Karbandi et al1

Evidence Based Care Journal

http://ebcj.mums.ac.ir/

Effect of Flourishing Promotion

Program on Social Health in the
Elderly
Azam Nojabaee, Amir Reza Salehmoghaddam, Seyed Reza Mazlom, Negar
Asgharipour, Samira Mohajer

The online version of this article can be found at

http://ebcj.mums.ac.ir/article_11083.html

Evidence Based Care Journal 2018 8:39 originally published

online 01 July 2018
DOI: 10.22038/ebcj.2018.30277.1749
Online ISSN: 2008-370X

Address: Mashhad Nursing and Midwifery School, Ebn-e-Sina St., Mashhad, Iran
P.O.Box: 9137913199
Tel.: (098 51) 38591511-294
Fax: (098 51) 38539775
Email: [email protected]
39 Evidence Based Care Journal, 8 (2): 39-48

Original Article

Effect of Flourishing Promotion Program on Social Health

in the Elderly

Azam Nojabaee1*, Amir Reza Salehmoghaddam2, Seyed Reza Mazlom3, Negar Asgharipour4,
Samira Mohajer5

Received: 07/03/2018 Evidence Based Care Journal, 8 (2): 39-48

Accepted: 24/06/2018

Abstract
Background: Social health is considered of utmost importance as a social necessity. Thus, the
Flourishing Promotion Program (FPP) can be effective in promoting social health.
Aim: To determine the effect of the FPP on social health in the elderly.
Method: A randomized controlled clinical trial of 60 elderly individuals residing in Toos Nursing
Home and Salamati Nursing Home, Mashhad, Iran, was performed in 2017. The participants were
assigned to intervention and control groups. The intervention group enrolled in the FPP for eight 90-
minute sessions, and the control group only performed the routine activities. Keyes’ Social Well-
Being Scale was completed before, as well as immediately and one month after the intervention. To
analyze the data, Mann-Whitney U test and Friedman test were run in SPSS, version 21.
Results: The mean ages of the control and intervention groups were 74.9±11.4 and 78.1±7.0,
respectively. According to the Mann-Whitney U test, the mean score of social health in the
intervention (57.1±6.3) and control (50.4±9.0) groups were significantly different before the
intervention (P=0.001). Given the findings of the analysis of covariance, the mean score of social
health in the intervention (67.9±5.5) and control (50.4±9.0) groups immediately post-intervention
were also significantly different (P=0.001). Such a significant difference was also observed between
the intervention (66.8±5.5) and control (49.3±8.7) groups one month post-intervention (P=0.001).
Implications for Practice: The FPP could effectively enhance mental and social health and
functioning in the elderly through providing a sense of belonging, positive excitement, and better
interactions.

Keywords: Elderly, Health promotion, Mental health

1. MSc Student in Geriatric Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences,
Mashhad, Iran
2. Assistant Professor, Department of Management Nursing, School of Nursing and Midwifery, Mashhad University of
Medical Sciences, Mashhad, Iran
3. Instructor of Medical-Surgical Nursing, Evidence-Based Care Research Centre, School of Nursing and Midwifery,
Mashhad University of Medical Sciences, Mashhad, Iran
4. Assistant Professor of Clinical Psychology, Research Center of Psychiatry and Behavioral Sciences, Mashhad University
of Medical Sciences, Mashhad, Iran
5. Instructor of Gerontological Nursing, Evidence-based Care Research Center, School of Nursing and Midwifery,
Mashhad University of Medical Sciences, Mashhad, Iran
* Corresponding author, Email: [email protected]
Nojabaee et al. The Effect of Flourishing Promotion Program on Social Health in the Elderly 40

