The Role of Spirituality and Social Support in Iranian Elderly Happiness: A Cross-sectional Study

Background: Spiritual well-being and social support are important factors in reducing loneliness and depression, improving the quality of life, and successful aging in elderly people. This study aimed to investigate the relationship between spiritual well-being, social support, and happiness among elderly people. Methods: This cross-sectional research was performed on 434 elderly people recruited from the health centers of Saveh University of Medical Sciences in Iran. Eligible participants who matched the selection criteria were selected through a multi-stage random sampling method. Socio-demographic information, the Spiritual Well-Being Scale, social support, and the Oxford Happiness Scale were used as tools for data collection. Finally, all data were analyzed by SPSS, and a multiple linear regression analysis was employed to determine factors associated with happiness. Results: The mean scores of happiness, spiritual well-being, and social support were 64.0 ± 13.2, 96.4 ± 18.6, and 42.8 ± 10.9, respectively. Overall, 211 (48.6%) elderly people had high levels of spiritual well-being. The findings indicated that 43% (R2 = 0.43) of the variance of change in happiness could be attributed to spiritual health, social support, and socio-demographic variables, including membership in non-governmental organizations, age, underlying disease status, marital status, and physical activity. Conclusion: Spiritual well-being and social support play an important role in elderly happiness. The results of the current study might be considered a basis for planning health promotion programs among the elderly. It is recommended that authorities assist in meeting the social and spiritual needs of the elderly to increase their overall happiness.

between happiness and physical and mental health among the elderly, the World Health Organization has placed great emphasis on happiness as an important component of health and the focus of research seeking to improve overall well-being (7). According to some studies, there is a direct relationship between inner religiosity and spiritual health with positive moods and satisfaction (1)(2)(3).
Studies indicate that spiritual well-being is a significant factor in healthy and successful aging. Spirituality has been linked to increased happiness, calmness, and reduced depression in elderly people (8). These findings suggest that elderly people use spirituality and religion to cope with stress and foster peace. The literature on spirituality also demonstrates the positive effect of religious and spiritual practices on coping with chronic diseases, mental wellbeing, depression, and distress (9). Researchers believe that without spiritual well-being, other physical, mental, and social dimensions may not reach their highest capacity among elderly populations, resulting in lower quality of life (10). On the other hand, Ansari et al reported that spiritual health variables with perceived social support can predict mental well-being. Perceived social support and spiritual health can be effective in promoting health by creating adaptation to the conditions of the elderly. In fact, strengthening the variables of social support in family, friends, and important people, along with paying attention to spiritual health, will improve mental health and happiness (11).
Social support is an essential variable in the quality of life in older people, and a lack of social support is associated with depression and lower levels of happiness. Some studies represented that perceived social support is a contributing factor in effectively coping with stressful life events and conditions (12)(13)(14). Furthermore, higher levels of social support, especially familial support, are related to higher life satisfaction and less mental health issues such as depression in older people (3,15). Research indicates that greater social support is linked to better physical functioning and lower mortality rates; therefore, social support is a vital resource in improving the daily lives, happiness, and overall wellbeing of elderly individuals (12,13).
Due to the global increase in the senior population, there is an increased necessity in improving health and overall well-being for this group; however, there is limited research on the determinants of happiness in older people (16), particularly in developing countries such as Iran (a country with a growing number of the elderly population). Considering the increase in the elderly population in Iran, the need to pay attention to the health issue is extremely necessary to ensure the welfare of this group in society and solve their problems (3,12). Given that only the spiritual health variable has been considered in most studies related to happiness, the present study sought to address this gap in the literature by examining the relationship between happiness and spiritual well-being and social support among elderly people covered by the health centers of Saveh, Iran.

Study Population
The present cross-sectional study recruited 448 elderly participants covered by the health centers of Saveh University of Medical Sciences in Iran in 2020. Multistage random sampling was used to select participants through a three-step process. First, researchers selected those who met the criteria from all 16 comprehensive health centers in Saveh. Further, all eligible individuals were given a number each and recorded in a list. Finally, 28 individuals who met eligibility criteria (14 males and 14 females) were selected from each health center using the random sampling system and included in the study as the target population. The inclusion criteria were willingness to participate in the study, aged ≥ 60 years, no history of psychotropic drug use, the absence of a first-degree relative with an incurable disease or physical illness, mental or psychological disability, and no factors relating to psychological discomforts such as deaths of relatives or divorce in the past 6 months.
On the other hand, unwillingness to participate in the study, illiteracy, and the presence of an acute illness and mental disorders were the exclusion criteria.
An initial sample size target of 374 was decided based on similar studies of happiness in elderly individuals with an accuracy of 0.05% and a 95% confidence level; however, the sample size was increased to 448 to reach the desired effect size of 1.1 (3,17). All participants were informed about the purpose of the study and confidentiality protocols, and they all gave written informed consent. The questionnaire was completed via self-report by the elderly. If some of the participants were unable to write for any reason, the researcher personally read the questions to them and recorded their answers without any intervention.

