Journal of Psychiatric and Mental Health Nursing, 2014, ••, ••–••

Effects of physical exercise programme on happiness among older people M . K H A Z A E E - P O O L 1 Ph D, R . S A D E G H I 2 & A . R A H I M I F O R O U S H A N I 4 Ph D

Ph D,

F. M A J L E S S I 3

MD

&

MPH

in

MCH

1

PhD Candidate, 2Assistant Professor, 3Professor, Department of Health Education and Promotion, and Associated Professor, Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

4

Keywords: exercise programme, happiness, Iran, older Correspondence: M. Khazaeepool Department of Health Education and Promotion School of Public Health Tehran University of Medical Sciences Tehran 0098-46511-84866 Iran

Accessible summary

• • •

This randomized-controlled trial investigated the effect of physical exercise programme (PEP) on happiness among older adults in Nowshahr, Iran. Results of this study on 120 male and female volunteers showed that an 8-week group physical exercise programme was significantly effective in older adults’ happiness. Findings showed that physical exercise programme is so beneficial for increasing older adults’ happiness.

E-mail: [email protected]

Abstract

Accepted for publication: 22 June 2014

Physical activity is associated with well-being and happiness. The purpose of this study was to determine the effects of an 8-week long physical exercise programme (PEP) on happiness among older adults in Nowshahr, Iran. This was a randomized control trial study. The participants consisted of a group of 120 male and female volunteers (mean ± SD age: 71 ± 5.86 years) in a convenience sampling among older adults in public parks in Nowshahr, Iran. We randomly allocated them into experimental (n = 60) and control (n = 60) groups. A validated instrument was used to measure well-being and happiness [Oxford Happiness Inventory (OHI)]. Respondents were asked to complete the OHI before and 2 months after implementing PEP. The 8-week PEP was implemented with the intervention group. The statistical analysis of the data was conducted using paired t-test, Fisher’s exact test and χ2. Before the intervention, there was no significant difference in the happiness mean score between the case and control groups; however, after implementing PEP, happiness significantly improved among the experimental group (P = 0.001) and did not improve within the control group (P = 0.79). It can be concluded that PEP had positive effects on happiness among older adults. Planning and implementing of physical activity is so important for older happiness.

doi: 10.1111/jpm.12168

Introduction Ageing is a complex process of physical, psychological and social changes. Older people are among the most vulnerable groups to health-care quality problems, and they have particular needs. Ageing is an unavoidable and irreversible phenomenon (Ferhan & Vesile 2011) but can be experi© 2014 John Wiley & Sons Ltd

enced in a manner deemed successful. Successful ageing encompasses multiple dimensions of health, including physical, functional, social and psychological well-being (Phelan et al. 2004). The numbers of older people in the total population is currently increasing throughout the world (Ferhan & Vesile 2011). This increase in the older population is more attributable to advances in public 1

M. Khazaee-pool et al.

health and the social determinants than to medical care (Taleb et al. 2009). Since 2000, the proportion of older adults in the world has increased from 10.0% to 14.2% by 2009, and it will increase to 21.0% in 2025–2050 (Population Division, Department of Economic and Social Affairs 2009). The number of older adults in Iran is 5 600 000, which constitutes 5.7% of Iran’s population in year 2012, but it will rise by approximately 21% by 2050 ( SCI 2011). Based on the last Iranian census in 2011, a life expectancy of 74.6 and 72.1 has been registered for Iranian women and men, respectively (Islamic Republic News Agency 2012). As the World Health Organization (WHO) indicates, this increase in the number of older adults has led to the need for health-care system reform to integrate elder health services into routine health services (WHO 2001). The advancing age of the population has produced an increased need to identify factors that contribute to the ability of the older adults to maintain their activity and independent lifestyle, specifically to identify factors that may delay or prevent frailty and disability (Abellan van Kan et al. 2009). Ageing is associated with many social and psychological changes that may lead to disease and disability, and reduce the level of happiness in older adults. Happiness is improving significant component of mental health for older adults (Angner et al. 2009). Internal and external factors influencing life happiness are self-esteem, satisfaction with self performance, adequate income and living in a healthy family (Argyle & Martin 1991). Happiness has been defined as ‘a lasting, complete, and justified satisfaction with life as a whole’ (Tatarkiewicz 1979). Also, happiness has been conceptualized as a positive inner experience, the highest good and the ultimate motivator for all human behaviours (Lu et al. 2001). Happiness is a multidimensional construct comprising both emotional and cognitive elements (Argyle & Crossland 1987). The three main components of happiness that have been identified by researchers are frequent positive affection or joy, high level of life satisfaction over a period of time, and the absence of negative feelings such as depression and anxiety (Argyle & Crossland 1987). One of the key strategies for improving happiness and reducing negative feeling is physical activity, which contributes to healthy ageing by preventing disability, morbidity and mortality in older adults (Christ & Ross 2010, Fararouei et al. 2013). Despite its many benefits, physical activity participation declines progressively with age (United States Department of Health and Human Services 2006). People living with limitations to physical activity might have fewer opportunities to be satisfied with life or experience happiness, which can have 2