Introduction
The concept of social health in old age has been addressed as the foundation of successful aging and
considered as an objective for providing social welfare and health care services to this age group (1).
As a global concern in the present era, the world’s population is increasingly aging, which has
brought about numerous challenges for different societies across the world (2, 3). According to the
estimates released by the United Nations (UN), the global rate of older population will rise from about
12% in 2012 to approximately 22% by 2050 (4-6). Old age is correspondingly known as a sensitive
stage in human life span, thus, paying attention to its related issues and needs is a social necessity.
Respecting special needs and health-promoting behaviors at this stage is of utmost importance even
though it has been so far neglected (7).
Nowadays, the elderly population is growing owing to increased life expectancy, low mortality rates,
and decreased birth rates (1). As a developing country, Iran has been similarly facing the same
situation. In this regard, statistical and demographic indicators and tools have revealed that the older
population growth in Iran has already started (8), therefore, it can be one of the fundamental
challenges in this country in upcoming years wherein social health, the ability to play social roles
effectively and efficiently, can be at risk as one of the health dimensions.
It should be noted that healthy older adults regard society as a meaningful, coherent, and potential
complex for growth and flourishing and have a sense of belonging to it. They are correspondingly
accepted by the society through having a share in its development (9). In this respect, Seifzadeh
concluded that 56.5% of the elderly were endowed with social health and well-being and 43.5% of
them had very little of this health dimension (10). It is noteworthy that social health, as one of the
human health dimensions, can play an important role in social life balance. Thus, lack of attention
to the dimensions of social health in the elderly in the era of communications and globalization is
likely to increase social vulnerability in this age group within society. Moreover, considering the
dimensions of social health and reinforcing social health indicators among older adults in each
society can lead to the decreased burden of physical and psychological illnesses (11). Due to losing
social support and having less participation in the society, the elderly residing in nursing homes
have much more feelings of sorrow and depression, as well as lower health status. Accordingly,
high levels of social health in this age group can meet their emotional needs and attachments and
put their life in the right direction. Such a health status can also encourage the elderly to do all their
best and make efforts to deal with their life problems and to cope with them as well as possible
(12). Besides, social participation (engagement) is considered as one of the main components of
social health, which can decrease mortality rates and levels of depression and disability in the old
age and improve well-being, cognitive health, and health-related behaviors (13). Promoting social
participation (engagement) and social health status in the elderly is also assumed as one of the key
policies of the World Health Organization (WHO) (14).
It has been indicated that there is a proximity between the concepts of social health and mental health,
and related studies have demonstrated a positive correlation between social health indicators and those
of mental health (9). The highest level of mental health has been assumed as the flourishing level (15),
and the main purpose of positive psychology is to increase flourishing in one’s own life and that of
others (16). High levels of flourishing can produce high levels of social and mental well-being,
happiness (vitality), personal growth, purpose in life, as well as close and meaningful relationships
(15). Thus, it can be argued that an individual endowed with mental flourishment is able to benefit
from social health although the quality and quantity of this relationship needs to be further
investigated. If such a relationship is strong enough, the skills affecting flourishing can be exploited to
increase social health.
Psychological methods and treatments are assumed to be more effective in social groups of the elderly
(17). One of the recent treatments in the domain of aging is positive psychotherapy (PPT), which can
have an impact on moderating depression and increasing happiness (vitality) and satisfaction with life
(16). PPT can initiate a balance in individuals’ attention in a way that they can show their experiences
associated with kindness, forgiveness, encouragement, and humanity in a voluntary manner (18).
Attending educational sessions in this respect can also improve the sense of being sociable in older
adults and affect their functioning and social coherence, and consequently, help them to get rid of the
state of stagnation and loneliness (19). Furthermore, such positive interventions can reduce
depression, increase happiness, and bring about mental and psychological well-being in an individual
41 Evidence Based Care Journal, 8 (2): 39-48

(20). Therefore, positive-therapeutic interventions can be used in Flourishing Promotion Program

(FPP) for the elderly.
In this regard, the findings of the study by Bahadori Khosroshahi et al. in 2016 showed that
teaching group-based reality therapy could improve social well-being and its components in the
elderly (12). According to the results of the investigation by Sadri Damirchi et al. in 2015, the
emotional, mental, and social components of well-being could be similarly enhanced in the elderly
through a reality therapy program (21). In the study by Farnam in 2016, quality of life as well as
life expectancy was enhanced in a group of older adults via a positive thinking training program
(22). It should be noted that research studies in the domain of elderly social health had been
mostly conducted with qualitative, descriptive, and analytical designs and no interventional studies
with codified and specific training programs aiming at improving social health in the elderly was
found.
Improved health and well-being in older adults is considered as a research priority, especially when
the determinants affecting the individual’s abilities and social health are used. This issue highlights
the fact that it is not only beneficial, but also necessary to administer interventions at the social level.
Issues related to the elderly as one of the challenges in the health system are highly sensitive, and
nursing role in training older adults as well as the prevention and improvement of mental well-being
and social health in the elderly is very significant, which highlights the need for new programs
including FPP. With this background in mind, we aimed to determine the effect of the FPP on social
health status among the elderly.