Questionnaires
Participants completed several questionnaires to assess background information, happiness, social support, and spiritual well-being.
Background. Questionnaire items assessed sociodemographic characteristics, including age, gender, education, marital status (i.e., divorced, married, and single), insurance status, number of family members, occupation, housing status, physical activity, owning a personal car, and working in a non-governmental organization (NGO).
Happiness. It was measured using the Oxford Happiness Questionnaire. The 29-item measure, based on the Beck Depression Inventory (BDI), uses 4 response options ranging from 0 (completely unhappy) to 3 (completely happy). High (87) and low scores (0) indicate high levels of happiness and unhappiness, respectively. The normal score of the test was in the range of 40-42, and its cut-off point was considered to be 50. Previous studies confirmed the validity and reliability of the Oxford Happiness Questionnaire (17). An examination of the internal consistency of the questionnaire indicated that all 29 items were highly correlated with the total score and had a Cronbach's alpha of 0.87.
Perceive social support. Social support was determined using the Multidimensional Scale of Perceived Social Support, which is a 12-item tool designed to assess perceived social support in three subscales of friends, family, and important others. In this questionnaire, a 7-point Likert-type scale was used with responses rating 1 (strongly disagree) to 7 (strongly agree). Overall high scores indicate high levels of perceived social support. A previous validation study reported that the measure had high reliability among Iranian populations (α = 0.81) (12), which is in line with the one obtained in the present study (α = 0.82).
Spiritual well-being. It was assessed using the Spiritual Well-Being Scale (Paloutzian & Ellison, 1982), ranging from 1 (strongly disagree) to 6 (strongly agree), in a 20item questionnaire in which religious health was measured through some questions that were 10 in number, and the other 10 questions measured existential health. Responses and negatively worded questions were scored reversely. Spiritual well-being was classified into low (20-40), moderate (41-99), and high (100-120) levels (18). High overall scores represent high levels of spiritual well-being. The results of the present study demonstrated that the measure had high reliability among the target population (α = 0.83).

Statistical Analyses
The obtained data were analyzed using IBM SPSS, version 22.0. Independent t-tests, one-way analysis of variance, Pearson's correlation analysis, and multiple linear regression were conducted to determine the association between background variables, happiness, social support, and spiritual well-being among elderly individuals. All methods were performed in accordance with the relevant guidelines and regulations.

Results
Overall, 434 (96.8%) out of 448 participants completed the questionnaires, while 14 cases were excluded due to the incompleteness of the questionnaires. The mean age of the population was 68.7 ± 3.0 years, and 50.9% of the participants were males. Among the participants, 64 (14.8%) and 71 (16.4%) had remarried and were divorced/widowed, respectively. A total of 287 (66%) individuals had underlying health diseases. There was a significant difference between being happy and having a male/female gender, having a personal car, and having a house. Further, there were differences in marital status, age, physical activity, the presence of an underlying illness, and membership in NGO groups (P < 0.05), while no significant difference was found in the level of happiness with the education, remarriage, insurance status, and family dimension (P > 0.05). There was a significant difference between Spiritual well-being and housing, physical activity, marital status, and membership in NGO groups (P < 0.05). Additionally, a significant difference was observed between receiving social support with marital status and membership in NGO groups and having a house and a car, as well as insurance status and remarriage (P < 0.05). Table 1 presents information regarding associations among additional variables.
Based on data in Table 2, the mean scores of happiness, spiritual well-being, and social support were 64.0 ± 13.2, 96.4 ± 18.6, and 42.8 ± 10.9, respectively. The results of the Pearson correlation test indicated a direct and significant relationship between spiritual well-being and happiness (r = 0.51, P < 0.01), social support and happiness (r = 0.47, P < 0.01), social support and spiritual well-being (r = 0.38, P < 0.01), and family dimension and social support (r = 0.13, P < 0.01) while a negative correlation between age and happiness (r = -0.27, P < 0.01). Figure 1 illustrates the level of spiritual well-being among the participants. Overall, 211 out of 434 and 205 participants reported high (score of 100-120) and moderate (41-99) levels of spiritual well-being, respectively.
Multiple linear regressions were conducted using happiness, social support, spiritual health, and demographic variables. The findings revealed that spiritual well-being (β = 0.30, P < 0.01), physical activity (β = 0.28, P < 0.01), social support (β = 0.27, P < 0.01), and age (β = -0.26, P < 0.01) significantly predicted happiness ( Table 3). The results indicated that 43% of the variance of happiness could be attributed to spiritual health, social support, and variables such as membership in NGOs, age, underlying disease status, marital status, and physical activity (R 2 = 0.43). Based on the results, there was a significant relationship between happiness, spiritual wellbeing, and social support when controlling for age and marital status (Table 3).

