Active Aging (AA), which is the process of health promotion, collaboration, and increasing the quality of life in old age, may be a strategy to prevent many future challenges in countries like Iran that have a rapidly aging population. This study aimed to measure AA dimensions in Iran and examine their associations with the quality of mental health among Iranian elderly. A quantitative cross-sectional survey of a random sample of 623 community residents of Tehran aged 55 years or older was conducted. In total, 590 people responded. AA was measured using the Active Aging Index (AAI), including four domains, and mental health of the participants was measured using the 15-item General Health Questionnaire (GHQ) scale. Associations between AA and GHQ was examined using Mixed-Effect Linear Regression analysis. The overall AAI score was calculated at 26.8 (men 33.9 vs. women 20.6) out of 100. Higher scores in the first domain (employment) and lower scores in the third domain (independent, healthy, and secure living) and the fourth domain (enabling environment) were linked with poorer mental health, but the second domain (participation in society) showed no association. Different aspects of AAI showed different associations with mental health. In addition, it seems that the AAI, as a tool for measuring AA, needs a profound modification in the Iranian context, using qualitative studies in Iran.
Iran is a country with a strong cultural and religious background and about 97% of its population are Shia Muslims (
Active Aging (AA) may be a strategy that can address many of the future challenges of population aging in Iran as well as other regions. AA refers to a situation where people participate in the formal labor market, engage in unpaid productive activities, and live healthy, independent, and secure lives as they age (
Mental disorders are very common in old age, which can also adversely influence the physical health and quality of life of older people (
One of the factors is the level of having an active life in old age, so that with increasing activity, mental health is expected to improve (
Despite the importance of population aging in Iran, the extent of active and productive life among older people of Iran and its link to health has not been well researched. There are only a few studies measuring selective aspects of activity or are qualitative studies (
This study was a quantitative cross-sectional survey of older people, aged 55+ years old, living in Tehran. This age border was selected based on the indicators defined in the original AAI. For this study, 623 samples were selected based on an alpha level of 0.05 and power of 80% using an expected odds ratio (OR) of 2 and a design effect of 1.5 and expected 10% non-response, based on results from earlier studies (
The study variables were collected using a structured multi-sectional questionnaire. Given that one third of the elderly were illiterate, the questionnaires, after providing the necessary explanations and obtaining their informed consent, were completed through face-to-face structured interviews at their home. Transparency and clarity of the questions were already checked in a pilot study with older people. The first section of the questionnaire consisted of demographic and socioeconomic characteristics of the elderly such as age, sex, education, marital status, family size, employment status, and income. The quality of participant mental health, as the outcome variable in this survey, was assessed by 15-item General Health Questionnaire (GHQ) scale, its’ reliability and validity already approved by Malakouti and colleagues (2007) in a previous study on Iranian elderly. This scale measures four dimensions of mental health including physical symptoms, social functioning, depression, and anxiety, with a maximum score of 45 and a minimum of zero. Higher scores on the scale indicate poorer mental wellbeing. The status of the AA among older people was also measured by the original AAI, as developed by Zaidi and colleagues (
This index comprises 22 individual indicators that are disaggregated by sex and grouped into four domains including “Employment” (four indicators), “Participation in society” (three indicators), “Independent, healthy and secure living capacity” (19 indicators), and “Enabling environment for active aging” (three indicators; see