Methods
The present study was a clinical trial comprised of two groups (intervention and control). The
statistical population included the elderly residing in Toos Nursing Home and Salamati Nursing
Home in the city of Mashhad, Iran. This research study was conducted from October to December
2017. The participants were 60 elderly individuals residing in the two centers who met the
inclusion criteria. The standard sample size was calculated to be 11 individuals in each group
according to the results of a similar study using two groups of 10 individuals and considering the
comparison of two population means with a 95% confidence interval and an 80% test power.
Given the probability of sample attrition, 30 individuals were included in each group. The
participants were selected through the convenience sampling method. For this purpose, the nursing
homes were divided into intervention (30 individuals) and control (30 individuals) groups through
simple random allocation. The reason behind the allocation of the centers instead of the elderly
individuals was to prevent the distribution and exchange of information among the participants.
The inclusion criteria in this study were age over 59 years, ability to establish communica tion,
fluency in Persian, minimum of primary school education, scores lower than 75 from Keyes’
Social Well-Being Scale (KSWBS), scores 7 and higher from Abbreviated Mental Test (AMT), no
acute or chronic physical and psychological illnesses (including asthma, chronic renal failure,
cancer, and heart failure), lack of addiction to narcotic drugs and psychedelics, and no vision and
hearing disorders causing disrupted activities. The exclusion criteria included absence from two
planned intervention sessions, hospitalization, and absence from nursing home for any reasons
during the study.
The research instruments in this study included a demographic characteristics form, AMT, and
KSWBS. The demographic characteristics form included 18 items developed according to the
research objectives and the latest references and related articles. The AMT as a test appropriate for
screening cognitive disorders in the elderly contained 10 items with true-false responses and
minimum and maximum scores of 0 and 10, respectively. In this scale, higher scores reflected lower
indicators of cognitive disorders. The validity of the translated version was similarly confirmed by
Bakhtiari et al. (23). Content validity of this test was established in the present study by 10
professors from Mashhad University of Medical Sciences. To measure the internal consistency,
Cronbach’s alpha coefficient was employed, which confirmed the reliability of this scale (∝=0.76).
Moreover, test-retest reliability was used to determine its external validity, in which the intra-rater
correlation was calculated through correlation coefficient between the test-retest scores of 10
participants (ICC: 0.89).
The KSWBS was developed by Keyes in the Ellen MacArthur Foundation in the United States in
Nojabaee et al. The Effect of Flourishing Promotion Program on Social Health in the Elderly 42

