Introduction

The global population is aging rapidly, driven by growing life expectancy and declining fertility rates [ 1 ]. The older adult population is expected to increase to 1,100 million by 2025 [ 2 ]. The relevance of the aging phenomenon and the prevention of associated disorders in Iran are heightened because all humans have the right to age healthily. Aging brings about several changes in the health of older persons, including a decline in physical, mental, and intellectual abilities, as well as a host of ailments [ 1 , 2 ]. Further, difficulties with self-care are inevitable for older people.

Recent research has shown that people over the age of 65 develop a wide range of medical conditions that necessitate the utilization of preexisting healthcare systems [ 3 ]. Older persons may have financial difficulties due to rising medical expenses and the strain of medical care caused by an increase in the frequency of medical treatments and hospital visits [ 4 ]. To avoid misusing health service resources, older adults may need effective health organization and self-care [ 5 ].

Self-care refers to meeting one’s needs and welfare, particularly during illness. It involves engaging in positive actions and adopting preventive habits to mitigate the risk of falling unwell. Self-care enhances health outcomes and promotes the proper utilization of health and social care resources [ 6 ]. Self-care maintenance consists of behaviors that boost welfare, protect health, or maintain emotional and physical stability [ 7 ]. Klainin and Ouannapiruk conducted a meta-analysis study on self-care among older individuals in Thailand. Their findings indicated that demographic factors, including age, gender, and education, did not exhibit a positive correlation with self-care activity [ 8 ]. Key health- promoting self-care activities encompass healthy dietary habits, regular physical exercise, effective stress management, spiritual development, positive emotions, and taking personal responsibility for one’s health . Self-care results in better health and quality of life, lower medical expenses, and greater contentment with life [ 10 ]. Quality of Life (QoL) is a crucial metric for assessing health status and is frequently utilized to gauge health disparities between various social groups [ 11 ]. Socioeconomic Status (SES) plays a significant role in defining an individual’s QoL because it is directly or indirectly associated with several conditions [ 12 ]. Over the last decade, the connection between (SES) and QoL has become a prominent topic in healthcare studies. Previous research has linked SES to various measures of QoL, including self-rated health [ 13 ]. This concept encompasses various facets of human life, such as spiritual, mental, physical, and social functions, as well as environmental and material aspects. Numerous issues, such as physical illnesses and psychological problems related to older age, can affect the QoL of frail older adults. Identifying the factors affecting QoL is a prerequisite for improving the health of the subgroups within each community [ 14 ]. Additionally, measuring QoL is the first step in designing effective interventions to enhance people’s health. Based on the Azar cohort study, which explored the relationship between self-care and QoL in hypertension patients in the northwestern provinces of Iran, medication use was the only significant predictor of QoL among older adults [ 15 ]. This study examined how self-care and socioeconomic status influences older individuals’ QoL.

Methods

Study Design and Setting

This observational cross-sectional research comprised 322 older individuals residing in Tabriz, Iran. It was conducted in early 2021 using telephone conversations with older adults in collaboration with three health specialists from Tabriz health institutions. Tabriz is the capital of the East Azerbaijan province and ranks as the fourth largest city in Iran. It is located in the country's northwest region, and over 10 percent of its residents are 60 years old or older. Tabriz is the predominant economic center and metropolis in the northwest region of Iran. The population is predominantly Azerbaijani, with Azerbaijani-Turkish being the primary language spoken. However, inhabitants also have proficiency in Persian as a secondary language [ 16 ].

Sampling

The sample size was calculated by using the following formula:

When n=sample size, Z=z statistic for a confidence

$N=\frac{Z^{2}P(1-P)}{d^2}$

level, P=expected proportion, d=precision. With a 50% chance of quality of life, a type I error of 0.05, and an absolute error of 0.5, the descriptive study formula determined that a minimum of 322 samples was needed for the study. The health center records all residents' health information according to the Iranian health system. As a result, participants were selected for the study following a review of their medical records at the health center. Using a multi-stage sampling method, sampling was performed randomly from each of the 16 health centers’ Health Integrated System (HIS) sources.

Eligibility and Exclusion Criteria

Older adults aged 60 and older with basic literacy skills and no self-reported history of chronic illness were included. Exclusion criteria were not residing in Tabriz City and having hearing or mental problems.

Measures Demographics

Demographic variables collected were sex, age, marital status, literacy, job status, and social support.

