Volume 29, Issue 1 (1-2019)                   J Holist Nurs Midwifery 2019, 29(1): 36-42 | Back to browse issues page


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Mirzazadeh A, Emami Sigaroudi A, Moghaddamnia M T, Kazemnezhad Leyli E, Noori Saeed A. Social Well-Being and Its Related Areas in Older People Living in Nursing Homes. J Holist Nurs Midwifery. 2019; 29 (1) :36-42
URL: http://hnmj.gums.ac.ir/article-1-618-en.html
1- Nursing Student (MSN), School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.
2- Associate Professor, Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. , Emamisig@gums.ac.ir
3- Assistant Professor, Social Determinants of Health Research Center (SDHRC), Guilan University of Medical Sciences, Rasht, Iran.
4- Associate Professor, Social Determinants of Health Research Center (SDHRC), Bio-Statistics, Guilan University of Medical Sciences, Rasht, Iran.
5- Department of the Islamic Studies, Guilan University of Medical Sciences, Rasht, Iran.
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Introduction
Aging is a general process that begins from conception and continues throughout life, so that all living creatures experience it [1]. The surge in the aging population is a global phenomenon. Reduced fertility and increased life expectancy have increased the elderly population much faster than the general population [2, 3]. According to the World Health Organization, the number of elderly people in the world will increase from 606 million by now to 2 billion by 2050, and with the rapid growth of the world’s elderly population by this year, one in every five people will be old [1]. According to the United Nations report, the birth rate and mortality rates in the world, and in particular in developing countries, are declining and rapidly changing population structure from the young to the old structure [4]. 
The change in the age pattern of Iranian population indicates that the population of this country is rapidly aging and it is expected that by the year 2041, about 18-20 million people in Iran will be old [5]. As a result, with increasing the population of the elderly and the special condition of these people, it is important to pay attention to their health, comfort, and well-being [6]. In this regard, the Elderly Committee was established in the Health and Treatment Committee of The Islamic Consultative Assembly to support old people and prevent the population aging [5].
By growth and development of well-being and health systems and meeting the basic needs emerging out of development and economic growth, approaches to well-being have now focused more on the social and psychological well-beings that emphasize the relationship between people and their functions in the society. In this regard, the social dimension of well-being, especially in old age and in nursing homes, has been proposed as one of the main topics of health debates [7]. However, it has not received much attention compared to other dimensions [8]. Social Well-being (SW) sometimes refers to an individual characteristic which is a part of individual health, and sometimes refers to a healthy community [9]. The quantity and quality of engagement and interaction of individuals with the community in order to promote the welfare of the community are one of the definitions of SW. 
The final result of this interaction is the promotion of social capital and social security, and reduction of poverty and injustice which is the opposite of the social harm rising [10]. From SW perspective, everyone is considered a member of a family and larger society, which constitute the SW dimensions of family, society, friends, and relatives. Social conditions and situations not only increase the likelihood of illness or disability, but also provide a special horizon for disease prevention and health preservation [11]. A cross-sectional study showed a direct and significant relationship between them which suggests the need to pay more attention to SW of this vulnerable group [12]. Likewise, Croezen reported that social support might have a beneficial effect on lifestyle and health [13]. 
Changes in the structure of family from extended to nuclear, aging, and lack of welcoming the elderlies by their families have changed the elderly’s lifestyle. Thus, considering that Iranian population has begun to experience aging, addressing issues related to the well-being of older people is of great importance. It is to be noted that very limited studies have been conducted on the SW of the elderly in Iran with non-Iranian measurement tools. In this regard, we designed an Iranian SW questionnaire which is a new and native tool for this research. Regarding the increase in population and importance of older people health, we attempted to study the SW of the elderly living in nursing homes in Rasht, Iran.