2004 to measure social health. This questionnaire contained 20 items investigating 5 dimensions of
social integration, social actualization, social coherence, social contribution, and social acceptance,
which are scored using a 5-point Likert-type scale. The total score of the questionnaire was between
20 and 100 (24). The validity and reliability of this instrument was confirmed in different
demographic and age groups, particularly in the elderly with a Cronbach’s alpha coefficient of 0.83.
The validity and reliability of the translated version had been already verified by Saffarinia (2014)
(25). To determine the validity of this questionnaire, content validity was used. To this end, the
questionnaire was submitted to 10 professors from the Department of Internal Surgery and the School
of Nursing and Midwifery affiliated to Mashhad University of Medical Sciences, and its validity was
confirmed after the revisions and the suggestions were included. Cronbach’s alpha reliability of this
scale was determined to be 82.2.
Before the intervention, social health in the older adults was measured by KSWBS via interviews.
In the intervention phase, which was conducted during November-December 2017, the FPP was
administered by the researcher, who had acquired the required skills during some courses under the
supervision of a professional consultant; after confirming the titles and contents by the consultant
and faculty members, the intervention program was implemented using group discussion,
collaborative learning method, and lecture during eight 90-minute sessions (two sessions per week)
on 3 groups of 10 individuals in the meeting halls of the nursing homes. This program was
implemented using Seligman’s (2006) PPT guide translated by Kamakar and Hozhabrian (16).
Given the extensiveness of the PPT sessions, the given sessions were reduced to 8 sessions and
their contents were simplified by a professor as a professional consultant. During the sessions, in-
person question and answer sessions were held as breaks. In each session, an assignment was also
given to the elderly individuals about the issues raised to present during the next session.
Considering the subject of each session, the assignments were read out by the elderly and discussed.
The first session was associated with introductions and explanations about the FPP. The second
session was about positive sources and excitement. The third, fourth, and fifth sessions were
focused on recognizing personality strengths, reinforcing personality positive points, and
forgiveness, respectively. Moreover, the sixth session was associated with appreciation. The
seventh session was concentrated on the art of gaining pleasure, and finally the eight session was
related to optimism, positive thinking, hope, and reviews of the contents acquired during all
previous sessions in the form of collaborative learning and group discussion. To ensure the regular
presence of the participants, the researcher reminded the head of the center in-person or via
telephone contacts. It should be noted that all the routine activities of the centers were conducted
for all the participants with the coordination of the managers of the two nursing homes. It should be
noted that the control group only conducted the routine activities of the centers including recreation
and pilgrimage accompanied by an educational pamphlet of the FPP submitted to them by the
researcher. During the implementation of the eight sessions of the FPP, the levels of social health in
the elderly were measured using KSWBS immediately after and one month following the
intervention in the intervention and control groups residing in Toos Nursing Home and Salamati
Nursing Home (Table 1).
All the ethical considerations were observed, which included obtaining written permission from the
Ethics Committee of Mashhad University of Medical Sciences, acquiring a letter of introduction from
the School of Nursing and Midwifery and submitting it to the authorities of Toos Nursing Home and
Salamati Nursing, getting written informed consent from the study participants, codification of the
questionnaires to keep the confidentiality of data, and allowing the participants to withdraw from the
study at any time.
The data were analyzed using SPSS version 21. Considering the demographic and underlying
characteristics of the study samples, Kolmogorov-Smirnov (K-S) test and Shapiro-Wilk test were used
to examine the normality of the quantitative data. To compare the two study groups with regard to
non-normal quantitative and ranked variables, Mann-Whitney U test was employed. Nominal
variables were also tested and compared via Chi-square test, exact Chi-square test, and Fisher’s exact
test. Social health and its dimensions in both intervention and control groups were examined and
compared before, immediately after, and one month after the intervention. To compare the two study
groups considering non-normal quantitative and ranked variables, Mann-Whitney U test was
employed. For intragroup comparisons and to compare the three phases of before, immediately after,
43 Evidence Based Care Journal, 8 (2): 39-48

Table 1. Flourishing Promotion Program

Sessions Subject Time
Greeting the elderly and getting to know each other, introducing the FPP
Session 1 Assignment for the next session: Introduce yourself positively on one page with 90 minutes
the help of your caregiver
Positive sources and positive excitement
Assignment for the next session: Getting help from your caregiver, check the page
Session 2 90 minutes
you have introduced yourself on and express your personality strengths aiding you in
the past
Understanding personality strengths
Session 3 Assignment for the next session: Make a list of ways to reinforce your personality 90 minutes
strengths
Reinforcing personality strengths
Session 4 Assignment for the next session: Write a letter of forgiveness to a guilty person with 90 minutes
the help of your caregiver and swear to that person that he or she will be forgiven.
Forgiveness
Assignment for the next session: Getting help from your caregiver, write a letter of
Session 5 90 minutes
appreciation to the one not appreciated for any reasons. If possible, deliver the
letter to that person.
Appreciation
Session 6 Assignment for the next session: With the help of your caregiver, write down a list 90 minutes
of fun activities in the center you are residing in and try to do them.
Art of gaining pleasure
Assignment for the next session: Getting help from your caregiver, write about
Session 7 90 minutes
three lifetime situations you have lost an important thing in; then, think about the
blessings after these failures or achievements and note them down
Optimism, positive thinking, and hope
Session 8 Assignment for the next session: Review the points acquired in all sessions in a 90 minutes
group discussion

and one month after the intervention, Friedman test was used considering the non-normal distribution
of the variables. During these tests, the confidence coefficient and the significant level were
considered 95% and 0.05, respectively.