a negative effect on their overall quality of life (QOL) (Newall et al. 2013). In line with this tenet, research has shown that the more that older adults engage in social, physical and cognitive activities, the happier they are (Inal et al. 2007). The health benefits of physical activity for older adults are well documented in terms of reduced mortality (Chakravarty et al. 2008), better functional, physical and more positive affect (Netz et al. 2007), and less cognitive decline (Klusmann et al. 2010). Studies have shown that physical activity has a positive effect on happiness, mental health, self-efficacy, self-esteem, life satisfaction and positive mood (Hills & Argyle 1998, Allison & Keller 2004, Spence et al. 2005, McNeill et al. 2006, Denny & Steiner 2009, Martin et al. 2009). Within this context, self-esteem and self-efficacy have been regarded as an important element of well-being and are constructs that might be amenable to change through exercise. Self-esteem is defined as the experience of being able to deal with life’s problems and the appraisal of being worthy of happiness (Acil et al. 2008). Physical exercise largely increases a person’s self-esteem and mental health while reducing stress (Spence et al. 2005, Acil et al. 2008). Selfefficacy is defined as one’s confidence in his/her own ability to promote suitable solutions and perfect duties necessary to be successful in various efforts (Allison & Keller 2004, McNeill et al. 2006). Also, studies show that regular physical activity can improve mental health, increase social interaction and decrease social isolation among people with serious mental illness (Faulkner & Sparkes 1999, Carter-Morris & Faulkner 2003, Chodzko-Zajko et al. 2009). Despite these positive effects, controlled studies on older adults and happiness in the context of physical activity are limited, and many older adults are not sufficiently active to enjoy these health benefits (Schoenborn et al. 2006). Hence, recognizing strategies to enhance physical activity in this large and growing segment of the population is a public health priority ( Task Force on Community Preventive Services 2002). The level of physical activity is too low among Iranians, specifically older adults, as evidenced by survey of risk factors for noncommunicable diseases in Iran that found that about 60.6% of older men and 77% of older women were inactive because of smoking, air pollution, busy life, lack of time and low literacy (Alikhani 2005). Other study in Yazd, centre of Iran, showed that the rate of physical inactivity among adult was approximately 65.8%, and women (81.6%) were more active than men (54.4%) (Motefaker et al. 2007), and Iranian older adults, especially women, are at risk for sedentary behaviour due to specific cultural barriers, such as exercise limitations in public places (Taymoori et al. 2010). © 2014 John Wiley & Sons Ltd

Physical exercise programme and happiness

Although it is clear that there is a statistical relationship between physical activity and happiness, limited research has delved into the issue of cause and effect. There is a lack of information regarding the association between physical exercise and happiness in older adults. In particular, the casual nature of this relationship remains unclear. It can be hypothesized that correlations can exist due to the effect of physical activity on happiness rather than by the effects of happiness on physical activity. To disentangle cause and effect, we need controlled trials. Therefore, this study was designed to examine physical exercises programme and its impact on happiness of older adults. In considering the influences of physical activity, it was hypothesized that it would be positively related to happiness.