Materials and Methods
This research is a cross-sectional study conducted in 2014. Study population consists of all older people resident in nursing homes in Rasht (6 private and one semi-private centers). Census method was used for sampling. Inclusion criteria were having older than 60 years, having at least 6 months stay at a nursing home, lacking any known cognitive and psychological disorders (according to the health records), having literacy or ability to interview, and having no problems in communicating. Considering that the sampling method was census, all elderly residents of study nursing homes who were interested and met the inclusion criteria were entered into the study. In this regard, a total of 185 subjects, who completed the informed consent forms, were enrolled.
The data collection tools were a socio-demographic form for surveying age, gender, marital status, education level, last occupation, income source, number of children, type of nursing home, in-person visit/phone call from loved ones, and length of stay and the Iranian social well-being questionnaire designed by Iranian Ministry of Health and Medical Education, Bureau of Mental Health and Substance Abuse. It has 33 items assessing well-being of the subjects in three areas of family (6 items), community (19 items) and friend/relative (8 items) based on 5-Point Likert-Type Scale ranged from “very low” to “very high”. The total score ranges from 33 to 165, and higher scores indicate better SW. In this inventory, SW has been divided into three levels: poor (scores 33-66), moderate (scores 67-131), and high (scores 132-165). 
For ease of examining the results based on 5-Point Likert-Type Scale, the scores 3.5-5 shows a good level, scores 2.5-3.5 indicate moderate level, and scores 1-2.5 indicate the poor level of SW [14]. In order to test the validity of the tool, we used the opinions of 11 university professors and Content Validity Ratio (CVR) and Content Validity Index (CVI) were reported as 82% and 80%, respectively. The test-retest reliability method was used to determine the reliability of instrument and the Intraclass Correlation Coefficient (ICC) was obtained as 0.971 (P<0.001).
After obtaining permission from the Ethics Committee of Guilan University of Medical Sciences, the Welfare Organization, and the nursing homes, the researcher completed the questionnaires via interview with the participants. The collected data were analyzed in SPSS V. 21. To analyze the SW scores, we used mean, standard and standard deviation at 95% confidence level, also for determining the relationship between SW and study variables, Mann-Whitney and Kruskal-Wallis Tests were used. Finally, to determine the relation between SW and study variables after controlling demographic variables, we used multivariate logistic regression model. The significance level was set at 0.05 for all tests.

Results
Most participants (57.1%) were women. In terms of marital status, 22.2% were single, 9.7% married, 12.4% divorced, and 55.7% widows/widowers.  In terms of educational level, 69.2% were illiterate, 2.7% had Quranic literacy, 18.4% were at junior high school level, 3.8% had high school diploma, and 5.9% had academic education. Last occupation of 14.8% was employment in an office, 17.5% worker, 13.7% farmer, and 54.1% had other occupations. In terms of income source, 39.7% received income from their children/relatives, 22.9% from the Welfare Organization, 12.8% from the Relief Committee, and 24.6% by receiving retirement pension. In terms of the number of children, 37% had no child, 12.2% had one, 9.9% had two, and 40.9% had more than two children. 
Most subjects (54.1%) were residents of semi-private nursing homes and remaining (45.9%) were resident of private nursing homes. Furthermore, 58.9% had weekly visits, and 7.6% had visits more than twice a week. Also, 67.6% had no weekly phone call, and 9.7% had phone 
 


 