Results
The mean ages of the elderly in the intervention and control groups were 78.1±0.7 and 74.9±11.4
years, respectively, and 76.7% and 60.0% of the older adults in the intervention and control groups
were female, respectively. Moreover, 76.7% of the participants in the intervention group and
73.3% of the elderly in the control group had lost their spouses. In addition, 83.3% and 70.0% of
the individuals in the intervention and control groups had primary school education, respectively.
The findings also showed that 76.7% of the older adults in the intervention group and 70.0% of
them in the control group had a history of chronic diseases. In addition, 56.7% and 83.3% of the
elderly in the intervention and control groups had not experienced any social activities during their
lifetime, respectively. In addition, 83.3% of the participants in the intervention group and 66.7% of
them in the control group had benefited from a social support system. Moreover, 56.7% and 43.3%
of the elderly in the intervention and control groups had enough income, respectively. The mean
lengths of stay in the nursing homes among the elderly in the intervention and control groups were
2.9±1.7 and 2.9±2.3 years, respectively. Furthermore, both intervention and control groups were
homogenous in most cases in terms of demographic and underlying characteristics (P=0.05;
Table 2).
The mean score of social health before the intervention was 57.1±6.3 in the intervention group
and it was 50.4±9.0 in the control group, which was significantly different according to the
results of Mann-Whitney U test (P=0.001). The mean score of social health immediately after the
intervention was 67.9±5.5 in the intervention group and 50.4± 9.0 in the control group, which was
significantly different based on the findings of Mann-Whitney U test (P=0.001). Considering the
lack of homogeneity of the mean scores of social health in the two groups before the intervention,
analysis of covariance (ANCOVA) was used to remove its effect size. The results showed a
Nojabaee et al. The Effect of Flourishing Promotion Program on Social Health in the Elderly 44

significant difference between the mean score of social health before the intervention and the
total score of social health immediately after the intervention in both study groups (P=0.001).
There was also a rising trend in the mean of changes in scores of social health immediately after
and before the intervention in the intervention (10.8±2.8) and control (0.1±0.4) groups, which
was reported as a significant difference according to the results of Mann-Whitney U test
(P=0.001).
The mean score of social health in the intervention group was 66.8±5.5 one month after the
intervention, and it was 49.3±8.7 in the control group. Mann Whitney U test reflected a significant
difference between these two groups (P=0.001). Considering that the total score of social health
status before the intervention was not homogenous in both groups, ANCOVA was run to remove
the effect size, which indicated that the total score of social health one month after the intervention
was significantly different between the two groups (P=0.001). The mean score of social health
immediately after the intervention in the intervention and control groups were 67.9±5.5 and
50.4±9.0, respectively. According to Mann-Whitney U test, such a difference was significant
(P=0.001). The mean of total social health scores in the intervention and control groups one month
after the intervention were 66.8±5.5 and 49.3±8.7, respectively. Regarding the findings of Mann-
Whitney U test, such a difference was significant (P=0.001).
The mean of changes in the scores of social health also reduced immediately and one month after
the intervention to 1.1±1.2 in the intervention group and to 1.1±0.8 in the control group, which
were not significantly different according to the results of Mann-Whitney U test (P=0.589).
Considering that the total score of social health status before the intervention was not homogenous
in both groups, the ANCOVA was used to remove the effect size, which indicated that the changes
in the total score of social health one month after the intervention was significantly different in
both study groups compared to before the intervention (P=0.001).
Given the intragroup comparison and the results of Friedman test, the total score of social health in
the intervention group could entail significant changes at different phases, that is, before,
immediately after, and one month following the intervention (P=0.001). Using Wilcoxon signed -
rank test with Bonferroni correction to compare the phases in a pairwise manner, we found that
changes in all the phases were significant. According to the results of Friedman test, the total score
of social health before, immediately after, and one month following the intervention had
significantly changed in the control group (P=0.001). The findings of Wilcoxon signed-rank test
with Bonferroni correction for pairwise comparison also showed that the changes immediately
after the intervention were not significant compared to those before the intervention; however,
there was a significant difference between one month after the intervention and before the
intervention and between one month post-intervention and immediately following the intervention
(Table 3).

