Abstract
Background
Population aging is one of the most significant global social changes, making the improvement of the health and quality of life for the elderly a key health priority. The adoption of health promotion behaviors and having self-worth are effective approaches to maintain the health of older people. The current study aimed to investigate health promotion behaviors and their relationship with self-worth among the elderly in Tabriz, Iran.
Methods
This cross-sectional study recruited 427 older people, who lived in Tabriz in 2022. The participants were selected using multistage random cluster sampling. The Health Promotion Activities of Older Adults Measure, and the Contingencies of Self-Worth Scale were used for collecting the data. Descriptive and inferential statistics methods were applied to the data.
Results
The results showed a moderate mean score of health promotion behaviors (93.25 ± 15.39) and a low mean score of self-worth (79.30 ± 10.29) for the participants. The multivariate linear regression analysis showed a significant relationship between health promotion behaviors and self-worth among the older adults (p < 0.01). Therefore, self-worth could predict about 3.7% of the variance of health promotion behaviors among this population (R2 = 0.037, t = 4.01). Although the association was statistically significant, the explained variance was low, indicating that self-worth had a limited predictive value for health promotion behaviors in this sample.
Conclusions
While self-worth showed a modest correlation with health promotion behaviors, multivariable analysis revealed socioeconomic factors as stronger predictors. Interventions should address structural determinants alongside psychosocial factors to improve elderly health. Future studies are needed to explore causal pathways between self-worth and health behaviors in aging populations.
Keywords: Health promotion behaviors, Self-Worth, Older people, Ageing, Iran, Elderly health, Socioeconomic factors
Background
Aging, a natural and inevitable part of the life cycle [1], is often associated with various challenges such as increased risk of chronic diseases, loneliness, isolation, and reduced social support, particularly after the age of 60 [2, 3]. This phenomenon ultimately affects all economic, social, and health dimensions of one’s life [4]. Globally, the percentage of the population aged 65 years or over increased from 6% in 1990 to 9% in 2019 [5]. According to a report from WHO, the proportion of the world’s population over 60 years will nearly double from 12 to 22% between 2015 and 2050 [6]. Based on the Iranian Population and Housing Census report in 2016, 9.3% of the whole Iranian population are over 60 years (7.4 million out of 80 million) which is an increasing trend in Iran [7].
Old age is associated with higher rate of disabilities and diseases that can negatively affect the health care system [8]. Considering the increasing pace of population aging around the world, due to improved health and socioeconomic conditions and demographic development; one of the most important challenges is to address the health issues of this age group and possible ways to improve their quality of life [9]. As the aging population grows, the demand for chronic disease management, long-term care services, and age-related health interventions increases significantly, thereby placing a considerable burden on healthcare infrastructure and workforce capacity.
The results of comprehensive literature review showed that the quality of life and health of the elderly are associated with various individual and social factors; and health promotion behaviors are paramount among these factors [2, 10]. Studies have shown that the elderly can protect themselves against health risks by learning certain self-care skills [11]. The adoption of health promotion behaviors is a way for the elderly to maintain their health [12]. The literature review showed that health promotion behaviors are directly linked to better health and quality of life in the elderly, and adopting these behaviors can reduce their mortality over time [13]. According to Pender’s model, health promotion behaviors include any action taken to increase or maintain the health and self-sufficiency of individuals and groups [14]. Prevention of diseases and the improvement of life satisfaction are among the factors with a key role in improving the health status [15]. Examples of these health promotion behaviors include regular exercise, avoiding alcohol and smoking, maintaining a strong immune system, enhancing independence and cognitive function, and increasing social interaction. Adopting these health promotion behaviors can increase the quality of life in the remaining years of life, and reduce years of potential life lost (YPLL) as well as health care costs [16]. In other words, maintaining health promotion behaviors in the elderly can lead to increase their independence in daily life, higher their cognitive and physical function, and enhance their social life [17].
