Today, with the advancement of medical knowledge, lower reproductive rate, socioeconomic development and the improvement of nutritional status, life expectancy and consequently the elderly population is rapidly increasing in the world. According to the estimation of UN Population Division, the population of elderly in the world will increase by approximately 22% by 2050 [1]. In Iran, according to the last census, the population of elderly people is increasing, as it has increased from 7.27% in 2006 to 8.26% in 2011, and based on forecasts, it will reach to over 10 million by 2021 [2]. According to the statistics, Iran is in a transition stage from young population to middle-age population and soon will be among countries with old population [3].
Health, which often declines with increasing age, is one of the determinants of quality of life, and one of the most common health-threatening problem in old age is mental health disorder [4]. Mental health is one of the most important aspects of elderly health, which requires special attention [5]. The concept of aging refers to gradual deterioration of body function including mental deterioration, which reduces freshness and vitality, self-confidence, risk taking desire, and sense of being useful and belonging; therefore, creates different degree of mental problems at different age [6].
Mental health, as a psychological and social phenomenon, not only plays a role in psychological status of individuals, but also creates a healthy life style for the entire society in a positive social environment. According to the theory of Karl Menninger, mental health is the maximum compatibility of individuals with the world around them, is such way that, makes them happy [7]. What current knowledge pays attention to, is not just prolonging life, but trying to make the final years of people’s life peaceful alongwith mental and physical health. If such condition is not provided, scientific advances, to ensure longer life, will be faced with precarious results [8].
Thus, knowing the mental status of elderly population helps to find out their needs and facilitate healthcare planners to make appropriate plan for them. Since, the evaluation of mental health in a society is important to determine the type of interventions and predict health and social needs of the society, and also as in Iran no study could be located which specifically focused on this issue, this qualitative study was conducted to identify factors that affect the mental health of elderly population.
Materials and Methods
This was a qualitative study with content analysis approach which was conducted on 15 elderly individuals in the city of Tehran from June to October in 2015. Participants (15 elderly people’s) were chosen based on purposive sampling and saturation principles. The inclusion criteria was: lack of cognitive problems, lack of mental illness, age of over 65 years and ability to speak in Farsi. Elderly reluctance to continue cooperation was excluded.
Study data were collected by conducting semi-structured face-to-face in-depth interviews. The interview began with the main question about their experiences of everyday life, and thereafter exploratory questions were asked to encourage the participants and to access deeper information. The participants were asked questions such as; what makes you happy or gives you psychological pleasure? Each participant was interviewed for one to three times. Interviews lasted from 45 to 90 minutes. The time and the place of interview sessions was determined based on participants’ preferences. Accordingly, interviews were conducted either at participants’ home or in public places such as city parks. We recorded all the interviews by using a digital sound recorder. Data collection was continued until data saturation was reached.
After each interview, in the shortest possible time, the recorded information was studies several times and was written down on paper word by word.
The information that had been transferred on paper was typed and compared with the audio recorded information. The data analysis began during the initial phase of the data collection. This helped in the process of reading and re-reading and formation of concepts during data collection and can direct the collection of additional data to obtain appropriate information, so the best answer could be found to the study question [9,10]. During the data analysis, firstly the analysis units were identified. The entire text of the interview was considered as the unit of analysis for the present study.
Then meaning units were determined which covered various aspects of the concept. Then coding process was done, during which the meaning units (Coding) were compressed and converted to the code. The codes were summarized and categorized and formed into categories. Then, the repeated categories formed the theme [11,12]. For data credibility, long-term engagement, integrated data collection (field notes, manuscripts and recordings), review and revise of supervisor and constant comparison of data were used. For dependency, which indicates the stability and reliability of the data, external review (Member Check) in the form of additional comments of colleagues and review of manuscripts by the participants were used. By presenting reports, manuscripts and notes of two nursing professors (who were not among study researchers) and receiving their result, the confirmability of results was determined. Transferability was achieved with rich descriptions of the study data [13,14].
Ethical Considerations
The present study was taken from a research project approved by Behavioral Sciences Research Center, Baqiyatallah University of Medical sciences, ethical committee. Before data collection, the research objectives were explained to the participants and only after acquiring their agreement, the interviews were recorded. Also, it was ensured that information be kept confidential and the participants were free to leave or continue with the study.
Results
In total, eight women and seven men aged from 65 to 84 years participated in the study. Eight participants had elementary or secondary education and the remaining held diploma or university degree. Moreover, nine participants were married, one was single, and five were widowed. The details are shown in [Table/Fig-1].