 
calls twice a week. Finally, length of stay of 29.3% was 1-2 years and for 21.7% it was less than one year. According to Table 1, the SW of the majority of subjects in the area of family was “good” (56.2%); in the area of friend/relative, was “poor” (53.5%); and in the area of community, it was at “moderate” level (63.8%). Overall, the SW status of most subjects was moderate (56.2%). 
The Mean±SD scores of SW in the areas of family, friend/relative and community were 3.53±1.03, 2.56±0.93, and 3.01±0.64, respectively. The overall Mean±SD score of SW was 2.99±0.68 out of maximum 5. The highest score was related to the family and the lowest to the area of friends/relatives (Figure 1).
The Mean±SD SW scores were significantly different in subjects with respect to gender, educational level, income source, type of nursing house, and received in-person visit and phone call (Table 2). But no significant difference was seen in terms of age, marital status, last occupation, number of children and length of stay. Accordingly, older women had higher level of SW than older men. Also, the subjects with higher educational level had significantly better SW, so that subjects with academic degrees had higher SW scores.
The elderly receiving retirement pension had higher SW level, while those received assistance from the Relief Committee had the lowest SW. Moreover, the residents in private nursing homes had higher SW than those who were in the semi-private nursing homes. Finally, the elderly who had visits from loved ones more than twice a week had higher SW level than those with no weekly visits. Also, those received phone calls twice a week had the highest SW and those received no phone calls had the lowest SW scores.
Multivariate logistic regression method was used to investigate the factors related to SW of the elderly by controlling the socio-demographic factors. In this regard, multivariate regression analysis was conducted. In this model, the response variable is divided into two groups of 0 (values under mean) and 1 (values above mean). To this end, the logistic model with forward approach was used with the entry and exit probability of 0.05 and 0.1. Based on this model, the regression coefficients, odds ratio, and confidence interval of 95% with respect to related factors to SW have been presented (Table 3). 
Based on the findings, the SW scores of the elderly living in privately-owned nursing homes are 2.8 times more than those living in the semi-private nursing homes. Also those who had phone calls 1, 2, and more than 2 times a week had respectively 19.7, 5.2, and 11.1 times odds ratio SW than those received no phone call from loved ones. The significance levels were 0.0001, 0.031, and 0.004, respectively.

Discussion
This study results revealed that the SW status of the majority of study samples living in nursing homes was “moderate”. Among three areas of SW, participants had higher scores in area of family compared to the areas of friends/relatives and community. This result is consistent with the results of Hosseini [15] who studied correlation between social support and SW of the elderly in Tehran, and those reported by Abachizadeh [16]. Also it 
 


 
is in agreement with the findings of Khalili who studied the relationship between perceived social support and SW of elderly people in Isfahan [12]. It should be noted that in traditional and Islamic societies, couple’s intimacy and relations between family members are strong, and if one of the spouses face disability and problems during old period, usually the wife/husband or children take care of him/her. In addition, the SW score of study samples in the family area were higher than their scores in friends/relatives and community areas. This is consistent with the findings a few studies [12-17]
The participants’ SW status were significantly different in terms of gender, educational level, income source, type of nursing home ownership, and received in-person visits/phone calls from loved ones. Older women had higher SW than older men. With regard to Iranian culture where women (especially previous generation) are less likely to participate in the social areas, receiving 
 

 
less contacts in the nursing homes is more plausible for older women.
Education is another effective factor where participants with higher educational level reported higher SW. This is in agreement with the findings of Zahedi Asl [18]. This can be because of greater sense of belonging to the community among educated people. These people consider themselves vital and valuable members of society and try to constantly evaluate and improve the quality of their interpersonal relationships in the social groups in which they are members.
In terms of income source, the elderly who were receiving retirement pension had higher SW level. This is in accordance with the findings of Vameghi et al. and Emami et al. [19, 20]. This relates to the fact that high socio-economic status is associated with better SW. With respect to the type of nursing home (private/semi-private), the elderly resident in privately-owned nursing homes showed higher SW which can be due to more interpersonal communications and more accessible facilities.
Receiving in-person visits and phone calls from loved ones were another factors affecting SW of the elderly. Those who had visits more than twice a week, and phone calls twice a week showed higher levels of SW. It seems that communications and social support that are related to the health, have decisive effect, and are social determinant on various aspects of health, including SW [21]. Gilmour in his study reported that Canadian seniors with more social contacts, had better health and well-being [22]. Therefore, the presence of those who can be trusted and counted on, makes people feel important and valuable. Therefore, communicating in person or over the phone has a beneficial role in maintaining older people’s social, spiritual, physical, and mental health.
Obviously, aging population continues and older people gradually lose their ability to do the daily activities due to the occurrence of physical and mental illness. On the other hand, families now become more and more nuclear, and no one in the family may have the time to look after an elderly person. As a result, the demand for nursing home care for the aged are increasing. Hence, it is very important to provide comfort and welfare and improve various dimensions of health, especially social well-being, in the nursing homes for seniors who are at risk of social exclusion. The findings of this study can be useful for proper planning to maintain the health of elderly people living in the nursing homes. Since this research was a questionnaire-based cross-sectional study, it might be influenced by the feelings and conditions of the elderly; it is suggested that a qualitative study be conducted with in-depth interviews in this area.