Subjects and method Designed to investigate the effects of an 8-week physical exercise programme (PEP) on happiness among older adults, this study was conducted using a randomized control trial methodology. A total of 120 male and female volunteers ranging from 65 to 89 years were randomly allocated to subgroups ‘experimental (n = 60) and control (n = 60) groups’ over 2 months, from April to June 2011. Blinding of allocation was assured by the separation of the randomization process from researchers involved in the assessment. To ensure that each group was uniformly represented over the time course of the study, a varying-block randomization protocol was used: varying block sizes of four and six were used to ensure that randomization outcomes could not be predicted. Each new participant was assigned to the next consecutive number. All members who were involved in the project (investigators, outcome assessors, and participants) were blinded to this study. Prior to investigation, each participant completed a written informed consent. The study was conducted with the approval of the institutional review mayoralty at the Nowshahr province of Iran. No external funding was provided for this project. Due to the low level of physical activity among Iranian older adults, researchers used a convenience sampling among older adults who were available in public parks in Nowshahr, Iran. Sample size was determined based on the estimation of happiness proportion in older adults. Based on previous study in Iran, 60% of older adults had lower happiness (Salesi & Jowkar 2011). In this study also, the proportion of older adults with lower happiness was equal to 60%, and people who had good happiness were 40%. It was assumed that if happiness score increases at least 20% after the exercise programme, it would be statistically significant. Therefore, the sample size in each group was 47 older adults, with 95% confidence interval and the power of a hypothesis © 2014 John Wiley & Sons Ltd

test was 80%. About 30% more samples to reduce the possible loss of the samples was considered. In total, it was used 120 older adults for sample size.

(Zα + Zβ )2 P (1 − P )

D = 0.2 P = 0.6 zα = 1.96 zβ = 0.84 d2 2 (1.96 + 0.84) (0.6 6 × 0 .4 ) = 47 N= (0.2)2 47 × 2 = 94 + 30% = 120 N=

Inclusion and exclusion criteria Inclusion criteria were men or women of at least 65 years of age; have no medical contraindication for physical activity, such as stroke, Parkinson’s disease, cardiovascular disorders, acute heart failure, uncontrolled hypertension and diabetes; and have the ability to perform routine daily tasks without dependence on others. Participants with a history of overt cardiovascular disease, stroke and congestive heart failure, and lower extremity revascularization were excluded because of the possible confounding influences that cardiovascular disease may have on physical activity. A final exclusion criterion was severe anxiety. Based on the multidimensional anxiety theory (Martens et al. 1990), severe anxiety can significantly reduce athletic performance. Therefore, according to the target group in this study, people with severe anxiety were excluded as they might not be able to exercise properly according to the designed programme.

Measures In order to collect data, a two-section instrument was used, including a demographic data form (consisting of questions related to age, gender, level of education, marital status, occupation, and level of physical activity in the past and the present) and the Oxford Happiness Inventory (OHI). The OHI is a broad measure of personal happiness that was designed by the Department of Experimental Psychology of the University of Oxford in the late 1980s (Argyle et al. 1989). The OHI follows the design and format of the Beck Depression Inventory (BDI) (Argyle et al. 1989). We used the Persian/Farsi version of the OHI in this project. Alipoor & Noorbala (1999) translated the inventory into Farsi and adapted it to Iranian culture (Alipoor & Noorbala 1999). The instrument consists of 29 items in five domains, namely satisfaction (eleven items), positive mood (eight items), mental health (six items), efficiency (four items) and self-esteem (two items). Each item is presented in four incremental levels, namely (1) strongly disagree, (2) fairly disagree, (3) fairly agree and (4) strongly agree. The score 3

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range is between zero and three (the maximum score = 87, with a minimum of 0). The internal consistency coefficient of the Iranian format of the OHI was 0.98. To determine the validity of the instrument, content validity has been utilized and confirmed (0.92) (Alipoor & Noorbala 1999, Alipour & Agah Heris 2007). Validity has also been evaluated by a number of researchers and instructors of subject matter at the Isfahan University of Medical Sciences, and by some psychology experts in Isfahan University (Liaghatdar et al. 2008). In a pilot study, 20 questionnaires were distributed among older adults in the study area. Data analysis was conducted and Cronbach’s alpha coefficients were r = 0.95, r = 0.91 and r = 0.87 for the first, second and third week, respectively. The questionnaires were completed by all respondents, and the data were analysed using the SPSS software version 14 (IBM Company, New York, United States). Based on the results of this analysis, a physical activity programme was designed and implemented on the experimental group. Participants in the intervention group were followed for 8 weeks of their training programme supervised by physical education expert. The PEP used in this study was based on a training package that was prepared for older adults by the Health Ministry of Iran. The place of exercise programme was separated for two groups. The intervention group participated in the designed activity programme, but the control group just did their regular activities. The PEP occurred three times a week, in the morning at 10:30 in a public park. After implementing the educational programme for 8 weeks, the questionnaire was again completed by both the experimental and control groups. The PEP was divided into three consecutive parts, as shown in Table 1.