Domains, indicators and overall scores of AAI (raw and weighted) of people 55+ years old in Tehran-2018
Domains | Indicators | Indicator Score | Indicator weight within domain | Weighted Indicator Score | Domain Score | Domain weight within overall AAI | Weighted Domain Score | ||||
---|---|---|---|---|---|---|---|---|---|---|---|
Total | Male | Female | Total | Male | Female | ||||||
1. Employment | 1.1 Employment rate 55–59 | 37.5 | 65.7 | 19.8 | 25 | 9.4 | 14.4 | 4.9 | Total: 27.2 |
35 | Total: 9.5 |
1.2 Employment rate 60–64 | 24.5 | 44.0 | 6.6 | 25 | 6.1 | 11.0 | 1.6 | ||||
1.3 Employment rate 65–69 | 24.5 | 39.3 | 8.6 | 25 | 6.1 | 9.8 | 2.1 | ||||
1.4 Employment rate 70–74 | 22.5 | 32.0 | 6.6 | 25 | 5.6 | 8.0 | 1.6 | ||||
2. Participation in society | 2.1 Voluntary work (aged 55+) | 31.0 | 38.3 | 23.5 | 25 | 7.7 | 9.6 | 5.9 | Total: 21.4 |
35 | Total: 7.5 |
2.2 Care to children (aged 55+) | 34.4 | 30.9 | 37.8 | 25 | 8.6 | 7.7 | 9.4 | ||||
2.3 Care to older adults (aged 55+) | 12.5 | 11.7 | 13.3 | 30 | 3.7 | 3.5 | 4.0 | ||||
2.4 Political participation (aged 55+) | 6.9 | 8.0 | 5.8 | 20 | 1.4 | 2.4 | 1.7 | ||||
3. Independent, healthy and secure living | 3.1 Physical exercise (aged 55+) | 49.6 | 57.5 | 41.6 | 10 | 5.0 | 5.7 | 4.2 | Total: 41.4 |
10 | Total: 4.1 |
3.2 Access to health and dental care (aged 55+) | 26.5 | 21.0 | 32.0 | 20 | 5.3 | 4.2 | 6.4 | ||||
3.3 Independent living (aged 75+) | 44.8 | 42.8 | 48.3 | 20 | 9.0 | 8.5 | 9.7 | ||||
3.4 Relative median income (aged 65+) | 55.0 | 60.0 | 50.0 | 10 | 5.5 | 6.0 | 5.0 | ||||
3.5 No poverty risk (aged 65+) | 50.0 | 60.0 | 40.0 | 10 | 5.0 | 6.0 | 4.0 | ||||
3.6 No material deprivation (aged 65+) | 22.9 | 23.6 | 22.2 | 10 | 2.3 | 2.4 | 2.2 | ||||
3.7 Physical safety (aged 55+) | 76.1 | 73.4 | 78.8 | 10 | 7.6 | 7.3 | 7.9 | ||||
3.8 Lifelong learning (aged 55–74) | 16.9 | 15.8 | 17.9 | 10 | 1.7 | 1.6 | 1.8 | ||||
4. Capacity and enabling environment for active aging | 4.1 Life expectancy at age 55 | 24.2 | 23.6 | 24.7 | 33 | 8.0 | 7.8 | 8.1 | Total: 28.7 |
20 | Total: 5.7 |
4.2 Share of healthy life expectancy at age 55 | 13.9 | 13.2 | 14.5 | 23 | 3.2 | 3.0 | 3.3 | ||||
4.3 Mental well-being (aged 55+) | 42.8 | 42.7 | 43.0 | 17 | 7.2 | 7.3 | 7.3 | ||||
4.4 Use of ICT (aged 55–74) | 34.6 | 36.6 | 32.8 | 7 | 2.4 | 2.5 | 2.3 | ||||
4.5 Social connectedness (aged 55+) | 45.2 | 47.1 | 43.3 | 7 | 5.9 | 6.1 | 5.6 | ||||
4.6 Educational attainment (aged 55+) | 29.0 | 35.4 | 23.2 | 13 | 2.0 | 2.5 | 1.6 | ||||
Overall score of AAI | 100 | Total: 26.8 |
The data were described using descriptive statistics including mean, standard deviation, frequency, and percentage. Normality of the outcome variable (mental health) was checked through Kolmogorov-Smirnov test, histograms, and Q-Q plots, which all indicated non-normal distribution. Thus, Spearman Correlation Analysis was used to check the correlations among exposure and outcome variables. In order to examine associations between the domains of the AAI and its overall score with the mental health of older people, multi-level linear regression analysis (mixed-effect model) was used, due to the clustering of samples in different neighborhoods. Before decision on the inclusion of covariates in the models, co-linearity between all the study variables was checked and the highly correlated variables were removed. Regression analysis were performed in four models; in Model 1, crude analysis was conducted to check the association of each independent variable (domains and overall score of the AAI) with the GHQ scores separately. As the overall AAI score was calculated by its four domains, separate models were then used for associations of domains and the overall score of the AAI with the outcomes. In Model 2, first the crude associations of domains were checked and then in Model 3 associations with adjusting the effects of covariates were tested. Finally, in Model 4, the associations of the overall AAI score with GHQ scores adjusted for the effects of covariates were examined. The rate of missing data was very low in this study (about 3%), thus observations with missing values were disregarded in the analyses. All the analyses were conducted using STATA software version 14.
