1. Introduction
ealthy aging is the right of all human beings, which highlights the need for preventing its related problems. The elderly have more leisure time after retirement. Leisure time gives them the opportunity to gain strength, confidence, creativity, and physical and mental health [1]. The elderly face many risks such as retirement/unemployment, reduced income, loneliness, lack of social support, industrialization of communities, loss of spouse, separation from children, emotional/psychological separation of family members, and ultimately reduced physical and mental function. Creating opportunities for the elderly to have social participation, including healthy leisure time, can be an effective step in addressing these risks and threats and improving their quality of life. The purpose of this study is to investigate the effect of leisure-spending patterns on the mental health of the elderly.
2. Methods & Materials 
This is a descriptive-analytical study with cross-sectional design conducted in 2018. The participants were 430 community-dwelling elderly aged ≥60 years in Tehran, Iran. Inclusion criteria were: No dementia and any critical physical condition, ability to understand and respond to questions, and willingness to participate in the study. Multistage random cluster sampling method was used for sampling. Data collection tools were a demographic form, a researcher-made Leisure Spending Questionnaire, the 36-Item Short Form Survey (SF-36) to assess the physical health of the elderly [3], and the 15-item General Health Questionnaire (GHQ-15) to assess their mental health [2]. 
Descriptive statistics and analytical tests were conducted in SPSS V. 21 software. In this study, the dependent variable was mental health and the main independent variable was leisure spending. The descriptive statistics describe the frequency and standard deviation of demographic factors, leisure spending patterns, and mental health of the elderly. Kolmogorov-Smirnov test was used to measure the normality of leisure spending and mental health scores. Based on its Results, Spearman correlation test was used to investigate the correlation between different patterns of leisure spending and the mental health of the elderly. Multiple regression analysis was also used to examine the simultaneous effect of leisure spending patterns on the mental health. Since the Results of Saberian et al. and Ilali et al. showed the significant relationship of age, gender, education, income and physical health with leisure spending and mental health [4, 5], in this study, the effects of age, gender, education, financial status, and physical health on the regression model as confounding factors were controlled.
3. Results
In this study, out of 430 participants, the data from 413 were used for statistical analysis and 17 were excluded. Most of them (n=408, 98.8%) were reported to watch television during their leisure time. In terms of gender, Results showed that the participation of women in recreational, sports, cultural, and social media activities was significantly lower compared to men. However, women were more involved in social and religious activities. In terms of age, the Results showed that the participation of the elderly in recreational, social and arts activities was significantly reduced with the increase of age.
According to Spearman correlation test Results, all patterns of leisure spending were significantly correlated with the mental health, except the resting and social media activities. To examine the simultaneous effect of leisure spending patterns on the mental health, multiple regression analysis was used after excluding resting and social media activities from the model. The Results are presented in Table 1, considering that the higher GHQ scores indicate the lower mental health. 



According to the regression model 2, the recreational activity lost its significant effect in the presence of confounding factors. Among the confounding variables, physical health had the most negative effect (β=-0.418). In the regression model 3, leisure spending was inversely correlated with the GHQ score in the absence of confounding factors. In the regression model 4, leisure spending was inversely correlated with GHQ in the presence of confounding factors (β=-0.173), but its effect was lower than in the absence of confounding factors. Most of effect in the confounding factors was related to physical health; however, financial status, education, and age were also important factors.
4. Conclusion 
The Results of this study showed that physical health is an effective confounding factor in the relationship of leisure spending with the mental health of the elderly. Since physical activity plays an important role in enhancing the ability and prevention of diseases, it is important to address the leisure issues that involve physical activity. Policymakers’ awareness of the current situation, identifying the important needs of the elderly, considering the welfare facilities, and encouraging the elderly to participate in sports activities are effective steps to improve their physical health and thus participate in more leisure programs, which help improve their mental health. According to the Results, recreational and religious activities had a significant relationship with the mental health of the elderly. Therefore, more detailed plans for mosques and volunteered activities are suggested for improving both the mental and physical health of the elderly. Providing facilities in these places that can engage the elderly in recreational activities can improve their mental health. Furthermore, with appropriate planning in the neighborhood level by the Municipality, necessary actions can be taken.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of  Tehran University of Medical Sciences (Code:  IR.TUMS.VCR.REC.1395.320).
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors' contributions
All authors contributed equally in preparing all parts of the research.
Conflicts of interest
The authors declared no conflict of interest.