Statistical analysis The statistical tests included paired t-test, Fisher’s exact test and χ2.

Results A total of 120 older adults participated in this study. The mean age of the respondents was 71 years (SD = 5.86), the majority of them (43%) ranging from 65 to 89 years. More than half (69.2%) of the participants were males, 86.65% were married, and 83.35% had less than a diploma education. Nearly 82.5% of the participants were being financially supported by their spouse and/or children. The majority (80.85%) of individuals had an income under $500 per month. The majority (76.7%) of participants had health insurance. As shown in Table 2, there was no significant difference between the experimental and control 4

Table 1 Educational structure of exercise programme and key content areas Target population Method/ duration

Programme costs Content areas

Men and women – at least 65 years – having no medical contraindication for physical activity Sessions had three stages as follows: First stage: Warm-up that consists of 4 min of running slowly and 6-min stretching. It includes bending and straightening the limb, close to and to distant organs from trunk, and rotation of the neck and waist, in addition to bending and straightening theme. Second stage: Kinetic movements, including a series of physical exercises in style upper and lower extremities that is 5 min in the early stages and increasing gradually by the end of the sixth week to 10 min, and in the eighth week reaching 15 min. Balance exercises included balance while walking, walking back and forth, along with balancing, transferring weight from one foot to the other foot, walking on tiptoes and soles of the feet, and standing on one leg. Third stage: Cooling stage (includes 5 min of slow movements) and was used for three types of appropriate music with type of training in three stages (warm-up, movement and cooling). All the project costs were paid by the researchers’ personal funds. Approval of experimental group was attracted after sampling of eligible people and explanation about stage of study, concepts that are needed for exercise programme. After passing the above processes, the experimental group participated in the exercise programme of 8 weeks. Participants in the intervention group followed an 8-week training programme. Exercise programme was three times a week, in the morning, at 10:30 in the public park.

groups in terms of marital status, education, social support sources, work status, leisure time physical activity and health insurance. The results of this study showed a significant inverse relationship between age and the level of happiness before the exercise programme, while such a relationship was not observed after the exercise programme in the intervention group. Across the whole sample, before the exercise programme, those with higher subjective happiness were more likely to be younger than those with lower happiness. This association was not present after intervention (P = 0.002). In our results, there was significant relationship between gender and happiness (P = 0.04); in particular, females were happier than males. Study subjects with lower incomes reported lower levels of happiness. There was a significant inverse relationship between level of happiness and dependency on other people, as people who were dependent on others reported lower levels of happiness, but after the training programme this relationship was not observed (P = 0.004). © 2014 John Wiley & Sons Ltd

Physical exercise programme and happiness

Table 2 Demographic data of elders in the experimental and control groups Demographic characteristics

Experimental group Frequency (%) (n = 60)

Control group Frequency (%) (n = 60)

P value

2

Gender Male Female Marital status2 Married Single Education1 Under diploma Diploma University Social support sources1 Spouse, children Siblings Friends Relatives Total Work status1 Active Inactive Homemaker Leisure time physical activity2 Yes No Income (Can$)1 1001 Health insurance Yes No Age (year) Md ± SD range 1 2

43 (71.7) 17 (28.3)

40 (66.7) 20 (33.3)

0.04

53 (88.3) 7 (11.7)

51 (85) 9 (15)

52 (86.7) 5 (8.3) 3 (5)

48 (80) 7 (11.7) 5 (8.3)

0.1

51 (85) 6 (10) 1 (1.7) 2 (3.3) 60 (100)

48 (80) 7 (11.7) 2 (3.3) 3 (5) 60 (100)

0.77

27 (45) 21 (35) 12 (20)

29 (48.3) 20 (33.4) 11 (18.3)

0.82

37 (61.7) 23 (38.3)

35 (58.3) 25 (41.7)

51 (85) 6 (10) 3 (5)

46 (76.7) 12 (20) 2 (3.3)

0.69

0.61

0.004

0.58 47 (78.3) 13 (21.7) 73.3 ± 6.11 65–89

45 (75) 15 (25) 68.12 ± 5.6 65–89

0.002

In order to determine significant difference between groups, X2 was used. In order to determine significant difference between groups, t-test was used.