Discussion
This study assessed the association between spiritual well-being, happiness, and social support in elderly people. The results of the present study showed that spiritual well-being was the most important predictor of happiness, and roughly half of the sample (48.6%) had high spiritual well-being scores. This relationship between spiritual well-being and happiness is supported by the current literature (19,20). The finding of one study demonstrated that spiritual well-being could be a useful resource in improving the happiness of older people (21). In a similar study, spiritual well-being predicted 35% of the variance of happiness (22), further indicating the important role of spirituality in promoting happiness among elderly individuals. According to the results of our study and previous studies (23,24), acting on religious beliefs strengthens the spiritual relationship with God and improves meaning-finding in one's life, which increases reported happiness. A possible explanation for these findings is that religious people often choose their closest friends among their religious affiliations, religion values positive outlook, and kindness to others which can  generally increase happiness.
The results of the present study demonstrated that physical activity was a significant predictor of happiness. Our findings are consistent with those of previous studies, indicating that happiness was higher for active elderly individuals than for inactive elderly (12,25). This same study examined the health status of participants and represented that regular exercise increased the physical and mental performance of the sample (26). Similarly, researchers found that among older people who exercised and had no underlying diseases, there was less reported depression (27). The literature and our current findings suggest that physical activity is integral in achieving and maintaining happiness and physical health among elderly people (28). Furthermore, the findings suggest that physical activity impacts important components of happiness, including greater job success, work satisfaction, social interactions, improvements in physical health, and self-confidence (29).
In the current study, social support and membership in NGOs were predictors of happiness. Consistent with our findings, Lu (30) and Moeini et al (3) found that social support and membership in social groups were also strong predictors of happiness. Some studies (13,31) showed that social support is an important item in maintaining and promoting physical and cognitive health in older people, and it was further revealed that having social support positively could affect their daily life (e.g., participants reported feeling refreshed). These findings, in addition to the literature, suggest that belonging to social groups can increase self-confidence, self-efficacy, and self-esteem in individuals. This impact is important because selfconfidence and self-esteem are associated with overall life satisfaction and thus happiness. Considering that loneliness and isolation are potential health threats to old age, it is necessary for society to promote supportive environments and empowerment of the elderly to establish and utilize social support more robustly.
The results indicated that happiness was higher in married elderly individuals and men and was inversely related to aging such that as age increased, happiness represented a decrease. The findings also indicate that there is an essential relationship between happiness and underlying diseases, car ownership, and housing ownership. In line with these findings, researchers concluded that health-related factors and the absence of disease not only affected self-reported happiness but were also affected by happiness (32). Furthermore, studies examining the prevalence of successful aging in the United States reported that male gender and social and economic status were significantly associated with successful aging and happiness (33). The literature also posits that marriage is an important factor in happiness among East Asian countries (34). This evidence supports the economic theory that low income meant low levels of happiness as reported earlier (35).
One of the strengths of this study was the investigation and analysis of several important variables related to happiness in the elderly. In addition, three standard questionnaires with different questions were used in the current study compared to other studies. On the other hand, a limitation of the present study was the physical weakness of elderly participants and their early fatigue, which could influence the study data. Additionally, hearing impairments are common among elderly populations, which resulted in questions needing to be explained numerous times. This may have caused confusion or lack of an understanding of items within the questionnaires; however, the recruiting researcher decreased the bias in data collection. The cross-sectional nature of the study    makes it challenging to derive causal relationships from the cross-sectional analysis.

Conclusion
According to the results of the present study, there was a significant relationship between spiritual well-being, social support, and happiness in older people; therefore, it appears that spiritual well-being, along with factors such as membership in social groups and economic support, can increase happiness in older people, and in turn, contribute to a higher quality of life among elderly. The results of our study provide insights for planning health promotion programs among the elderly. It is recommended that authorities assist in meeting the social and spiritual needs of the elderly to increase their overall happiness.