Demographic characteristics of participants.
| Number interviewees | Gender | Education | Age (years) | Marital status | Employment status |
|---|
| 1 | Female | Elementary education | 67 | Widowed | Housekeeper |
| 2 | Female | University degree | 68 | Married | Retired |
| 3 | Male | Diploma | 74 | Married | Retired |
| 4 | Male | Secondary education | 84 | Married | Retired |
| 5 | Female | Secondary education | 73 | Married | Housekeeper |
| 6 | Female | Elementary education | 79 | Widowed | Housekeeper |
| 7 | Male | Secondary education | 73 | Widowed | Retired |
| 8 | Female | Diploma | 74 | Married | Retired |
| 9 | Male | University degree | 65 | Married | Retired |
| 10 | Female | Elementary education | 72 | Married | Housekeeper |
| 11 | Male | Secondary education | 74 | Married | Retired |
| 12 | Male | University degree | 65 | Widowed | Retired |
| 13 | Female | University degree | 68 | Single | Retired |
| 14 | Female | Secondary education | 72 | Widowed | Housekeeper |
| 15 | Male | Diploma | 66 | Married | Retired |
Data analysis of the study summarized the mental health of participants in two themes of “interaction” and “Worthiness”.
Themes and categories extracted in relation to mental health of the elderly are shown in [Table/Fig-2].
Themes and categories extracted in relation to mental health of the elderlies.
| Theme | Main categories | Sub-categories | Selected codes |
|---|
| Interaction | Communication/relationship | Interpersonal communication | Talking to own, recalling past memories, visiting relatives, visiting friends visiting neighbours, observing prayer (Namaz), Praying |
| Communication with others |
| Communication with God |
| Empathy/compassion | Talking to people | Listening to him, talking to him, asking for guidance, paying attention to his advice, accepting his opinions, being consulted |
| Being consulted |
| Entertainment/ amusement | Being employed | Retirement, reading book, reading newspaper, going to park, watching TV, listening to radio, doing domestic work |
| Studying and learning |
| Using the media |
| Going to park |
| Worthiness | Support | Family support | Support of spouse, support of children, support of neighbours, support of friends, support of brothers and sisters, social support |
| Social support |
| Respect | Social respect | Being respected by spouse, being respected by children, being respected by neighbours, being respected by brothers and sisters, being respected by society, respect for personal space, respect for home and privacy, respect for religious belief |
| Family respect |
| Respect for personal space |
| Respect for beliefs |
Interaction
Elderly population requires interaction with family members, friends, relatives and society, to maintain mental health. As shown in the present study, this theme consisted of three main categories of communication/relationship, empathy/compassion and entertain-ment/amusement.
1-A: Communication/relationship
According to results of the present study, when old age people achieve healthy communication with inner and outer world, they have a sense of satisfaction and a sound mental health. This category consists of three sub-categories: interpersonal communication, communication with people, communication with God.
A 79-year-old female elderly with Elementary education said:
“The best time for me is when I talk to myself, telling myself that I still have to live and be on my feet .... This way, I lift my spirit” (n=6).
A 68-year-old female graduate went on to suggest that:
“I have a good relationship with my neighbours, some of them always come over to see me, and I go to visit them. When they go shopping, they ask me if I need anything they can buy for me. At work, I had good colleagues; they used to call me on Eid (New Year). They still call me sometimes to ask how am I, and come over to visit me. I have a good relationship with them, which is nice” (n=2).
A 72-year-old female widowed, who believed relationship with the God is important to keep the spirit and mental health, stated that:
“By talking to God, I make myself empty and feel lighter. God has given me 6 children and I am still healthy so I am thankful........I pray a lot and communicating with God makes me feel lighter” (n=14).
1-B: Empathy/compassion
Participants believed that, achieving positive interaction require empathy and compassion towards others, which creates feeling of importance and maintains mental health. According to the results of this study, this category included two subcategories of talking to other people and being consulted.
A 79-year-old woman whose amusement was visiting and talking with others stated that:
“I have few friends who are the same age as me. We talk, and keep each other’ company. It makes us busy and lifts our spirit” (n=6).
A 68-year-old woman who had higher education talked about being consulted by her children and how that makes her happy:
“My children don’t do anything without consulting me; they trust me one hundred percent. My son lives in Canada but consults me when he has any problem for instance, when he wants to move his home or about his work situation. My younger son lives in Holland, and he calls me whenever he wants to go somewhere or buy anything. He consults with me when he wants to do something” (n=2).
1-C: Entertainment/amusement
Majority of the elderly believed that, life without entertainment and amusement leads to boredom and depression and consequently mental health disorder. This category consisted of 4 subcategories; being employed, studying and learning, using media, and going to park.
A 68-year-old female participant who believed retirement had harmed her mental health stated that:
“When I retired I began to feel empty, I loved my job”(n=13).
A 74-year-old woman in this regard said:
“I watch TV and listen to the radio, especially medical programs. I also like TV series” (n=8).
A 65-year-old educated male sated:
“I often fill my free times with study, especially at nights when I have more free time. I read books and newspapers but I get tired very soon. I’m interested to study during morning. It is an amusement for me and keeps me active mentally and intellectually” (n=9).
Worthiness
Sense of worthiness was another factor expressed by the participants, which had a great impact on their mental health. This Theme consisted of two categories: support and respect.