Table 3 Mean scores of comparison in happiness characteristics before and after exercise programme between two groups after 2 months Experimental group

Control group

Variables

Baseline mean (SD)

Post-intervention mean (SD)

Baseline mean (SD)

Post-intervention mean (SD)

Mean differences

P value

Self-esteem Life satisfaction Efficiency Positive mood Mental health Global happiness

4.21 (2.11) 14.01 (6.2) 4.82 (2.18) 10.3 (4.03) 7.97 (3.31) 42.64 (17.39)

9.54 (1.82) 19.94 (6.01) 10.04 (2.13) 15.91 (3.97) 12.83 (3.27) 62.07 (17.2)

3.62 (1.79) 13.54 (6.43) 4.1 (2.33) 10.76 (3.37) 7.25 (2.69) 37.54 (13.16)

3.71 (1.88) 13.79 (6.39) 4.07 (2.38) 10.99 (3.4) 7.48 (2.17) 37.83 (13.31)

+5.33 +5.93 +5.22 +5.61 +4.86 +19.43

0.002 0.001 0.000 0.004 0.003 0.001

Table 3 shows a comparison of mean scores of happiness and its dimensions based on the OHI in the experimental and control groups before and after the intervention. Before intervention, there was no significant difference between happiness status among the two groups (P = 0.001). Using a paired t-test, after intervention there was significant difference (P = 0.001). Moreover, after intervention, there was a significant increase of happiness © 2014 John Wiley & Sons Ltd

subscales among the experimental group [self-esteem (P = 0.002), life satisfaction (P = 0.001), efficacy (P = 0.001), positive mood (P = 0.004), mental health (P = 0.003) and global happiness (P = 0.001)]. The results in Table 4 show the mean scores of happiness based on the OHI in the experimental and control groups after intervention. The mean scores of intervention group was 42.64 ± 17.39, but in control group it was 37.83 5

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Table 4 Mean and standard deviation (SD) score of elder’s happiness comparison after 8 weeks between intervention and control groups Intervention

Control

Variable

Mean

SD

Mean

SD

Independent t

P

Happiness

62.07

17.2

37.83

13.31

−5.86

0.001

± 13.31, before intervention. However, after intervention, a significant increase in happiness (62.07 ± 17.2) was found among the experimental group (P = 0.001), and the happiness proportion was increased approximately 50% than before intervention.

Discussion Major findings This study aimed to examine the effects of an 8-week long physical exercises programme on happiness among older adults in Nowshahr, Iran. As previously mentioned, the key issue of the article focused on happiness, and the OHI was used in this study (validated by Noorbala and Alipoor in Iran). However, one might argue that there are specific questionnaires to measure each of the dimensions of happiness inventory, such as life satisfaction, positive mood, mental health, self-efficiency and self-esteem; the analysis focused only on happiness and addressed five dimensions of it. The results showed that the mean happiness scores in the control group did not increase after 2 months of followup. Contrarily, after 2 months of exercise education programme in the experimental group, the level of happiness scores among older adults was significantly increased 42.64–62.07. Generally, the results showed that the level of happiness scores significantly increased among the intervention group than in the control group in subscales of self-esteem, life satisfaction, efficacy, positive mood, mental health and general happiness. This result was in accordance with a study in Japan, which concluded that the influence of regular exercise on subjective sense of burden among community-dwelling caregivers of dementia patients improved psychological factors such as nervousness, satisfaction ratings of work, home life and social life (Hirano et al. 2011). Based on our results, however, there were no significant age and physical health difference by gender; after physical activity programme, women were happier than men. These findings were consistent with the results of previously reported study showing positive and significant associations between levels of physical activity and life satisfaction 6