In total, 590 people (297 men, 293 women) out of 623 pre-defined sample size responded (response rate 94%). The main (SD) age was 64.9 (9.4) years and 78% were married. The mean (SD) of family size of participants was 13.7 (7.9%) and 13% were living alone. Regarding education, 28% of participants were illiterate and 34% had ended with primary schooling. Most of the participants (59%) reported to have very low or low income and 37% described themselves as being poorer than the average of residents of Tehran.
Scores of the AAI of the participants by gender, including the domain scores and the overall score, is shown in
The descriptive results regarding the mental health of participants as measured by the GHQ-15 are reported in
Frequency distribution of mental health status of older people aged 55+ using GHQ-15
Have you recently… | 0 (No) N (%) | 1 (Sometimes) N (%) | 2 (Often) N (%) | 3 (Always) N (%) | |
---|---|---|---|---|---|
GHQ1 | Been getting any pains in your head? | 197 (33.4) | 278 (47.1) | 82 (13.9) | 33 (5.6) |
GHQ2 | Lost much sleep over worry? | 183 (31) | 223 (37.8) | 150 (25.4) | 34 (5.8) |
GHQ3 | Had difficulty in staying asleep once you are off? | 200 (33.9) | 230 (39) | 133 (22.5) | 27 (4.6) |
GHQ4 | Been feeling nervous and strung-up all the time? | 186 (31.5) | 225 (38.1) | 152 (25.8) | 27 (4.6) |
GHQ5 | Been taking longer over the things than usual you do? | 72 (12.2) | 341 (57.8) | 170 (28.8) | 7 (1.2) |
GHQ6 | Been managing to keep yourself busy and occupied? | 119 (20.2) | 332 (56.3) | 134 (22.7) | 5 (0.8) |
GHQ7 | Felt on the whole you were doing things well? | 59 (10) | 308 (52.2) | 214 (36.3) | 9 (1.5) |
GHQ8 | Been satisfied with the way you have carried out your tasks? | 64 (10.8) | 302 (51.2) | 210 (35.6) | 14 (2.4) |
GHQ9 | Felt that you are playing a useful part in things? | 61 (10.3) | 311 (52.7) | 203 (34.4) | 15 (2.5) |
GHQ10 | Been able to enjoy your normal day-to-day activities? | 99 (16.8) | 313 (53.1) | 170 (28.2) | 8 (1.4) |
GHQ11 | Been thinking of yourself as a worthless person? | 361 (61.2) | 163 (27.6) | 55 (9.3) | 11 (1.9) |
GHQ12 | Felt that life is entirely hopeless? | 343 (58.1) | 151 (25.6) | 78 (13.2) | 18 (3.1) |
GHQ13 | Felt that life isn’t worth living? | 374 (63.4) | 127 (21.5) | 71 (12) | 18 (3.1) |
GHQ14 | Found at times you couldn’t do anything because your nerves were too bad? | 251 (42.5) | 222 (37.6) | 99 (16.8) | 18 (3.1) |
GHQ15 | Found yourself wishing you were dead and away from it all? | 400 (67.8) | 114 (19.3) | 49 (8.3) | 27 (4.6) |
The results of mixed-effect linear regression model on the associations between the AAI and the GHQ using four models are presented in
Associations between the domains of Active Aging Index and its overall score and GHQ (Mixed-effect linear regression analysis)
GHQ | Model 1 Crude analysis | Model 2 Association with domains | Model 3 Association with domains + Covariates | Model 4 Association with overall AAI+ Covariates |
---|---|---|---|---|
Coefficient (p) | Coefficient (p) | Coefficient (p) | Coefficient (p) | |
AAI1 | 0.006 (0.331) | 0.007 (0.214) | - | |
AAI2 | 0.01 (0.396) | 0.02 (0.053) | 0.009 (0.411) | - |
AAI3 | - | |||
AAI4 | - | |||
Overall AAI | - | - | 0.01 (0.404) | |
Age (older) | - | - | 0.04 (0.261) | 0.06 (0.098) |
Gender (women) | - | - | 0.90 (0.178) | 0.28 (0.699) |
Income (poorer) | - | - | 1.01 (0.091) | 0.87 (0.211) |
Marital status (non-married) | - | - | 0.42 (0.582) | 0.97 (0.238) |
Family Size (larger) | - | - | 0.01 (0.64) | 0.03 (0.481) |
Education (illiterate) | - | - | ||
Ethnicity (non-Persian) |
Aging is usually associated with a decline in physical and mental functioning. Functional disabilities, together with the sedentary lifestyle in old age, exacerbates the problems facing old people and imposes heavy economic, social, and psychological costs on their own health and on communities (
Research on mental health status among Muslim population is limited. It is generally expected that religion plays a positive role in filling the voids of life and supporting aging, coping with stress, adapting to circumstances, providing meaning for life and death, and encouraging older people to engage in group religious activities and ceremonies (
“Active Aging” strategies, could enable people to enhance their potential for physical, social, and mental wellbeing throughout the whole life course and to participate in society according to their needs, desires, and capacities (