Among other factors that are also involved in well-being of people, is self-worth [18]. A high level of self-worth improves general health, increases the motivation, reduce depression, and contribute to adoption of better coping mechanisms in facing unpleasant life events [19]. Since self-worth is related to self-esteem, any progress or success in boosting self-worth has effect on one’s self-esteem and vice versa [20]. Thus, impaired self-esteem leads to mental and psychological discomfort, indifference, a sense of loneliness, and unhealthy behaviors in the elderly [19]. For instance, Suzanne et al. has discussed that increasing self-worth in the elderly reduces their mental stresses [21]. Moreover, those with a high level of self-worth can easily deal with threatening and stressful life events without going through a severe negative experience [22]. These findings reiterate the importance of self-worth, especially among the elderly population. Individuals with higher self-worth are more likely to value their health, believe in their ability to influence outcomes, and therefore engage more actively in behaviors that promote physical and mental well-being. However, a comprehensive literature review conducted for this study showed that only a few studies have directly examined the relationship between self-worth and health promotion behaviors in the elderly. In particular, this relationship has not been adequately explored in the Iranian context. Therefore, there is a need for studies that address this gap and provide localized evidence. This study was conducted to explore the relationship between self-worth and health promotion behaviors among older adults living in the community in Tabriz, Iran. The main hypothesis was that there is positive association between self-worth and health promotion behaviors among community older adults.
Methods
Study design and setting
This cross-sectional analytical study was conducted in 2022 in Tabriz, Iran. The study population consisted of elderly individuals (aged 60 years and above) who were registered in the electronic health system across 20 health districts in the city.
Participants
The required sample size for investigating the correlation between self-worth and health promotion behaviors was estimated using STATA 17 software. Based on a pilot study with 20 participants, the expected correlation coefficient was found to be 0.18. Considering a significance level (Type I error) of 0.05, statistical power (1 - Type II error) of 0.90, and the effect size obtained from the pilot, the minimum required sample size was calculated to be 321 participants (C = 0.5 * ln[(1 + r)/(1-r)] = 0.182, N = [(Zα + Zβ)/C]^2 + 3 = 321). Given that cluster sampling was used in this study, a design effect of 1.3 was applied, resulting in an adjusted sample size of approximately 418 participants (321 × 1.3). To increase the precision of the estimates and account for potential dropouts, the final sample size was increased to 430 participants. Of these, data from 3 participants were excluded due to dropout, resulting in a final analyzed sample of 427 participants.
There are 20 health districts in Tabriz with demographic and contact information of all elderly available. The participants were selected using multistage random cluster sampling. First, one-third of health districts were randomly selected using an online randomization program, and then two health centers were randomly selected from each health district. Based on the demographic information of the elderly, the required samples from each center were estimated proportional to its total sample size. Then, a list of all elderly who received health services from each center was developed, and samples were randomly selected proportional to each center using randomization software. Eligible individuals were contacted by telephone, provided with a brief explanation of the study, and, if willing, were invited to attend the health center at a specified time. Written informed consent was obtained, and the questionnaires were completed by the researcher via interview. When any participant had disability, research staff helped them in reading and understanding the questions and assisted them in providing answer. The inclusion criteria were age 60 years and over, absence of any cognitive or psychiatric diseases (according to health record), and absence of severe visual and auditory impairment. The exclusion criteria were death during the study phase, having Limiting physical disorders” referred to conditions (e.g., cognitive impairments, difficulty speaking, severe movement problems) that prevented communication or questionnaire completion, and/or incomplete questionnaire. Educational attainment was originally recorded in more detailed categories (e.g., middle school, high school diploma, university degree), but these were consolidated into three broader groups—illiterate, primary school, and diploma or higher—for the purposes of analysis and to ensure adequate group sizes for statistical comparisons.
Data collection
The following data collection tools were used in this study: [1] Socio-demographic questionnaire [2], Health Promotion Activities of Older Adults Measure (HPAOAM), and. [3] Contingencies of Self-Worth Scale (CSWS).