by gender. In Grant et al.’s study (2009), the majority of cases reported positive well-being, with 70% of men and 79% of women saying that they were moderately or very satisfied with their lives (Grant et al. 2009). Also, Farmer et al. suggested that men and women differentially reported physical activity because of cultural expectations and habits (Farmer et al. 1988). In contrast, Stubbe et al. reported that life satisfaction and happiness decreased with increasing age, and men were significantly more satisfied with their lives and happier than women (Stubbe et al. 2007). Also, results indicated that participants who received the PEP were more confident in their ability to return to physical activity compared with control group, while before intervention there was inverse relationship between age and confidence in the ability to return to physical activity and happiness. It may be that physical activity brings skills in confronting with health problems, and that in turn those skills prepare older adults to engage in physical activity. However, there were some ambiguities in the findings of studies; for example, some studies have shown that lower levels of happiness are found among 35 and 62 years of age – middle age – across gender and countries (Blanchflower & Oswald 2008). As Dear et al. reported, life satisfaction was higher in young adults than in older adults (Dear et al. 2002). Our results show that there was a negative relationship between income and level of happiness, and that people with higher level of income were happier than those with lower level of income, and confidence to adhering exercise. These results were consistent with those of Acil et al., who reported that physical exercise and self-efficacy were positively correlated with income level (Acil et al. 2008). It is also possible that people who have higher income levels have less exhausting jobs, making them less tired during the day. Also, people with higher levels of income may be able to manage their time and resources to maintain physical exercise behaviour better than others. Consequently, they have more interest and energy to engage in physical exercise.

Physical activity and its influences on positive mood The results of this study showed that a greater level of physical activity was associated with positive mood (one of the dimensions of happiness inventory). In intervention groups, the more participants reported to receive exercise programme, the less they had negative mood. These findings were consistent with the results of previous studies that show significant associations between low levels of physical activity and depression in older women (Ruuskanen & Ruoppila 1995, Williams & Lord 1997, © 2014 John Wiley & Sons Ltd

Physical exercise programme and happiness

Kritz-Silverstein et al. 2001). Additionally, this finding indirectly was supported with the notion of Acil et al. (2008), who stated that PEP applied by patients with schizophrenia in 10 weeks provided a positive effect on QOL and increased their QOL (Acil et al. 2008). Thus, the PEP provided a significant improvement in terms of physical domain consisting of overall physical activity, and in terms of mental domain consisting of emotions, cognitive functions and behaviours (P < 0.05). Moreover, Deslandes et al. studied about identifying changes in depressive symptoms, QOL and cortical asymmetry after aerobic activity. In his study, participants attended control physical exercise for two sessions per week for 12 months. They were evaluated by depression scales (BDI, Hamilton Depression Rating Scale, Montgomery-Asberg Depression Rating Scale) and the Short Form Health Survey-36. In the intervention group, depressive symptoms significantly decreased, and functional capacity increased (assessed by physical tests), which was not observed in the control group (Deslandes et al. 2010). Depressed mood has negative effect on physical activities in older adults and restrict their participation, which in turn may affect their happiness. It is possible that the range in physical activity level is too narrow within the sedentary older adults, thereby limiting the influence that physical activity may have exerted on happiness domains. Also, this study supported this notion that the higher levels of physical activity had a positive effect on the HealthRelated Quality of Life (HRQL) domains related to physical health (i.e. physical function, role restrictions due to physical and general health) than their more sedentary peers. Therefore, following physically active lifestyle was positively associated with components of mental health among older adults as it was demonstrated in this study and previous study results (Rejeski & Mihalko 2001).

activity in daily lives can be expected to have a positive psychological effect, and it was reported that physical exercises improved psychological factors such as nervousness, satisfaction ratings of work, home life and social life, and finally QOL (Martin et al. 2009). Therefore, it can be said that if physical exercise is used in association with other psychosocial approaches, it has positive contribution to the happiness of older adults, and may lead to much more significant improvement in mental states and happiness of older adults.