Self-care

Hemmati claims that 45 items were extracted based on a review of studies according to Orem's theory [ 17 ]. The questionnaire was condensed to 40 items in five primary categories after the content validity was validated quantitatively and qualitatively. The five identified factors accounted for 79.9% of the total variance observed in the questionnaire. The first was physical self-care, with a Cronbach's alpha (α) of 0.746. The second was daily self- care, with an α factor of 0.74; the third was psychological self-care, with an α of 0.84; the fourth was social self- care, with an α of 0.83; and finally, the fifth was the dimension of self-care during illness, which had an α of 0.90. Overall, the scale had an internal consistency of 0.86 [ 17 ]. Our study's self-care questionnaire had a Cronbach's alpha of 0.93.

Socio-economic Status (SES)

We utilized the validated and dependable questionnaire designed by Abobakri et al. to assess five domains: the primary factor (α=0.84), self-assessment of spending capability (α=0.96), income (α=0.70), home and furnishings (α=0.66), and health-related expenses (α=0.55). All components, except the wealth domain, had an interclass correlation coefficient greater than 0.6 [ 16 ].

Quality of Life

The Iranian version of the 12-item Short Form Health Survey (SF-12), a shortened form of SF-36, was used to assess the QoL related to the subjects' health. Montazeri et al. examined the validity and reliability of this questionnaire in Iran. The reliability of 12 questions on psychological and physical constituents was found to be

0.73 and 0.72, respectively. This questionnaire includes eight subscales of general understanding of self-health, encompassing emotional problems, social functioning, physical pain, physical health, vitality and vital energy, physical function, and mental health. The first four subscales are physical components, and the second four subscales are the psychological components of QoL. This questionnaire has a score range of 12 to 48 points. The items' response categories range from two to six points on a six-point scale, while the raw scores range from one to six [ 18 ]. The transformed scores are used to calculate the scores for the eight scales, with a higher score indicating better-perceived health [ 19 ]. In the current investigation, the scale's reliability was 0.90 using Cronbach’s alpha. For the quantitative content validity assessment, a panel of 8 specialized professionals found that the CVI (between 0.90 and 1.00) and CVR (between 0.88 and 0.98) results were adequate for each item and, consequently, for the SF-12.

Ethical Consideration

Before initiating the interview, verbal informed consent was secured from the legal guardians of each prospective participant. The selected individuals were invited to a research briefing, where obligatory explanations were provided about the research objectives and the implementation method. The study was approved by the regional Ethics Committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1398.753).

Statistical Analysis

Descriptive statistical methods, namely mean, standard deviation (SD), frequency, and percentage, were used to describe the data. The t-test was utilized for continuous variables, and the chi-square test was employed for stratified variables to screen for differences in fundamental features between the two groups. Initially, we incorporated the demographic characteristics variables into the study utilizing the entry approach. Next, we incorporated the demographic features and SES variables into the model during the second step. Finally, in the third step, we entered the self-care dimensions in addition to the variables from the second step. The dependent variables were dimensions of QoL, including physical health and mental health, respectively. Statistical evaluations were conducted utilizing SPSS software version 20 (Armonk, NY: IBM Corp.), and the significance level was set at 0.05.

Results

Description of the Participants

Finally, 322 older adults participated in the study (response rate: 88%). The ages of individuals spanned from 60 to 96 years, with a mean age of 68.02 (SD: 8.14). Out of 322 samples, 49.1% were male. Most participants possessed only a low or medium level of education (88%). In terms of marital status distribution, 85.8% were married. It was found that 57% were retired, 3% were employed, 21% received money from their family, and 19% had no income. About 22% of the older persons' families supported them, 22.5% were supported by their children, and 55.5% had other forms of support. Table 1 presents an overview of sample characteristics.

We used hierarchical regression to predict QoL through demographic characteristics, SES, and self-care.

A hierarchical regression analysis was used to predict QoL based on demographic variables, SES, and self-care. In the first step, demographic variables, including marital status, age, gender, and level of education, were entered into block one. Then, in the second block, SES was added to the model in addition to demographic variables.

Physical Health

In the first step (block 1), as shown in Table 2, the demographic characteristics of the respondents explained 13% of the observed variance in physical health, which was statistically significant. Marital status was the only significant predictor in this block. However, in the second block, SES increased the observed variance in physical health by only 1% (R2=0.14), which was not statistically significant. The third block studied the predictive power of self-care (physical, daily, emotional, social, and during illness self-care), combined with demographic and SES variables, for physical health. The variables in this block explained 27% of the observed variance in physical health (P<0.01).

Mental Health

In block 3, for a unit increase in during-illness self- care, the mental health dimension increased by 0.25 units (P<0.001). Additionally, in block 3, the variables predicted 29% of the variance in the mental health dimension of QoL (Table 2).