Measures
The Health Promotion Activities of Older Adults Measure (HPAOAM) is a standardized questionnaire developed by Padula in 1997 to investigate health promotion behaviors in the elderly [23]. The Health Promotion Activities of Older Adults Measure (HPAOAM) includes 44 five subscales that collectively capture key dimensions of health-promoting behaviors among the elderly. The first subscale, Collaborative Health Management/Injury Prevention, encompasses behaviors such as working with healthcare providers, adhering to medical advice, and taking safety precautions—practices essential for preventing injuries and managing chronic conditions in later life. The second subscale, Stress Reduction/Relaxation, reflects the use of techniques like rest, mindfulness, or leisure activities to manage psychological stress, which is crucial for emotional resilience and mental well-being. The third subscale, Physical Exercise, assesses the frequency and consistency of physical activity, which is vital for maintaining mobility, muscle strength, cardiovascular health, and overall functional independence. The fourth subscale, Substance Abuse Prevention, evaluates behaviors related to avoiding harmful substances such as tobacco, alcohol, and non-prescribed drugs—factors closely tied to long-term health outcomes. Finally, the Nutrition subscale examines dietary practices that support healthy aging, including balanced eating, adequate fluid intake, and consumption of essential nutrients. Together, these subscales offer a comprehensive view of the multidimensional lifestyle behaviors that contribute to promoting health and preventing disease in older adults. Items are scored on a 4-point Likert scale. The total score ranges from 44 to 177, with higher scores indicating greater participation in health-promoting behaviors. The content and construct validity of the HPAOAM were confirmed in previous studies, and in this study, translation validity was assessed by backward-forward translation, with face and content validity confirmed by academic experts. Reliability was assessed using Cronbach’s alpha (approximately 0.83 in a sample of 20 elderly).
The CSWS, developed by Crocker et al. (2003), consists of 35 items across 7 subscales: Other’s Approval, Family Support, Appearance, Competition, Academic Competence, God’s Love, and Virtue. Items are scored on a 7-point Likert scale, with total scores ranging from 35 to 245; higher scores indicate higher self-worth [24]. The scale’s validity and reliability have been confirmed in previous studies, and in this study, translation and cultural adaptation were performed, and Cronbach’s alpha was estimated at 0.78 in a sample of 20.
Statistical analysis
The completed questionnaires were collated, coded, and imported into SPSS-22 with confidentiality and anonymity preserved. Demographic data, HPAOAM, and CSWS scores were analyzed using descriptive statistics (frequencies, percentages, means, and standard deviations). The normal distribution of data was assessed using the Kolmogorov-Smirnov test. Prior to analysis, the dataset was examined for missing values and outliers. No substantial missing data or extreme outliers were identified; therefore, no data imputation or case exclusion was required. The relationship between the research variables was investigated using the Pearson correlation coefficient, and multivariate linear regression was used to predict health promotion behaviors by self-worth level of the elderly. Data analysis was conducted at a significance level of p < 0.05.
Results
A total of 427 elderly, aged 60 years and over, participated in this study. The results showed that the mean age of the participants was 67.47 ± 6.0 years. About half of the participants were men (51.3%) and mostly married (83.8%). Moreover, 45.7% of the participants were living with their spouse and 49.9% of them were illiterate (Table 1). The results indicated that the mean scores of health promotion behaviors were 93.25 ± 15.39, and the self-worth score of the participants was 79.31 ± 10.29. According to Table 2, the Pearson correlation coefficient demonstrated a direct and significant relationship between self-worth and health promotion behaviors among the elderly (p < 0.05). According to Table 3, among the dimensions of health promotion behaviors in the elderly, the highest mean score was observed in Participation in Health Management/Injury Prevention (31.27 ± 6.75), whereas the lowest mean score was reported for Substance Use Prevention (9.93 ± 3.31). The overall mean score of health promotion behaviors was 93.25 ± 15.39. As shown in Table 4, which presents self-worth and its dimensions among the elderly, the highest mean score was found in the domain of Approval and Recognition from Others (18.81 ± 5.16), while the lowest mean was observed in the domain of Divine Love (5.55 ± 1.60). For instance, the high score in the “Approval and Recognition from Others” domain suggests that social validation may be an important motivator for health-related behaviors in this population, while lower engagement in “Substance Use Prevention” may reflect limited awareness or cultural factors influencing risk perception. The total mean score of self-worth was 79.30 ± 10.29.