Ethical Considerations
Compliance with ethical guidelines

This study was approved by the Ethics Committee of Guilan University of Medical Sciences (Code: 912212).

Funding
This paper was extracted from master thesis authored by Arezoo Mirzazadeh which has been approved by School of nursing at Guilan University of Medical Sciences, and is an approved plan of Social Determinants of Health Research Center at Guilan University of Medical Sciences.

Authors contributions
Authors all contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank professors and authorities of the School of Nursing and Midwifery, the nursing homes (private and semi-private) in Rasht, and dear seniors who assisted us in this research. Hereby, we would like to thank Vice-Chancellor of Research at Guilan University of Medical Sciences and Social Determinants of Health (SDH) Research Center. We also express our gratitude towards agings who helped conducting the research.


Reference
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  2. Jadidi A, Farahaninia M, Janmohammadi S, Haghani H. [The relationship between spiritual well-being and quality of life among elderly people residing in Kahrizak senior house (Persian)]. Iranian Journal of Nursing. 2011; 24(72):48-56.
  3. Alidoust S, Holden G, Bosman C. [Urban environment and social health of the elderly: A critical discussion on physical, social and policy environments (Persian)]. Athens Journal of Health. 2014; 1(3):169-80.
  4. United Nations. Trends in contraceptive use worldwide. New York: United Nations; 2015.
  5. SalamatNews. [Formation of Seniority Committee for the prevention of aging of the population (Persian)] [Internet]. 2013 [Updated 2013 October 20]. Available from: http://www.salamatnews.com/news/84953 
  6. Khalili F, Sum S, Asayesh H. [Spiritual health among Isfehanian elderly people (Persian)]. Iranian Journal of Ageing. 2013; 8(28):16-23.
  7. Babapour khyraldyn J, Tosi F, Hekmati I. [Study of determinant factors role of students’ social well-being (Persian)]. Journal Management System. 2009; 4(16):1-19.
  8. Frouzbakht M, Riahi ME, Tirgar A. [A study of the effective factors on the woman,s social heath: A review in Persian scientific journals (Persian)]. Community Health Summer. 2017; 4(3):190-200.
  9. Negovan V. Dimensions of students’ psychosocial well-being and their measurement: Validation of a students’ psychosocial well being inventory. Europe’s Journal of Psychology. 2010; 6(2):85-104.
  10. Damari B, Nasehei A, Vosoogh Moghaddam A. [What should we do for improving Iranian social health? Situational analysis, national strategies and role of ministry of health and medical education (Persian)]. Journal of School of Public Health and Institute of Public Health Research. 2013; 11(1):45-58.