Physical activity and its influence on self-efficacy Findings of this study suggest increasing self-efficacy components in intervention group after the physical exercise program may enhance their happiness. Furthermore, a positive correlation was found between moderate physical activity and self-efficacy, and the consequences of this correlation were maintained 8 weeks post-intervention. Therefore, encouraging participants to do more physical activity could potentially act as an effective way to promote selfefficacy in older adults. Also, it may give them a sense of accomplishment and will reinforce their healthy physical activity habits, which can possibly improve their selfefficacy sense. This finding was indirectly supported by the notion of McNeill et al. (2006), who also showed that physical environment perceptions influence individual’s physical activity through motivation and self-efficacy in a diverse sample of adults. In general, self-efficacy was closely related to the levels of physical activity, as was reported on the study on self-efficacy of older people who continue the physical activity programme (Allison & Keller 2004). This fact can be thought us, participation of older adults in physical exercise improve their self-efficacy sense through increasing their social interactivity.

Physical activity and its influence on life satisfaction In our study, it was shown that life satisfaction increased through physical exercise intervention, which may improve participants’ happiness. After the PEP, all of the participants in the intervention group reported that they have been feeling more relaxed, cheerful and healthy, which created a sense of life satisfaction. Some of them even stated that they found themselves more active in daily activities. In other words, PEP could enhance social interaction. Satisfaction with participation may represent older adults’ adaptation and selection of physical activities that are most important to them. These results strongly indicated that the level of life satisfaction was improved by an appropriate habitual intervention through the reduction of negative moods and improvement in both physical and psychological symptoms. Moreover, increasing regular physical © 2014 John Wiley & Sons Ltd

Physical activity and its influence on self-esteem We observed that self-esteem was improved by physical exercise intervention. This is consistent with the previous findings reported by Acil et al. (2008), who stated that after a regular physical exercise intervention implemented for patients with schizophrenia, the overall conditions, such as general well-being, self-esteem and self-confidence, of patients were improved. Similarly, another study conducted on younger adolescents found a positive effect of physical activity on self-esteem (Schmalz et al. 2007).This was in contrast with previous research conducted on 11- to 15-year-old group adolescents that found no significant association between physical activity and self-esteem (Huang et al. 2007). However, another research finding reported that physical exercise boosted memory, built 7

M. Khazaee-pool et al.

self-esteem, removed depression and increased mental alertness. As a result, greater physical health and deeper emotional well-being were developed among the participants. Also, many scientific researches show remarkable preventive and treatment effects of physical exercise on depressive mood (e.g. Blumenthal et al. 2007) and cognitive performance (e.g. Andel et al. 2008). Exercise was also found to positively affect self-concept, stress management, control orientation (e.g. Alfermann & Stoll 2010) and current mental state. It was shown that self-esteem levels can be raised through positive experiences with physical activity. As reported, motivation and self-esteem had direct and mutual relationship, and regular exercise was shown as an important tool to build self-esteem and fight depression (Huang et al. 2007). Physical exercise participation in a group might boost self-confidence in older adults and enhanced their team activity. Besides, physical exercise may potentially enhance immunological function of the human body. Therefore, in this study we identified the most important factors and effective steps to improve older adults’ health. It was thought that the implemented physical educational programme has had enormous positive impacts on happiness in older adult.

Physical activity and its correlation with mental health In our study, we found positive relationship between PEP and mental health components of happiness inventory among the intervention group, when they were compared with the control group. There are few new studies in the area of physical activity and mental health, but many of them remain to be clarified with respect to evidence of physical activity and its diverse mental health outcomes. Our findings were consistent with the findings of previous study that examined the effects of exercise (moderateintensity PEP three times a week) on coping self-efficacy and depression. Craft found that physical exercise contributed to increasing perceptions of coping self-efficacy (beliefs in one’s abilities to cope with stress), and this was associated with lower reported depression. Craft noted that ‘in light of the fact’, women in the intervention group had significantly higher coping self-efficacy. She suggested that by goal setting and skill development in a supportive social environment, the programme contributed to enhancing participants’ beliefs on utilizing physical exercise to cope with depression (Craft 2005). In another direction, Motl et al. examined the effects of physical activity on depression among older adults. In his study, participants were randomly assigned to walking and training group. Before and 6, 12 and 60 months after intervention, depression was evaluated. Results showed that depressive symptoms 8

decreased after intervention and in the duration of 12 and 60 months (Motl et al. 2005). Another randomized controlled trial examined the effectiveness of an endurance exercise programme on depression and anxiety in sedentary older adults. Participants were randomized to aerobic exercise group (ergometer cycle sessions three times/week at a heart rate corresponding to ventilator threshold intensity) and control group. After 6 months of training, the authors found a significant decrease in depression and anxiety scores, and an improvement in the QOL among the intervention group, but it remained within the control group (Antunes et al. 2005).This finding was supportive of our study, which showed the effectiveness of physical exercise training for improving mental health among older adults, and showed a relationship between greater levels of physical activity and higher levels of mental health. That was not easy to say that the lower levels of physical activity cause problems of mental health. It might be the case that the less mental health an individual has, the less likely he/she engages in physical activity.

