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results also suggest that standardised public policies may be insufficient to address the diversity of ageing experiences. International studies have already indicated that overly homogeneous policies that fail to incorporate the real perceptions and needs of older adults tend to be ineffective in promoting active ageing [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Participants\u0026rsquo; narratives reinforce this gap, particularly when describing territory-specific barriers and different perceptions regarding the presence or absence of the State. Meaningful listening therefore emerges as a central element for improving public policies, as it allows the identification of gaps, expectations, and priorities that often remain invisible in purely quantitative approaches.\u003c/p\u003e \u003cp\u003eThis study has some limitations. The research was conducted in a specific regional context and included a relatively small sample, which may limit the generalisability of the findings. However, qualitative approaches aim to provide depth of understanding rather than statistical representativeness, and the study offers important insights into how territorial inequalities shape the ageing experience.\u003c/p\u003e \u003cp\u003eFinally, the findings reaffirm that quality of life in older age depends on strategies capable of integrating autonomy, social support, accessible environments, active participation, and health care, aligned with the expectations and subjective experiences of older adults themselves. Adopting a bioecological perspective, articulating person, process, context, and time in interaction with the framework of territorial inequalities, not only highlights the complexity surrounding the ageing process but also underscores the need for multisectoral strategies that are sensitive to territorial contexts and structural inequalities shaping the experience of ageing in Brazil.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlights the heterogeneity of the ageing process, showing that it is shaped by the interplay between individual, social and territorial factors. The findings demonstrate that place of residence plays a key role in structuring opportunities, constraints and responses to ageing, emphasising the importance of context in shaping these experiences. By adopting a bioecological perspective, this study provides a more integrated understanding of how different contextual levels interact within the same municipality. These insights reinforce the need for context-sensitive and territorially informed strategies to promote healthy and active living in older age, and to address persistent intra-urban inequalities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Research Ethics Committee of Centro Universit\u0026aacute;rio FMABC (approval no. 5.292.649). All participants provided informed consent prior to participation. All procedures were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eConceptualisation and study design: DCD, CG, JD and VBN; Data collection: DCD; Data curation: DCD, CG, JD and EF; Formal analysis: DCD, JF, CG, JD and VBN; Investigation: DCD and VBN; Methodology: DCD, JF, NCJ, CG, JD and VBN; Supervision: CG and JD; Writing \u0026ndash; original draft: DCD, JF, CG and VBN; Writing \u0026ndash; review and editing: all authors.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe data used in this study were generated as part of a previous project supported by the Institute of Global Innovation, University of Birmingham, UK. The current analysis did not receive any specific funding. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConceptualisation and study design: DCD, CG, JD and VBN; Data collection: DCD; Data curation: DCD, CG, JD and EF; Formal analysis: DCD, JF, CG, JD and VBN; Investigation: DCD and VBN; Methodology: DCD, JF, NCJ, CG, JD and VBN; Supervision: CG and JD; Writing \u0026ndash; original draft: DCD, JF, CG and VBN; Writing \u0026ndash; review and editing: all authors.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors would like to thank Dina Goodman-Palmer, Maria Lisa Odland, Sandra Agyapong-Badu, Natalia da Cruz-Alves, Meire Rosenburg, and Lisa R. Hirschhorn for their contributions to the earlier phases of the research on which this study is based.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to the qualitative nature of the data and ethical considerations related to participant confidentiality. As the data contain potentially identifiable information, they cannot be shared publicly. De-identified excerpts may be made available from the corresponding author on reasonable request, subject to approval by the relevant ethics committee.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePan American Health Organization (PAHO). 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Qual Life Res. 2017;26(11):2899\u0026ndash;907. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11136-017-1651-0\u003c/span\u003e\u003cspan address=\"10.1007/s11136-017-1651-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ageing, Older people, Healthy ageing, Public policy, Social determinants of health, Bioecological theory, Territorial inequalities, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-9499933/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9499933/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePopulation ageing in Brazil poses significant challenges to promoting quality of life among older adults, requiring intersectoral responses that address their multidimensional needs. Despite normative advances, persistent barriers continue to limit the effectiveness of strategies aimed at ensuring the rights of older people. Incorporating participatory approaches that value older adults\u0026rsquo; perceptions, expectations and demands is therefore essential, particularly in territories marked by socio-spatial inequalities that shape living conditions and ageing experiences. This study aimed to analyse older adults\u0026rsquo; perceptions of the ageing process and the conditions required for a healthy and active life across different socio-environmental contexts in a Brazilian municipality.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative, descriptive and exploratory study was grounded in the Bioecological Theory of Human Development. It was conducted in Santo Andr\u0026eacute;, S\u0026atilde;o Paulo, across two contrasting territories: a central urban area and a peripheral area with low urban connectivity. A total of 44 individuals aged 60 years and over participated (mean age 71.0 years, SD 6.4; range 60\u0026ndash;85), recruited with support from the Family Health Strategy. Data were collected between 21 and 30 June 2022 using the Nominal Group Technique, including discussion and prioritisation of elements related to ageing and healthy living, as well as perceived barriers and facilitators. Data were transcribed, thematically organised and interpreted in light of the theoretical framework.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFive themes emerged: (1) body, immediate relationships and well-being; (2) interactions between family, community and services; (3) institutional and social structures; (4) cultural and symbolic values; and (5) temporal and historical dimensions of ageing. Family, autonomy, self-care, spirituality and social support were central across both contexts. Territorial differences were evident: in the urban area, ageing was associated with adaptation and access to services despite structural barriers, whereas in the low-connectivity area, perceptions emphasised functional decline, isolation, limited transport and reduced state presence, alongside strong reliance on family and community networks.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePerceptions of ageing are shaped by interactions between individual, social, territorial and institutional factors. The findings highlight the need for territorially sensitive, intersectoral actions that address inequalities and promote autonomy, participation and dignity in ageing.\u003c/p\u003e","manuscriptTitle":"Ageing and conditions for active and healthy living: perceptions of older adults across diverse socio-environmental contexts in a Brazilian municipality","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-18 06:18:58","doi":"10.21203/rs.3.rs-9499933/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"65912863629089993805088213181411409088","date":"2026-05-10T16:25:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-08T07:59:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-08T07:53:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-05-07T06:28:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-07T05:01:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2026-05-06T20:34:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92eb8a49-28d3-49d0-9753-90506145e44b","owner":[],"postedDate":"May 18th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"65912863629089993805088213181411409088","date":"2026-05-10T16:25:20+00:00","index":23,"fulltext":""},{"type":"reviewersInvited","content":"3","date":"2026-05-08T07:59:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-08T07:53:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-05-07T06:28:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-07T05:01:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2026-05-06T20:34:57+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T06:18:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-18 06:18:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9499933","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9499933","identity":"rs-9499933","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}