Discussion

This cross-sectional study depicts the factors determining the various dimensions of QoL in older adults over 60 in Tabriz. The results showed that demographic factors and self-care aspects determine QoL in older adults. According to the results, single women, widows, and divorced women had lower physical health than the married population. These results were consistent with the study by Kyu-Tae Han, who stated that the problems of marriage and celibacy gradually increase with age [ 20 ]. Another research highlighted that being married could serve as a potential safeguard against depressive symptoms and mental disorders in late adulthood [ 21 ]. A possible explanation for this is that married people have more family and social support, which improves mental health and even increases the survival rate of older adults with chronic diseases such as cancer [ 22 ]. Our study also showed that increasing social self-care is an effective factor in improving the physical health dimension of QoL. This observation aligns with the results of prior research, showing that QoL improves with increasing social participation among older adults. Moreover, fewer relationships with friends are associated with decreased QoL [ 23 ]. It can be pointed out that older adults who have more opportunities to socialize and interact with others feel less lonely, and their self-esteem and life satisfaction are strengthened. Therefore, more participation by older adults in society can help increase their QoL.

Our study revealed that increasing self-care during illness is the only effective factor in raising the mental health dimension of QoL. Additionally, other studies have reported gender, SES, health insurance, and current employment status as factors affecting mental health and QoL in older adults [ 24 ]. Therefore, a possible reason for the increase in mental health and QoL when a person can take care of themselves during illness could be their self- confidence and lack of reliance on others, which prevent them from feeling like a burden.

The current study also found that SES, emotional, and physical self-care were directly and positively associated with the social health QoL of older adults. In contrast, age and social self-care were negatively associated with this dimension. Momenabadi's study indicated that social participation has a notable relationship with age, level of education, marital status, and occupation [ 25 , 26 ]. Moreover, a direct and substantial correlation was noted between social participation and QoL. Recent studies have mentioned socializing and communication with friends as positive and effective factors in increasing social QoL, which is not in line with our study [ 27 ].

Regarding the relationship between SES and the increase in QoL in the social dimension, Robert’s study also showed that higher SES in all age groups is associated with better QoL. Yang’s study indicates that higher SES is a significant element in increasing the QoL of the aged [ 27 ]. Most studies have confirmed the same result. Literacy, employment, and income play essential roles in human life and communication. Improving these factors leads to more social communication and, consequently, an increase in QoL.

Our study found an inverse correlation between age and social QoL. This was consistent with Samadarshi et al.’s study [ 28 ] and Momenabadi et al.’s study [ 25 ], which stated that QoL decreases with age. In contrast, Naser Khaki’s study [ 29 ] did not note a substantial relationship between age and any dimensions of QoL. This discrepancy can be attributed to older adults in lower age groups having fewer mental, physical, and social limitations. With aging, functional disorders increase, significantly impacting their QoL. Therefore, age can be an influential factor in classifying older adults based on their needs.

Our study reveals a direct relationship between physical self-care and social QoL. These results align with prior studies indicating a positive correlation between engaging in physical activity and enhanced QoL among elderly individuals. [ 30 ]. Research in Korea also found that perceived social support positively affects physical activity, subsequently impacting QoL [ 31 ]Therefore, developing extracurricular programs and physical activities can facilitate social engagement for elderly individuals.

Our research revealed a positive correlation between emotional self-care and social QoL. Other studies have also shown that spiritual and emotional self-care are significant predictors of QoL . Emotional and spiritual self-care makes life more meaningful and can improve QoL and social participation.

Our study found that age is an effective and positive factor in mental health, which is consistent with Vahia et al.’s study [ 33 ], indicating that older people probably have robust religious convictions and a higher life expectancy. In contrast, the investigation by Seraji et al. [ 34 ] showed no relationship between age and the psychological health of elderly individuals. The SES in our study was directly related to the spiritual QoL, which is consistent with Jafaripoor et al.’s study [ 35 ] and Sadrollahi’s [ 36 ]. In contrast, the study by Lynch et al. [ 37 ] depicted that people with higher education and income have lower spiritual health.

Several limitations of this study need to be acknowledged. The present research was conducted during the COVID-19 pandemic, and data was collected via telephone interview. As a result, high-quality information may not have been collected due to a lack of face-to-face interaction between the questioner and the older person. Additionally, the state of self-care and quality of life during an epidemic differs significantly from normal life conditions. Therefore, it may not be logical to generalize the results to other contexts and times. Moreover, as the present study design is unsuitable for proving causality, prospective studies with follow-up of older people and measurement of changes are necessary.

Furthermore, this study was performed only in the center of one province. Given the significant differences in the communities’ cultural, economic, and social conditions, these variables significantly impact the main findings of this study. Therefore, conducting various studies in other parts of the country is necessary for a more precise conclusion.