Table 1.
Demographic characteristics of the participants
| Variables | Frequency | Percentage (%) | |
|---|---|---|---|
| Gender | Female | 208 | 48.7 |
| Male | 219 | 51.3 | |
| Marital status | Married | 358 | 83.8 |
| Single | 69 | 16.2 | |
| Residence status | Alone | 39 | 9.1 |
| With a partner | 195 | 45.7 | |
| With children | 42 | 9.8 | |
| With wife and children | 148 | 34.7 | |
| With relatives | 3 | 0.7 | |
| Education level | illiterate | 213 | 49.9 |
| Elementary | 138 | 32.3 | |
| Diploma and Higher | 76 | 17.8 | |
| Housing status | Ownership | 396 | 92.7 |
| Rent | 17 | 4 | |
| Child’s home | 9 | 2.1 | |
| Other | 5 | 1.2 | |
| Insurance status | Yes | 375 | 87.8 |
| No | 51 | 11.9 | |
| Economic status | Income < Expenses | 7 | 1.6 |
| Income = Expenses | 357 | 83.6 | |
| Income > Expenses | 63 | 14.8 | |
| Physical activity | Regular (Three times a week) | 144 | 33.7 |
| Regular (Less than once a week) | 104 | 24.4 | |
| Never | 179 | 41.9 | |
| Perceived health status | Good | 80 | 18.7 |
| Medium | 263 | 61.6 | |
| Bad | 84 | 19.7 | |
| Age (year) * | 6.0 ± 67.47 | ||
*Mean ± SD
Table 2.
Relationship between health promotion behaviors and self-worth in the elderly
| Variables | Mean ± SD | Range | Correlation coefficient | P-Value |
|---|---|---|---|---|
| Self-worth | 10.29 ± 79.31 | 35–245 | r = 0.191 | p = 0.001** |
| Health promotion behaviors | 15.39 ± 93.25 | 44–176 |
**indicates statistical significant (р<0.01)
Table 3.
Mean and standard deviation scores of health promotion behavior dimensions (N = 427)
| Health promotion behavior dimensions (Score Range) | Mean ± SD | Score range obtained |
|---|---|---|
| Participation in health management/injury prevention (15–60) | 31.27 ± 6.75 | 17–52 |
| Stress reduction/rest and relaxation (10–40) | 19.96 ± 5.40 | 10–38 |
| Physical activity (5–20) | 16.44 ± 4.10 | 5–20 |
| Substance use prevention (6–24) | 9.93 ± 3.31 | 6–20 |
| Nutrition (8–32) | 14.04 ± 2.67 | 8–22 |
| Total health promotion behaviors (Score Range: 44–176) | 93.25 ± 15.39 | 47–131 |
Table 4.