The findings of this study on associations between the AAI and GHQ scores, controlled for the effects of covariates (Models 3 and 4) showed that except the AAI2 and the overall score of the AAI, other domains had a significant association with the GHQ score. However, the result of the AAI1 (employment) is in contrast with our earlier hypothesis, indicating higher employment rate is associated with poorer mental health, but the direction of association between the other two domains (AAI3 and AAI4) with mental health was compatible with the prior hypothesis. The opposite direction of the AAI1 with mental wellbeing might reflect a forced employment, rather than it being a choice, due to low retirement savings or pensions, poor working conditions, and poor economic status among the elderly. This conclusion is supported by an earlier study (
Comparison of the overall and domain-specific scores of the AAI of Iranian seniors with those of the EU-28 countries in 2018
The result of this study showed no significant association between the 2nd domain (participation in society) and mental health, while, based on the results of earlier studies (
As aforementioned, a significant positive link was found between the 3rd and 4th domains of the AAI with mental health, indicating that being dependent and also living in a disabling environment, would lead to significantly poorer mental wellbeing of older people. However, despite such an important effect, these two domains share only 20% and 10% of the overall weight of the AAI score, respectively. This needs considerable attention in further studies and probably require increasing the weight of these domains in the Iranian context. As shown in
With regard to the 3rd domain, “independent, healthy, and secure living capacity”, a crucial aspect is the capacity to live independently in older age, not only regarding housing but also in economic terms. It is stated that these aspects are highly correlated with education, e-literacy and physical and mental health, often developed in the earlier stages of life. Therefore, the life-course perspective should be taken into account when analyzing active aging (
As the AAI is a rather new instrument, there is little research examining the effects of the AA measured by the AAI and mental health of older people, which highlights the necessity of work and research on this relatively new area, as populations are becoming older. The AAI contributes to making older people’s participation to society more visible, and helps policymakers and other stakeholders understand which areas present more challenging situations, thus requiring more effective interventions to accomplish a societally more balanced aging experience (
The results of this study are valuable and have clinical implications for improvements of mental health of elderly. For instance, strong associations of enabling living environment including living independence and creating a safe life was approved and thus implementing relevant strategies by health workers could be suggested. Additionally, interventions to increase social participation and interaction, physical activity, living with other family members, lifelong learning and access to education are all effective in improving mental health that could be considered by health professionals. Providing regular health education for older people to encourage them to engage in regular physical activity, especially in groups with other people, engaging families and caregivers in more interaction with the elderly and emphasizing reducing their lonely feelings, delegating responsibilities to them so that the individual feel usefulness, and increasing elderly access to education and learning are all ways that mental health professionals can apply to promote the mental health of older people. However, the main weakness of this study is its cross-sectional design, so that the temporal relationships between the overall AAI and its domains with mental health of older people cannot be ascertained and a reverse causality is highly possible. Undertaking a longitudinal study in the future would help to address this concern. Additionally, the results of this study are only generalizable to older people of Tehran. The next survey should be conducted at the national level to be able to have a broader view on the status of the AAI among older people of the whole country including those in less urban areas. Before doing the next study, another recommendation is to conduct a qualitative study to develop a localized AAI questionnaire in the Iranian context. The weight of the indicators or domains might also be different from the original AAI. It is also recommended for further study to do analysis for data of men and women separately, as they had considerable differences in many of the indicators of the AAI.
Conflicts of interest: The authors have no conflicts of interest to disclose.