1. Introduction
elf-care includes activities that human beings perform specifically for survival, healthy functioning, continuous improvement, and feeling well [1]. By the aging of the world’s population and the increasing prevalence of chronic diseases in the elderly [2], the importance of self-care and health-promoting behaviors is increasing day by day, regarding the maintenance of function, independence of individuals, and increasing their quality of life [3]. Self-care helps the elderly to manage their health and stay independent [4]. Self-care is one of the main factors in the life of an elderly person in his own home, which is affected by many factors [5]. As people get older, they need more time to recover from the disease, which in turn affects their ability and motivation to take care of themselves [6].
 Research shows that self-care in the elderly is directly related to factors such as education level, socio-economic status, and social support and is inversely related to stressful life events. The elderly people, people with low socioeconomic status, and minority groups need special attention in terms of self-care [7 ,5]. These people are at the lowest level of health, have the minimum activity in self-care, and the least self-confidence in knowing and understanding how to take care of themselves. Self-efficacy improves self-care practices and reduces chronic disabilities [8]. Various studies have shown that elderly self-care is associated with several factors such as life satisfaction, self-esteem, functional capability, level of education, family reaction, and support from the family [9, 10, 11, 12].
Tracy et al. in a study entitled “Outcome Clinic: An Innovative International Primary Care Model for the Elderly With Complex Health Care Needs” showed that the frequency of disability and its effects on living conditions are two important determinants of quality of life in the elderly [5].
Today, with the increase in the average life expectancy, the distribution of the elderly population worldwide has significantly changed [13], so that the fastest population growth is related to the elderly [14]. In this regard, it is predicted that the elderly population will reach two billion people by 2050. In Iran, according to the Statistics Center, the elderly population will grow to 10 million by 2019 [15]. Aging is one of the most important social developments of the 21st century and its consequences affect all sectors of society, including the labor market, demand for goods and services such as housing, transportation, social support, and intergenerational relations [16]. In Iran between 1956 and 2016, over a period of six decades the population aged 65 and over increased 542% (about 9% per year) [17].
Today, about 4500000 elderly people live in Iran. According to the National Census of Iran in 2016, about 8.5% of the total population of the country and more than 7.5% of Tehran City is over 65 years old. Given the current demographic structure, the unpredictable aging population trend in the coming years, from 7.27% in 2006 to more than 16% in 2050, is predicted to be a phenomenon that has never occurred before [18]. Old age does not mean disability, and providing self-management and self-care programs to control chronic illness to the elderly can prevent and even delay disability in people with chronic illnesses such as arthritis, heart disease, or high blood pressure. Given the undeniable and key effects of self-care on aging with health, conducting more studies to promote self-care is one of the provisions of the health sector. Therefore, this study was performed using the Backman model in determining the dimensions of self-care and the factors affecting it in the elderly in Tehran City. This model is a systematic and integrated model that clarifies the self-care knowledge of the elderly.
2. Materials and Methods
This cross-sectional (descriptive-analytical) study was performed on 400 elderly members of 10 nursing homes in Tehran City. These ten homes were randomly selected among the elderly centers in Tehran City. Then, according to the number of elderly people in each home, they were examined and the subjects were systematically identified among the homes. The inclusion criteria were as follows: age over 60 years, speaking Persian, no hearing impairment or mental problems, and a desire to participate in the study. Assuming that 50% of the elderly had self-care, the sample size was determined to be about 385 with 80% power and 95% confidence level. Five questionnaires of self-care behaviors including self-care orientation, life satisfaction assessment, self-confidence, social support, and functional capability were used. At the beginning of the questionnaire, demographic characteristics of the elderly such as age, gender, occupation, lifestyle, and marital status were considered.
Elderly self-care behaviors were assessed by a self-care questionnaire that included 42 questions and 12 dimensions of awareness and willingness to self-care (4 questions), physical condition (5 questions), communication with health care staff (5 questions), communication with family (3 questions), meaningful and stimulating aging (3 questions), understanding the future (3 questions), treatment and medication management (2 questions), work habits (6 questions), past events (3 questions), confidence and trust (2 questions), medical treatment (2 questions), and future perspectives (4 questions). Scoring questions based on the 5-point Likert scale ranged from “strongly disagree” (score 1) to “strongly agree” (score 5). A higher score in this questionnaire indicated good status and a low score indicated a bad status. This tool was first designed by Backman and Hentinen based on their model [19].