  11. Hezar Jariby J, Arfaie Einaldyn R. [Eisure time and social health (Persian)]. Social Development & Welfare Planing. 2012; 3(10):39-64.
  12. Khalili F, Sum S, Sharifirad Gh, Hassanzadeh A, Kazemi M. [The relationship between perceived social support and social health of elderly (Persian)]. Health System Research. 2011; 7(6):1216-25.
  13. Croezen S, Picavet HS, Haveman Nies A, Verschuren WM, de Groot LC, van’t Veer P. Do positive or negative experiences of social support relate to current and future health? Results from the Doetinchem Cohort Study. BMC Public Health. 2012; 12:65. [DOI:10.1186/1471-2458-12-65] [PMID] [PMCID]
  14. Abachizadeh K, Tayefi B, Nasehi AA, Memaryan N, Rassouli M, Omidnia S, et al. Development of a scale for measuring social health of Iranians living in three big cities. Medical Journal of the Islamic Republic of Iran. 2014; 28:2. [PMID] [PMCID]
  15. Hosseini M, Dakhteh Harooni M, Yaghmaei F, Alavi Majd H . [Correlation of social support and health in an elderly population in Iran (Persian)]. Advances in Nursing & Midwifery. 2009; 21(73):25-30.
  16. Abachizadeh K, Omidnia S, Hajebi A, Asadi A, Rassouli M, Leila B. [Measuring self-rated social health of Iranians: A population based survey in three cities (Persian)]. Novelty in Biomedicine. 2014; 2(3):79-84.
  17. Seyfzadeh A. [Investigating the elders’ social health and Its related factors: A case study of Azarshahr city (Persian)]. Journal of Geriatric Nursing. 2015; 1(4):95-106. 
  18. Zahedi Asl M, Darvishifard AA. [Social factors influencing the social health of the elderly in Kouhdasht (Persian)]. Social Development and Welfare Planning. 2016; 7(26):9-32. [DOI: 10.22054/QJSD.2016.4880]
  19. Vameghi M, Sadighi J, Tavousi M, Jahangiri K, Azin A, Omidvari S, et al.  [Social relationships and health: Findings from the Iranian Health Perception Survey (IHPS) (Persian)]. Journal of the Iranian Institute for health Sciences Research. 2013; 12(2):183-94.
  20. Sigaroudi AE, Nayeri ND, Peyrovi H. Antecedents of elderly home residency in cognitive healthy elders: A qualitative study. Global Journal of Health Science. 2013; 5(2):200-7. [DOI:10.5539/gjhs.v5n2p200] [PMID] [PMCID]
  21. Alavi S, Ahmadi MA, Zar A. [Association beween physical activity and social health and spiritual intelligence among nurses (Persian)]. Community Health. 2018; 5(2):94-102.
  22. Gilmour H. Social participation and the health and well-being of Canadian seniors. Health Reports. 2012; 23(4):23-32. [PMID]
Article Type : Research | Subject: Special
Received: 2018/02/24 | Accepted: 2018/06/12 | Published: 2019/01/1