Mean and standard deviation scores of Self-Worth dimensions
| Self-worth dimensions (Score Range) | Mean ± SD | Score range obtained |
|---|---|---|
| Family Support (5–35) | 10.31 ± 1.77 | 5–20 |
| Superiority and competitiveness (5–35) | 9.68 ± 3.66 | 5–30 |
| Physical appearance (5–35) | 17.44 ± 3.65 | 6–35 |
| Divine love (5–35) | 5.55 ± 1.60 | 5–18 |
| Academic competence (5–35) | 11.33 ± 2.53 | 5–21 |
| Piety and religiousness (5–35) | 6.19 ± 2.34 | 5–21 |
| Approval and recognition from others (5–35) | 18.81 ± 5.16 | 5–36 |
| Total Score (35–245) | 79.31 ± 10.29 | 40–138 |
The findings of this study revealed that among the predictive variables of health-promoting behaviors, educational level and economic status had the most significant impact. Notably, educational level exhibited a significant inverse association, indicating that individuals with higher levels of education engaged less in health-promoting behaviors. In contrast, better economic status was positively associated with higher levels of health-promoting behaviors (Table 5).
Table 5.
Predictive effects of Self-Worth and resilience on health promotion behaviors adjusted for confounders*
| Variable | Regression coefficient (B) | 95% CI lower bound | 95% CI upper bound | p-value |
|---|---|---|---|---|
| Age | −0.27 | −0.48 | −0.06 | 0.009 |
| Gender: female | −6.61 | −9.39 | −3.83 | < 0.001 |
| Gender: male (reference) | – | – | – | – |
| Marital status: married | 0.85 | −2.51 | 4.28 | 0.62 |
| Marital status: single (reference) | – | – | – | – |
| Education: illiterate | 12.55 | 8.92 | 16.19 | < 0.001 |
| Education: primary school | 7.37 | 3.19 | 10.82 | < 0.001 |
| Education: higher (reference) | – | – | – | – |
| Insurance: yes | 2.42 | −1.14 | 5.98 | 0.18 |
| Insurance: no (reference) | – | – | – | – |
| Economic status: income > expenses | 0.97 | −8.40 | 10.36 | 0.83 |
| Economic status: income < expenses | 9.49 | 5.97 | 13.02 | < 0.001 |
| Economic status: income = expenses (reference) | – | – | – | – |
| Housing: ownership | −12.54 | −23.04 | −2.03 | 0.01 |
| Housing: rental | −5.85 | −17.70 | 6.00 | 0.33 |
| Housing: living in child’s home | −16.32 | −29.43 | −3.20 | 0.01 |
| Housing: other (reference) | – | – | – | – |
| Perceived health: good | −2.73 | −6.87 | 1.40 | 0.19 |
| Perceived health: moderate | −0.80 | −3.92 | 2.30 | 0.61 |
R Squared = 0.426. *Confounders: Age, Gender, Marital Status, Education, Insurance, Economic Status, Housing Status, and Perceived Health
Additionally, the predictive role of self-worth was examined using a multivariable linear regression model, adjusting for potential confounding variables including age, gender, marital status, education, insurance coverage, economic status, housing status, and perceived health. The results showed that self-worth was not a statistically significant predictor of health-promoting behaviors (p = 0.48), suggesting that it does not independently influence health-promoting behaviors in the presence of demographic and socioeconomic factors. Specifically, the standardized beta coefficient for self-worth was β = 0.05 (p = 0.48), indicating a small and non-significant effect when controlling for demographic and socioeconomic factors.
Discussion
The present study examined health promotion behaviors and their relationship with self-worth among community-dwelling older adults in Tabriz, Iran. Our findings revealed that the overall mean score of health promotion behaviors (93.25 ± 15.39) was moderate, consistent with previous studies conducted among Iranian elderly populations [10, 25, 26]. This moderate level may reflect the challenges older adults face in adopting and maintaining health-promoting behaviors, particularly in the context of limited community-level health promotion programs and the physical, psychological, and social changes associated with aging.
The mean self-worth score among participants was low, which aligns with the literature indicating that self-worth tends to decrease with age due to chronic illness, loss of social roles, and other age-related factors [21, 27]. Cultural and contextual differences may also influence self-worth, as shown by studies in other countries reporting higher or lower levels based on social support, family structure, and health system differences [27, 28].