The tendency to self-care was assessed based on a 14-item questionnaire by Backman and Hentinen (2001). The questions were scored on a 5-point Likert-type scale (strongly in favor of = 5 to strongly opposed to= 1). A higher score in this questionnaire indicated good status and a low score indicated a bad status [20]. To assess life satisfaction, the 5-item life satisfaction Dieners et al. questionnaire was used that checks whether the person was in a position of cognitive judgment in two comparative states of estimating or not estimating wishes and desires [20].
Each statement had 7 options and was rated from “strongly oppose” (score 1) to “strongly agree” (score 7). The validity and reliability of this scale were measured by Bayani et al. (2007). The validity of this scale was obtained using the Cronbach α coefficient method as 0.83 and with a retest method as 0.69. The construct validity of the life satisfaction scale was assessed through convergent validity, using the Oxford Happiness Index (OHI) (Argyle, 2001) and the Beck Depression Inventory (BDI) (Beck et al., 1961). The result indicated the validity and reliability of the tool [21].
Self-confidence was assessed based on the 10-item self-confidence questionnaire of Rosenberg et al. [22]. This questionnaire consists of 10 questions. The answer to each question consists of 4 options (strongly agree, agree, disagree, and strongly disagree) which is given from 1-4 points, so the range of points is from 10-40. A higher score indicates a person’s higher self-confidence, with a score of 40 being the highest score. Scores higher than 25 indicate high self-confidence, scores between 15 and 25 indicate moderate self-confidence, and less than 15 indicate low self-confidence [23]. The self-confidence questionnaire is a standard questionnaire whose reliability has been determined based on the opinions of various manufacturers and preliminary studies [24]. Sharifi Nistanak et al. in their study reported the Cronbach α coefficient for this instrument as 0.91 [25]; Mohammadi and Sajjadinejad also reported the Cronbach α coefficients of the Rosenberg self-esteem scale on Shiraz University students at 0.78 [26]. In the study of Akhlaghi et al., this scale had a satisfactory internal validity and its reliability in the test-retest method ranged from 0.88 to 0.77 [27].
Some researchers have reported the internal consistency coefficient of the Rosenberg self-esteem scale as 0.91 [28]. Social support was assessed based on the questionnaire of Zimet et al. (1988). The questionnaire assessed social support from three sources: family (4 questions), friends (4 questions), and important people (4 questions). It had 12 questions scoring based on a 5-point Likert-type scale. In this way, 5 points were given to “strongly agree” and 1 point to be “strongly oppose.” The score range was between 12 and 60. Performance capacity was assessed based on the ability to perform activities of daily living (ADL), which is a key indicator of long-term care [29]. If an elderly person is unable to care for himself/herself due to physical or mental health problems, this person needs to be cared for by another person. Long-term care Aims to empower the elderly to maintain the highest possible level of independent functioning.
Functional dependence is the inability to perform one or more of the ADL without help. To assess the ADL status of the elderly were asked in terms of doing housework such as washing, vacuuming, dusting, cooking, home repair by themselves and the need for assistance or supervision in personal care such as showering/bathing, dressing, going to the toilet, as well as helping to trim nails. For each of the above cases, three closed answers “Yes completely,” “Yes with help,” and “No” were considered to measure the individual’s ability that scored as follow: was done by oneself (score 2), needed help (score 1) and complete dependence on the other person (score 0). A high score indicates less need for supervision or assistance in performing ADL and a low score indicates a need for more supervision or assistance in performing ADL. This questionnaire is valid and reliable in Iran [30].
The content validation method was used to determine the validity of data collection tools. Thus, for data collection tools, standard and valid scales available, according to the type of study and the study group, were used. Then the questionnaires were presented to various professors and experts and their suggestions were included in the final questionnaire. In this study, the Cronbach α was calculated to determine the reliability of the questionnaires. The following results were obtained for self-care questionnaires (0.70), willingness to self-care (0.71), life satisfaction (0.85), functional capability (0.71), self-confidence (0.69), and social support (0.85). The questionnaires were filled in several stages, taking into account the resting times of the elderly.
According to Farrell’s definition of aging [31], and regarding the comparison of self-care dimensions in different age groups, the elderly were arranged into three groups of young elderly (65-74), middle-aged elderly (75-84), and old elderly (above 85) years. The Chi-square, Pearson correlation and regression analysis were used with a significance coefficient of 0.05. The data were entered and analyzed in SPSS V. 19. The response rate was 96.25%.
3. Results
The Mean±SD ages of elderly women and men were 7.47±67.31 and 7.47±70.92 years, respectively. About 42.5% of the elderly were male and the rest were female. They lived 42.1% with a spouse and 26% alone (Table 1). 