Study limitations and implications The current study provided evidence for the significance of the physical activity on happiness among older adults. It was among the few studies that concurrently considered physical activity and level of happiness among older adults. However, several limitations of the present study should be noted. First is sampling bias. The study might have attracted volunteer participants. Second is social desirability bias. As data collection was conducted in public parks, biased responses might occur even though participants were informed that each question should be answered as honestly as possible. Third is sample size. The results of this study are difficult to generalize because the number of participants is limited. Fourth is time limitation. This study was conducted in a short period of time, and long-term consequences of physical exercise have not been investigated. For this reason, it might be useful to investigate its consequences on a larger sample size and in longer time. Last is the lack of evaluation of other factors (except demographic characteristics and physical exercise) that related to happiness because multiple factors may lead to greater or lower level of happiness in a specific population.

Recommendation Although there were some limitations in this study, the findings have had important and sufficient implications for health professionals who provide services for older adults. The PEP is a new, cheap, effective, easily applicable and © 2014 John Wiley & Sons Ltd

Physical exercise programme and happiness

among older adults, but our study has documented positive effects of physical activity on happiness and its dimensions, including self-efficacy, self-esteem, positive mood and mental health, despite the limitations listed above. Thus, maintaining a physically active lifestyle contributes to happiness of older adults. Due to the rising costs of the health-care system, it would be relatively cost-effective, especially considering the effects of physical activity, to improve the QOL and well-being of a wide range of older adults (Cobiac et al. 2009, Gesell et al. 2013, Wilbur et al. 2013). As the number of older adults increases, the use of efficient strategies will be important in enhancing physical activity in this group. Because older adults are faced with many barriers to exercise, designing cost-effective interventions remains an important priority that enables participants not only to initiate physical exercise, but also to maintain it routinely over the long term. This is, in fact, important as health economic evaluations of such interventions have the potential to provide governments and payers with better insights on how to spend the available financial resources in a more efficient way.

readily available method for which the available facilities would be sufficient as an alternative approach for supporting older adults. Counselling intervention is one of the specific strategies for encouraging older adults to engage in physical activities that are appropriate to their level of physical fitness and individual preferences. Therefore, we recommend multidimensional and long-term studies to provide generalized evidence about the effects of physical activity and other factors on the happiness and general health of older adults. Additionally, the team would like to recommend designing programmes that provide information about the importance of physical activity for further improvement of elements associated with happiness, like self esteem, self-efficacy, positive mood, and in turn QOL. Conducting longitudinal studies about happiness and physical activity is recommended to find out more about the precise effects of happiness on physical activity.

Conclusions Few studies have been undertaken to investigate the relationship between happiness and physical activity

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Appendix I OXFORD HAPPINESS INVENTORY Questions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

Strongly disagree

Fairly disagree

Fairly agree

Strongly agree

I am incredibly happy. I feel sure that the future is overflowing with hope and promise. I am totally satisfied with everything. I feel that I am in total control of all aspects of my life. I feel that life is overflowing with rewards. I am delighted with the way I am. I always have a good influence on events. I love life. I am intensely interested in other people. I can make all decisions very easily. I feel able to take anything on. Nowadays I always wake up feeling more rested than I used to. I feel I have boundless energy. The whole world looks beautiful to me. I have never felt so mentally alert as I do nowadays. I feel on top of the world. I love everybody. All past events seem extremely happy. I am constantly in a state of joy and elation. I have done everything I ever wanted. My time is perfectly organized so that I can fit in all the things I want to do. I always have fun with other people. I always have a cheerful effect on others. My life is totally meaningful and purposive. I am always committed and involved. I think the world is an excellent place. I am always laughing. I think I look exceptionally attractive. I am amused by everything.

© 2014 John Wiley & Sons Ltd

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