Table 2. Demographic characteristics of the participants in both intervention and control groups
Group
Variable intervention control Test results
(30 individuals) (30 individuals)
Age (year) 78.1±7.0 74.9±1.4 *P=0.16
Length of stay in the nursing home (year) 2.9±1.7 2.9±2.3 *P=0.67
Gender
Male 7 (23.3) 12 (40.0)
**P=0.16
Female 23(76.7) 18 (60.0)
Marital status
Single 5(16.7) 2 (6.7)
Married 1(3.3) 5 (16.7)
***P=0.30
Deceased spouse 23(76.7) 22 (73.3)
Divorced 1(3.3) 1 (3.3)
Level of education
Primary school 25 (83.3) 21 (70.0)
Secondary school 4(13.3) 7 (23.3) *P=0.22
Higher education 1(3.3) 2 (6.7)
*Mann-Whitney U test **Chi-square test ***exact Chi-square test
45 Evidence Based Care Journal, 8 (2): 39-48

Table 3. Comparison of participants’ social health status in both intervention and control groups
Group
Intervention Control Intergroup
Variable (30 individuals) (30 individuals) Mann-Whitney
Mean±standard Mean±standard U test results
deviation deviation
Social health score before the intervention 57.1±6.3 50.4±9.0 P=0.001
Social health score immediately after the intervention 67.9±5.5 50.4±9.0 P=0.001
Social health score one month after the intervention 66.8±5.5 49.3±8.7 P=0.001
Intragroup Friedman test results P=0.001 P=0.001

Discussion
We sought to determine the effect of the FPP on the social health of the elderly residing in Toos
Nursing Home and Salamati Nursing Home in the city of Mashhad, Iran.
Considering the results of the present study, the social health status in older adults in the intervention
group was significantly higher than that in the control group before, immediately after, and one month
after the implementation of the FPP. There was also a statistically significant increase in social health
status in the intervention group immediately and one month after the intervention compared to that
before the intervention. In this respect, the study by Bahadori Khosroshahi et al. (2016) in Iran on
elderly subjects showed that the use of reality therapy for older adults led to an improvement in social
well-being and its components. In the meantime, a significant increase was reported in social health
dimensions in the elderly (26), which was consistent with the results of the present study since reality
therapy was originated from the concepts of positive psychology and it was to some extent in line
with the contents of the FPP. In other words, the implementation of the FPP could aid the elderly to
establish better relationships with others, sustain and reinforce the positive features of their
personality, and enhance their hope and positivism through group collaborations. Thus, the
dimensions of social health could be promoted and the post-intervention effects could be highlighted.
The study by Sohrabi et al. (2016) also showed that well-being and health could be increased in the
elderly as a result of practicing positive psychology techniques including those on friendship,
appreciation, and writing down positive attributes (27). The older adults in the present study also
practiced appreciation, forgiveness, and writing their own strengths throughout the FPP; they also
established positive emotions and recollections during group discussions, and consequently, their
social health was promoted.
The investigation by Sadri Demirchi et al. (2015) on the elderly also indicated increased emotional,
psychological, and social well-being in the intervention group compared to the control group (21),
which was consistent with the results of the present study. It should be noted that the older adults
could participate in a group and discuss their strengths and listen to those of others in the course of the
FPP, and consequently, experience sharing and have a sense of belonging to a community, which
could affect and increase their social coherence. In this study, one of the reasons for reduced social
coherence one month after the intervention was using the routine programs offered in the centers, no
continuation of group sessions in the form of educational sessions, and reduced ability to retain the
educational information in the elderly.
The results of the present study in terms of increased social health and its dimensions were in line
with those of Sadri Demirchi et al. Although the types of interventions were different, the reality
therapy program targeting increased positive feelings, as well as examining and identifying faulty and
incompatible cognition in individuals could be considered among PPT interventions, thus, the
obtained results could be expected. The study by Arabzadeh (2016) also demonstrated that the use of
PPT could augment self-management abilities in older adults. It should be noted that different
dimensions of elderly life are considered within PPT and the issues of prevention, promotion of
mental health, self-management abilities, and satisfaction with life are also highlighted (28). The
results of the present study were also consistent with the findings by Arabzadeh in terms of the types
of interventions as well as the results of self-management dimensions. It was concluded that the use of
educational programs for the elderly could improve all the dimensions of their life and health status.
Therefore, the elderly can improve their social relationships and attitudes towards others, and
ultimately, improve their social health if they try to associate their achievements, failures, and
Nojabaee et al. The Effect of Flourishing Promotion Program on Social Health in the Elderly 46