Conclusion

In this study, self-care during illness, marriage, and social self-care were identified as strong predictive factors for the quality of life in older adults. The results emphasize the supportive role of the spouse and family, highlighting the need for family support and increased responsibility toward older adults. Therefore, cultivating and educating society, especially families, is necessary. This study also emphasizes the role of social support, necessitating increased participation of older individuals in social activities. To support this, managers and policymakers must provide the necessary facilities and platforms in society, especially in the health sector. Finally, the study’s findings underline older people’s dependence on self-care, highlighting the need to provide the required knowledge and skills to empower older individuals.

Acknowledgment

The authors extend their appreciation to all older people who participated in this investigation. The research protocol received approval and support from the Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran (Registration code: 61419).

Conflict of Interest

None declared.

References

1. Rudnicka E, Napierała P, Podfigurna A, Męczekalski B, Smolarczyk R, Grymowicz M. The World Health Organization (WHO) approach to healthy ageing. Maturitas. 2020; 139:6-11.
2. Afshar PF, Asgari P, Shiri M, Bahramnezhad F. A review of the Iran’s elderly status according to the census records. Galen Medical Journal. 2016; 5(1):1-6.
3. Hopman P, De Bruin SR, Forjaz MJ, Rodriguez-Blazquez C, Tonnara G, Lemmens LC, et al. Effectiveness of comprehensive care programs for patients with multiple chronic conditions or frailty: a systematic literature review. Health policy. 2016; 120(7):818-32.
4. MacLeod S, Musich S, Hawkins K, Armstrong DG. The growing need for resources to help older adults manage their financial and healthcare choices. BMC geriatrics. 2017; 17(1):1-9.
5. Yun K, Paul P, Subedi P, Kuikel L, Nguyen GT, Barg FK. Help- seeking behavior and health care navigation by Bhutanese refugees. Journal of community health. 2016; 41(3):526-34.
6. Kirk S, Beatty S, Callery P, Gellatly J, Milnes L, Pryjmachuk S. The effectiveness of self‐care support interventions for children and young people with long‐term conditions: A systematic review. Child: care, health and development. 2013; 39(3):305-24.
7. Di Nitto M, Sollazzo F, Biagioli V, Pucciarelli G, Torino F, Alvaro R, et al. Self-care behaviors in patients with cancer treated with oral anticancer agents: a systematic review. Supportive Care in Cancer. 2022; 30(10):8465-83.
8. Klainin P, Ounnapiruk L. A meta-analysis of self-care behavior research on elders in Thailand: an update. Nursing science quarterly. 2010; 23(2):156-63.
9. Goudarzi H, Salehi L. Self-care and relevant factors shaping quality of life among the elderly with and without chronic disease. Preventive Care in Nursing & Midwifery Journal. 2017; 7(2):25-32.
10. Erci B, Yilmaz D, Budak F. Effect of Self-Care Ability and Life Satisfaction on the Levels of Hope in Elderly People. Journal of Psychiatric Nursing/Psikiyatri Hemsireleri Dernegi. 2017; 8(2)
11. Mielck A, Vogelmann M, Leidl R. Health-related quality of life and socioeconomic status: inequalities among adults with a chronic disease. Health and quality of life outcomes. 2014; 12(1):1-10.
12. Didsbury MS, Kim S, Medway MM, Tong A, McTaggart SJ, Walker AM, et al. Socio‐economic status and quality of life in children with chronic disease: a systematic review. Journal of paediatrics and child health. 2016; 52(12):1062-9.
13. Knorst JK, Sfreddo CS, de F Meira G, Zanatta FB, Vettore MV, Ardenghi TM. Socioeconomic status and oral health‐related quality of life: A systematic review and meta‐analysis. Community dentistry and oral epidemiology. 2021; 49(2):95-102.
14. Tomas JM, Sancho P, Blanco-Molina M, Pinazo-Hernandis S. Measurement invariance of the self-care Scale for older people in Costa Rica and Spain. Educational Gerontology. 2023; 49(3):190-200.
15. Shishavan MK, Jafarabadi MA, Aminisani N, Shahbazi M, Alizadeh M. The association between self-care and quality of life in hypertensive patients: findings from the Azar cohort study in the North West of Iran. Health promotion perspectives. 2018; 8(2):139.