References
1. Saydshohadai M, Heshmat Sh, Seidfatemi N, Haghani H, Mehrdad N. [The spiritual health of seniors living in sanitarium and home residents (Persian)]. Iranian Journal of Nursing. 2013; 26(81):11-20.
2. Jadidi A, Farahaninia M, Janmohammadi S, Haghani H. [The relationship between spiritual well-being and quality of life among elderly people residing in Kahrizak senior house (Persian)]. Iranian Journal of Nursing. 2011; 24(72):48-56.
3. Alidoust S, Holden G, Bosman C. [Urban environment and social health of the elderly: A critical discussion on physical, social and policy environments (Persian)]. Athens Journal of Health. 2014; 1(3):169-80. [DOI:10.30958/ajh.1-3-1]
4. United Nations. Trends in contraceptive use worldwide. New York: United Nations; 2015.
5. SalamatNews. [Formation of Seniority Committee for the prevention of aging of the population (Persian)] [Internet]. 2013 [Updated 2013 October 20]. Available from: http://www.salamatnews.com/news/84953
6. Khalili F, Sum S, Asayesh H. [Spiritual health among Isfehanian elderly people (Persian)]. Iranian Journal of Ageing. 2013; 8(28):16-23.
7. Babapour khyraldyn J, Tosi F, Hekmati I. [Study of determinant factors role of students' social well-being (Persian)]. Journal Management System. 2009; 4(16):1-19.
8. Frouzbakht M, Riahi ME, Tirgar A. [A study of the effective factors on the woman,s social heath: A review in Persian scientific journals (Persian)]. Community Health Summer. 2017; 4(3):190-200.
9. Negovan V. Dimensions of students' psychosocial well-being and their measurement: Validation of a students' psychosocial well being inventory. Europe's Journal of Psychology. 2010; 6(2):85-104. [DOI:10.5964/ejop.v6i2.186]
10. Damari B, Nasehei A, Vosoogh Moghaddam A. [What should we do for improving Iranian social health? Situational analysis, national strategies and role of ministry of health and medical education (Persian)]. Journal of School of Public Health and Institute of Public Health Research. 2013; 11(1):45-58.
11. Hezar Jariby J, Arfaie Einaldyn R. [Eisure time and social health (Persian)]. Social Development & Welfare Planing. 2012; 3(10):39-64.
12. Khalili F, Sum S, Sharifirad Gh, Hassanzadeh A, Kazemi M. [The relationship between perceived social support and social health of elderly (Persian)]. Health System Research. 2011; 7(6):1216-25.
13. Croezen S, Picavet HS, Haveman Nies A, Verschuren WM, de Groot LC, van't Veer P. Do positive or negative experiences of social support relate to current and future health? Results from the Doetinchem Cohort Study. BMC Public Health. 2012; 12:65. [DOI:10.1186/1471-2458-12-65] [PMID] [PMCID] [DOI:10.1186/1471-2458-12-65]
14. Abachizadeh K, Tayefi B, Nasehi AA, Memaryan N, Rassouli M, Omidnia S, et al. Development of a scale for measuring social health of Iranians living in three big cities. Medical Journal of the Islamic Republic of Iran. 2014; 28:2. [PMID] [PMCID] [PMID] [PMCID]
15. Hosseini M, Dakhteh Harooni M, Yaghmaei F, Alavi Majd H . [Correlation of social support and health in an elderly population in Iran (Persian)]. Advances in Nursing & Midwifery. 2009; 21(73):25-30.
16. Abachizadeh K, Omidnia S, Hajebi A, Asadi A, Rassouli M, Leila B. [Measuring self-rated social health of Iranians: A population based survey in three cities (Persian)]. Novelty in Biomedicine. 2014; 2(3):79-84.
17. Seyfzadeh A. [Investigating the elders' social health and Its related factors: A case study of Azarshahr city (Persian)]. Journal of Geriatric Nursing. 2015; 1(4):95-106.
18. Zahedi Asl M, Darvishifard AA. [Social factors influencing the social health of the elderly in Kouhdasht (Persian)]. Social Development and Welfare Planning. 2016; 7(26):9-32. [DOI: 10.22054/QJSD.2016.4880]
19. Vameghi M, Sadighi J, Tavousi M, Jahangiri K, Azin A, Omidvari S, et al. [Social relationships and health: Findings from the Iranian Health Perception Survey (IHPS) (Persian)]. Journal of the Iranian Institute for health Sciences Research. 2013; 12(2):183-94.
20. Sigaroudi AE, Nayeri ND, Peyrovi H. Antecedents of elderly home residency in cognitive healthy elders: A qualitative study. Global Journal of Health Science. 2013; 5(2):200-7. [DOI:10.5539/gjhs.v5n2p200] [PMID] [PMCID] [DOI:10.5539/gjhs.v5n2p200]
21. Alavi S, Ahmadi MA, Zar A. [Association beween physical activity and social health and spiritual intelligence among nurses (Persian)]. Community Health. 2018; 5(2):94-102.
22. Gilmour H. Social participation and the health and well-being of Canadian seniors. Health Reports. 2012; 23(4):23-32. [PMID] [PMID]

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