There was no significant difference between the types of self-care and gender except for the dimensions of work habits (P<0.001) and medical treatment (P<0.001) (Table 2). 



 There was a significant relationship between different age groups of the elderly only in terms of knowledge and willingness to take care of themselves, work habits, and past events. However, the two groups were not significantly different in terms of other dimensions (Table 3). 



There was a slight and positive statistical relationship between self-care and life satisfaction (P=0.01, r=0.343) and a weak and positive relationship between self-care and self-confidence (P=0.01, r=0.289) (Table 4). 



 4. Discussion
In this study, among the dimensions of self-care (awareness and desire to take care of themselves, physical condition, communication with health staff, communication with the family, aging with meaning and stimulation, understanding of the future, treatment and medication management, work habits, past events, and confidence), the highest average was related to “physical condition” and the lowest average was related to “medical treatment and foresight.” Therefore, the most important dimension of self-care in the elderly is their physical condition, because self-care is a practice in which each person uses their knowledge, skills, and abilities as a resource to “independently” take care of their health. In the meantime, the physical condition can be the key dimension in elderly self-care. Medical treatment in the elderly is often inappropriate and wrong, which can be attributed to the complexity and frequency of prescription treatments due to the presence of various chronic diseases. Also, in this study, the known effective factors on self-care of the elderly in Tehran City were “tendency to self-care,” “life satisfaction,” “self-confidence,” “functional capability,” and “social support.” 
According to a 2003 Backman study [32] and studies by Rabiner et al. [33] and Blair, self-care in the elderly is associated with functional capacity, life satisfaction, and self-confidence. Therefore, in this study, these factors were addressed and it was shown that by increasing the types of self-care and the tendency to it, the level of life satisfaction and self-confidence increases [34, 35, 36].
Other studies have shown that the functional capacity of older people is dependent on self-care in them [10] and [31] in this study, a direct and significant relationship was found between social support and the tendency to self-care behaviors. Backman and Hentinen also showed that social support promotes self-care activities in the elderly [10]. Regarding the role of social support, Isola et al. showed that relatives play a very important role in the self-care of the elderly [37].
The social support provided by the spouse and how it affects self-care behaviors has shown that the quality of marriage and marital intimacy leads to better self-care knowledge [38]. A study by Gallagher et al. (2011) found that higher social support in patients with heart failure compared with those with low or moderate social support increased consultation with health professionals about weight loss (P=0.01), fluid restriction (P=0.02), and drug use (P=0.017) [39].
It seems that social support increases a person’s motivation to take care of themselves. Based on the Findings of this study, there was a direct and significant relationship between self-confidence and self-care behaviors. Self-confidence is the result of self-esteem as well as the self-esteem of others. Evidence suggests that receiving respect from others increases self-care behaviors, promotes health, and prevents disease [40] and low self-esteem is a deterrent to self-care behaviors [41]. Since self-care is one way to earn the respect of others, older people with higher self-esteem were more likely to engage in self-care behaviors. Gaining the respect of others is one way to gain self-confidence.
The results of this study showed no significant difference between the dimensions of self-care except occupational habits (P<0.001) and medical treatment (P<0.001) between men and women. Lantz study, on the other hand, showed that women are more inclined to self-care than men [42]. In this study, there was a correlation between gender and the self-care dimension of work habits. There was also a correlation between gender and the self-care dimension of medical treatment. The average man was higher than women. Perhaps this finding can be interpreted because jobs are more important to men and they are more accustomed to their jobs than women. In order not to lose their job, men show more job-appropriate self-care behaviors than women. Also, men do not believe in traditional medicine and self-medication more and prefer medical treatment, but women are more in favor of traditional medicine and self-medication.
Statistical tests showed a significant difference between different age groups of the elderly in terms of knowledge and willingness to take care of themselves, work habits, past events. In this study, “awareness and willingness to take care of themselves” and “work habits” among the elderly age groups, young elderly, and middle-aged elderly were more than the old elderly. A review of the literature in this field shows an inverse and significant relationship between “awareness and desire for self-care” with age [42, 43] so that with increasing age, “awareness and desire for self-care in the elderly” decreases, which can be partially the ability to reduce the ability to self-care in them and related cognitive problems and issues. Accordingly, a positive and significant relationship has been shown between elderly awareness, self-care, and daily habits [43]. The relationship between awareness and self-care has also been shown by other studies [44، 45]. Studies and documents in this field show a significant relationship between increasing age and decreasing functional capacity [46, 47].
The average self-care dimension of “past events” was higher among the old elderly group than other age groups. Obviously, with increasing age and the decline in quality of life and the significant positive relationship that exists between all aspects of self-care and quality of life [48، 49], self-care of “past events” help the elderly to find their identity, alleviate discomfort, and disability.
This study was conducted in nursing homes in Tehran City and so the generalizability of its results to other elderly people is limited. Therefore, we recommended further studies at the national level to determine self-care challenges and factors affecting it [50].
5. Conclusion
Factors such as life satisfaction, functional capacity, social support, and self-confidence are associated with self-care in the elderly. It is suggested that health policymakers design programs support the elderly in various forms, such as designing programs for easy access of the elderly to transportation, facilities, tax exemptions, and so on.
It is suggested that national policies be developed with the aim of independence of the elderly and with an elderly-oriented approach. All measures to help the elderly should be exempt from taxes. The government should provide easy access to the community, proper housing, proper transportation services, as well as full-time home care services for the elderly. The government should take measures in the fields of health, sports, and medicine for the elderly.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Alborz University of Medical Sciences (Abzum.Rec.1396.207).
Funding
The study support financially by Alborz University of Medical Sciences.
Authors' contributions
All authors contributed equally in preparing all parts of the research.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
We would like to thank reseach committee of Alborz and Tehran University of Medical Sciences.


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