16. Abobakri O, Sadeghi-Bazargani H, Asghari-Jafarabadi M, Aghdam MBA, Imani A, Tabrizi J, et al. Development and psychometric evaluation of a socioeconomic status questionnaire for urban households (SESIran): the preliminary version. Health promotion perspectives. 2015; 5(4):250.
17. HEMMATI MM, Hashemlo L. Design and psychometric properties of a self-care questionnaire for the elderly. 2015.
18. Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of 12-item Short Form Health Survey (SF-12): factor structure, internal consistency and construct validity. BMC public health. 2009; 9(1):1-10.
19. Rohani C, Abedi HA, Langius A. The Iranian SF-12 Health Survey version 2 (SF-12v2): Factorial and convergent validity, internal Consistency and test-retest in a healthy sample. Iranian Rehabilitation Journal. 2010; 8(2):4-14.
20. Han K-T, Park E-C, Kim J-H, Kim SJ, Park S. Is marital status associated with quality of life? Health and quality of life outcomes. 2014; 12(1):1-10.
21. Gutiérrez-Vega M, Esparza-Del Villar OA, Carrillo-Saucedo IC, Montañez-Alvarado P. The possible protective effect of marital status in quality of life among elders in a US-Mexico border city. Community mental health journal. 2018; 54(4):480-4.
22. Han KT, Kim SJ, Song H, Chun SY, Kim CO, Kim JS, et al. Associations between quality of life and marital status in cancer patients and survivors. Asian Pacific journal of cancer prevention: APJCP. 2014; 15(13):5287-91. DOI | PubMed Epub 2014/07/22
23. García EL, Banegas J, Perez-Regadera AG, Cabrera RH, Rodriguez-Artalejo F. Social network and health-related quality of life in older adults: a population-based study in Spain. Quality of life research. 2005; 14(2):511-20.
24. Dongre AR, Deshmukh PR. Social determinants of quality of elderly life in a rural setting of India. Indian Journal of Palliative Care. 2012; 18(3):181.
25. Momenabadi V, Kaveh MH, Nazari M, Ghahremani L. Socio- Demographic Determinants of Quality of Life among Older People, a Population-Based Study. Elderly Health Journal. 2018; 4(2):60-7.
26. Zhuang Y, Ma Q-H, Pan C-W, Lu J. Health-related quality of life in older Chinese patients with diabetes. PloS one. 2020; 15(2):e0229652.
27. Yang Y, Wang S, Chen L, Luo M, Xue L, Cui D, et al. Socioeconomic status, social capital, health risk behaviors, and health-related quality of life among Chinese older adults. Health and quality of life outcomes. 2020; 18(1):1-8.
28. Acharya Samadarshi SC, Taechaboonsermsak P, Tipayamongkholgul M, Yodmai K. Quality of life and associated factors amongst older adults in a remote community, Nepal. Journal of Health Research. 2021. DOI
29. Khooshemehri G, Kaviani M, Asmari M, Rajabian H, Naserkhaki V. Comparison of Quality of Life for Elderly Men and Women Elderly Nursing Home Resident by Alborz Province in 1390. Alborz University Medical Journal. 2013; 2(1):19-24. DOI
30. Cunningham C, O’Sullivan R, Caserotti P, Tully MA. Consequences of physical inactivity in older adults: A systematic review of reviews and meta‐analyses. Scandinavian journal of medicine and science in sports. 2020; 30(5):816-27.
31. Kang H-W, Park M, Wallace JP. The impact of perceived social support, loneliness, and physical activity on quality of life in South Korean older adults. Journal of sport and health science. 2018; 7(2):237-44.
32. Bélanger E, Ahmed T, Vafaei A, Curcio CL, Phillips SP, Zunzunegui MV. Sources of social support associated with health and quality of life: a cross-sectional study among Canadian and Latin American older adults. BMJ open. 2016; 6(6):e011503.
33. Vahia IV, Jeste DV, Reynolds CF. Older adults and the mental health effects of COVID-19. Jama. 2020; 324(22):2253-4.
34. Seraji M, Shojaezade D, Rakhshani F. The relationship between spiritual well-being and quality of life among the elderly people residing in Zahedan city (South-East of Iran). Elderly Health Journal. 2016; 2(2):84-8.
35. Jafaripoor H, Safarabadi M, Pourandish Y, Khanmohammadi A, Mohammad Aghaiepoor S, Rahbarian A, et al. The elders’ spiritual well-being and their quality of life: a cross-sectional study. Journal of Client-Centered Nursing Care. 2018; 4(3):145-54.
36. Sadrollahi A. Spiritual Well-being and associated factors among the elderly population in Kashan. Iranian Journal of Geriatric Nursing. 2015; 1(2):94-104.
37. Lynch CP, Hernandez-Tejada MA, Strom JL, Egede LE. Association between spirituality and depression in adults with type 2 diabetes. Diabetes Educ. 2012; 38(3):427-35. DOI | PubMed