conditions to themselves and their thoughts and believe that thoughts, behaviors, and emotions they
experience are under their control (29).
Regarding social acceptance as one of the social health dimensions, a person can have a positive
attitude and feeling to oneself and their past life and accept all their dimensions despite their
weaknesses and disabilities (30). In line with the study by Sadri Demirchi et al., the elderly receiving
the FPP in the present investigation could learn how to reinforce positive characteristics, appreciation,
and forgiveness in their own groups, change their compatibility with others, establish interpersonal
relationships with others, and accept the positive and negative aspects of their lives (31). The older
adults receiving the FPP could also practice how to appreciate others and realize the importance of
forgiveness in collective life in nursing homes; therefore, their social acceptance could be changed.
Yazdani et al. (2014) also outlined different levels of social participation in their study from being
with others without doing any activities to assuming different roles in the society. It should be noted
that most individuals aged 65 years and over feel a state of social isolation, which prevents them to
have close and intimate relationships with others (1). In this study, social participation in the elderly
could be increased through their presence in groups during the FPP as well as contribution to group
discussions and establishment of social contacts with other elderly individuals residing in nursing
homes. The study by Pietrowsky and Mikutta (2012) entitled as “Effects of positive psychology
interventions in depressive patients: A randomized controlled study” (32) was to some extent in line
with the present study in terms of its intervention program because social participation in the elderly
had increased through using the FPP and practicing appreciation and positive thinking, reinforcing
their strengths, and gaining pleasure via increasing social relationships and identifying their positive
characteristics and those of others. Also, the contribution of the elderly to meaningful activities,
usually in the form of organized friendship and collaboration such as taking part in different classes,
can be one of the key elements in promoting quality of life and public health status (33).
Furthermore, there was a significant decrease in social health in older adults in the present study one
month after the intervention compared to that immediately after the intervention in both groups due to
the return of the elderly to normal activities in the nursing homes, information retention problems in
the elderly, and non-implementation of the educational programs. In the study by Bahadori and Sadri,
the follow-up phase was not carried out one month after the intervention and there was no possibility
to compare these findings with those in the related articles. Among the distinct features of the present
study compared with those conducted in the domain of social health in the elderly were simplified and
comprehensible contents for the elderly, summarized educational subjects, as well as follow-up
phases one month after the intervention.
The results of the present study showed that the FPP was capable of raising the level of knowledge,
awareness, and skills in older adults, and consequently, increased social health and its dimensions;
therefore, FPP as an accessible, effective, and low-cost program was recommended for teaching the
elderly and promoting their social health. Accordingly, the elderly individuals, especially those
residing in nursing homes, can reinforce their positive characteristics and practice appreciation,
forgiveness, sense of pleasure, positive thinking, and sense of hope after implementing this program;
thus, they can engage in public and have a sense of belonging to community, compatibility with
others, increased objective activities, and improved interpersonal relationships. Given the growth in
aging population in Iran and the importance of prevention and promotion of social and mental health
status in older adults, the FPP as a simple, accessible, and non-pharmaceutical strategy with no
complications, which is accepted by the elderly and is in accordance with their culture, can be an
effective step contributing to the development of innovative programs improving geriatric health.
Among the limitations of this study was that this investigation was only conducted on elderly people
residing in nursing homes and the intervention used had not been compared with other ones in this
domain. Moreover, information about the participants’ levels of education as well as Persian and
English sources in the domain of social health was not available.

Implications for Practice

Considering the effect of the FPP on increased social health in the elderly, the results of this study
could be used in planning for geriatric health care, improving public health, and preventing reduced
social health status in the elderly residing in nursing homes and day care centers. Accordingly, the
FPP can improve social health through increasing communications and interactions between older
47 Evidence Based Care Journal, 8 (2): 39-48

adults, participating in significant activities, obtaining a sense of belonging to society, increasing

objective activities, and establishing better interpersonal relationships. To improve generalizability, it
was suggested to conduct the same study on the elderly residing at home and those with higher levels
of education and compare this type of intervention with other health-related ones among the elderly.

Acknowledgments
This article with the clinical trial code of IRCT20170822035848N1 was extracted from the research
project with the code of ethics of IR.MUMS.REC.1396.249 approved by the Deputy of Research of
Mashhad University of Medical Sciences dated November 1, 2017. We hereby appreciate Mashhad
University of Medical Sciences for providing financial support. We also express our sincere gratitude
to the authorities as well as professors and instructors of the School of Nursing and Midwifery,
officials and personnel of Toos Nursing Home and Salamati Nursing Home in the city of Mashhad,
and the respected elderly participants and all those who collaborated in this study.

Conflicts of Interest
The authors declared no conflicts of interest concerning the publication of this article.

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