A key finding of this study is the significant and direct correlation between self-worth and health promotion behaviors in the elderly, as demonstrated by the Pearson correlation coefficient (p < 0.05). This relationship is supported by previous research suggesting that higher self-worth improves general health, motivation, and coping strategies, thereby facilitating the adoption of health-promoting behaviors [29–31]. However, our multivariable linear regression analysis-which adjusted for demographic and socioeconomic confounders-showed that self-worth was not an independent predictor of health-promoting behaviors (p = 0.48). Instead, educational level and economic status emerged as the most significant predictors: higher education was inversely associated with health-promoting behaviors, while better economic status was positively associated. This finding is noteworthy and may reflect the unique socioeconomic context of the study population, where higher education does not always equate to better health behaviors, possibly due to lifestyle factors or occupational stress (Table 5). In the context of Tabriz and similar urban settings in Iran, individuals with higher education may be more likely to engage in sedentary professional roles, which could limit their physical activity. Additionally, those with higher education often have better access to formal healthcare systems and preventive services, potentially reducing their perceived need for personal health-promoting behaviors. Cultural expectations may also play a role; for instance, more educated older adults may rely more on clinical care rather than self-care or community-based health initiatives. These dynamics suggest that educational attainment alone is not a sufficient predictor of healthy lifestyle practices and must be considered alongside contextual and structural variables.
These results highlight the importance of considering broader structural determinants alongside psychosocial factors when designing interventions to improve health behaviors in older adults. While previous studies have emphasized self-worth, self-esteem, and self-confidence as important for health behavior adoption [29, 30, 32], our findings suggest that socioeconomic factors such as education and income play a more substantial role in this population. This is consistent with other Iranian studies showing that self-care and quality of life are strongly influenced by socioeconomic status and access to resources [6].
The study’s limitations include its cross-sectional design, which precludes causal inference, and reliance on self-reported data, which may be subject to recall bias. Additionally, the sample was limited to urban elderly in Tabriz, reducing generalizability to rural or institutionalized populations. The relatively large number of questionnaire items may have also contributed to respondent fatigue.
In summary, although self-worth is correlated with health promotion behaviors among older adults, it does not independently predict these behaviors when demographic and socioeconomic variables are considered. Interventions aiming to improve health behaviors in this population should address both psychosocial and structural determinants, such as economic security and educational opportunities. Future research should employ longitudinal or mixed-methods designs to further elucidate the pathways linking self-worth, socioeconomic status, and health promotion behaviors in diverse elderly populations.
Conclusions
While a significant correlation was observed between self-worth and health promotion behaviors, multivariable analysis indicated that self-worth was not an independent predictor when controlling for demographic and socioeconomic factors. Therefore, although enhancing self-worth may support elderly well-being, broader determinants such as economic status and education appear to play a more substantial role in health behavior. Future research should explore the pathways through which self-worth interacts with other psychosocial variables using longitudinal or mixed-methods designs. Interventions aiming to improve health behaviors in older adults should consider both psychosocial and structural factors to be effective.
Acknowledgements
We hereby thank all participants and the esteemed Vice President of Research and Technology of Tabriz University of Medical Sciences for financing this study.
Abbreviations
- HPAOAM
Health Promotion Activities of Older Adults Measure
- CSWS
Contingencies of Self-Worth Scale
Authors’ contributions
VP, RS, PS designed the study. RS, SP collected the data. VP, FZ, RS analyzed the data. FZ, VP, RS, PS, SP involved in manuscript writing. All authors approved the manuscript.
Funding
This research was supported by the Tabriz University of Medical Sciences.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
The research was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The research objectives were explained to the eligible participants and then their informed consent was obtained. The Ethics Committee of Tabriz University of Medical Sciences approved the conduct of this study (Ethical code IR.TBZMED.REC.1397.425). The participants were assured that their information will be kept confidential and they could withdraw from the study whenever they desired to.
Consent for publication
All participants were first informed that details such as personal or clinical information might be used in the publication, and then their consent for publication was obtained.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.