2-A: Support
Majority of participants in this study required the support of others due to decline in their abilities. They referred to support as one of the main factors that affect the sense of worthiness and improve their mental health. This category contained two subcategories of family support and social support.
An 84-year-old male participant stated:
“If I am not able to do daily activities, I expect others to help me, or if I want to go to doctor, I expect them to come and take to doctor...... I have good children, and they help me with the rent” (n=4).
A 74-year-old retired male with 20 years of work experience, who felt ashamed for not being able to cover his living costs, stated that:
“Society does not help and support elderlies with low-income who do not have the ability to work due to old age” (n=3).
2-B: Respect
All elderly participants stated that, being respected is an important factor in maintaining mental health of old age people. This category consisted of 4 subcategories; social respect, family respect, respect for personal space, and respect for belief.
A 65-year-old participant in respect to respectful behaviour of spouse and children stated that:
“My wife always respects me. I can see that in her behaviour; when I return home, she warmly greets me and respects my wishes. My children respect me too, and always answer me politely” (n=12).
A 67-year-old female in regard to respect for privacy, stated that:
“One of our neighbours causes problem, their television voice is too loud; they make a lot of noise and have many guests. They speak loud in the stairs, and often have guests until late night" (n=1).
Discussion
Based on the findings of the research, the themes extracted from the data included; interaction and worthiness. In regard to the theme “interaction”, the participants believed that, their mental health depends on effective communication/relationship, empathy/compassion, and entertainment/amusement.
Results of other studies confirm these findings. Eriksen KA et al., in their study on the recognition of human worth concluded that, in human interaction, effective communication based on respect is essential [14]. Jakobsen R and Sørlie V stated that, forming an interaction along with compatibility, empathy and comfort creates a sense of self-confidence, encouragement and hope in people [15]. In another study by Kondo N et al., on Japanese elderly population, the result showed that, old age people who had a stronger social interaction had higher mental health [16]. In regard to the impact of communication with God on the mental health of elderly, which was one of the findings in the present study, Shankar A et al., stated that, informal participations, such as prayer, praying or reading holly book had a positive effect on mental health and by influencing physiological processes, affect physical health [17]. Furthermore, considering the results of the present study regarding the effect of empathy and compassion on mental health of elderly, the study of Burkhardt MA et al., indicated that, people’s participation in decision making promotes and maintains existing potentials, and this is one of the basic rights of humans specially old age people [18].
In this regard, study of Magee H et al., indicated that, elderly tend to talk about their everyday activities, needs, limitations, thoughts, and death. Therefore, careful listening creates a perfect relationship among the elderly and caregivers [19]. In relation to subcategory of entertainment and amusement and its effect on the mental health of elderlies, Cress C in a study of 700 individuals over 65-year-old revealed that, mental activities such as reading newspaper and books on daily basis increase mental skills. Activities such as; visiting museums and reading favourite books or articles promote deep mental stimulation and quality of life [20], which is in line with the findings of this study.
Worthiness was another theme extracted in this study that included two main categories of support and respect. In this regard, Jakobsen R and Sørlie V in their study on dignity at care homes found that, losing the value of soul leads to the loss of self-confidence that can exacerbate a person’s physical or mental harm [15].
In relation to the findings of this study about the elderlies’ need for social support to maintain mental health, a study by Sinha SP et al., showed that, social support in the elderly population encourages them to have more positive attitude towards life [21]. The results of a study showed that, 58% of people over 65 years need help to carry out their daily activities [22]. Drageset J et al., stated that, the main sources of support for elderly include spouse, children, friends and relatives [23]. In relation to the impact of respect on the mental health of elderly, Levenson EA stated that, respecting old age people gives them a sense of worthiness [24]. Self-respect forms in elderlies when others respect them. However, this respect should form based on the cultural perspective of elderlies. Sometimes, it can be the respect for space, or preserving the symbols or things that make the individuality of elderlies or cause comfort in their life [22]. In regard to the subcategory of respect for personal space, studies indicate that, respecting personal space is one of the main components of holistic care to meet the needs of individuals. This gives elderlies dignity and creates a range of mutual trust, so that, a safe environment leads elderlies towards physical and mental health [21].
Limitation
Some of the social and familial characteristics were not under the control of the researcher. It is better to do a wider quantitative and qualitative study in this field in future.
Conclusion
The results of this study showed a clear picture of the impact of interaction and promoting a sense of worthiness on the mental health of elderly people. These results should encourage the officials and healthcare providers to identify the factors that influence the interaction and sense of worthiness in elderlies by keeping continuous contact with them and taking advantage of the unique opportunity they have to interact with them in order to increase the knowledge of healthcare workers and families of elderlies, about the impact of factors that influence the mental health (communication, empathy, entertainment, respect and personal space) on older age. By designing educational programs for the elderly, development of mental disorders, may be prevented in future.