References

1. Jandaghi J, Majd M, Maghsodnya S, Froghan M, Rhmani K, Fariver F, et al. Revision of elderly medicine. Semnan: Semnan University of Medical Sciences. 2003.
2. Kaveh Firouz Z. [The study of the effect of socio-demographic structures on the elderly ‘s quality of life in Tehran (Persian)] [PhD. dissertation]. Tehran: University of Tehran; 2011.
3. Joghataei MT, Nejati V. [Assessment of health status of elderly people in the city of Kashan (Persian)]. Salmand: Iranian Journal of Ageing. 2006; 1(1):3-10. http://salmandj.uswr.ac.ir/article-1-26-en.html
4. Momeni Kh, Karimi H. [Comparison of mental health between elderly admitted in sanitarium with elderly in sited in personal home (Persian)]. Journal of Kermanshah University of Medical Sciences. 2011; 14(4):e79446. https://sites.kowsarpub.com/jkums/articles/79446.html
5. Dadkhah A. [Review of aged rendered services in USA and Japan and guidelines for Iran aging strategic plan (Persian)]. Salmand: Iranian Journal of Ageing. 2007; 2(1):166-76. http://salmandj.uswr.ac.ir/browse.php?a_id=1236&sid=1&slc_lang=fa
6. World Health Organization. Aging and health [Internet]. 2018 [Updated 2018 February 5]. Available from: https://www.who.int/news-room/fact-sheets/detail/ageing-and-health
7. Rezaii E. [The effect of demographic changes on government social expenditure and life cycle expenditure in Iran economy (Persian)]. Quarterly Journal of Fiscal and Economic Policies. 2016; 3(11):62-84. http://qjfep.ir/article-1-341-en.html
8. Yousefi H, Abedi HA, Yarmohammadian MH, Elliott D. Comfort as a basic need in hospitalized patients in Iran: A hermeneutic phenomenology study. Journal of Advanced Nursing. 2009; 65(9):1891-8. [DOI:10.1111/j.1365-2648.2009.05026.x] [PMID]
9. Ghazi Moradi H. [Work and leisure in Iranian people (Persian)]. 3^rd ed. Tehran: Ameh Book; 2012. http://opac.nlai.ir/opac-prod/bibliographic/2069378
10. Abedi HA, Lali M, Keyvanniya Sh, Nikbakht A. [Life experiences of older people who are used to spend their time in parks (Persian)]. Journal of Qualitative Research in Health Sciences. 2013; 2(2):184-93. http://eprints.kmu.ac.ir/30687/
11. Lampinen P, Heikkinen RL, Kauppinen M, Heikkinen E. Activity as a predictor of mental well-being among older adults. Aging and Mental Health. 2006; 10(5):454-66. [DOI:10.1080/13607860600640962] [PMID]
12. Lee HY, Yu CP, Wu CD, Pan WC. The effect of leisure activity diversity and exercise time on the prevention of depression in the middle-aged and elderly residents of Taiwan. International Journal of Environmental Research and Public Health. 2018; 15(4):654. [DOI:10.3390/ijerph15040654] [PMID] [PMCID]
13. Heesch KC, van Uffelen JG, van Gellecum YR, Brown WJ. Dose-response relationships between physical activity, walking and health-related quality of life in mid-age and older women. Journal of Epidemiology and Community Health. 2012; 66(8):670-7. [DOI:10.1136/jech-2011-200850] [PMID]
14. Wolin KY, Glynn RJ, Colditz GA, Lee IM, Kawachi I. Long-term physical activity patterns and health-related quality of life in U.S. women. American Journal of Preventive Medicine. 2007; 32(6):490-9. [DOI:10.1016/j.amepre.2007.02.014] [PMID] [PMCID]
15. Barcelos-Ferreira R, Nakano EY, Steffens DC, Bottino CM. Quality of life and physical activity associated to lower prevalence of depression in community-dwelling elderly subjects from Sao Paulo. Journal of Affective Disorders. 2013; 150(2):616-22. [DOI:10.1016/j.jad.2013.02.024] [PMID]
16. Wada K, Satoh T, Tanaka K, Tsunoda M, Aizawa Y. Associations of depressive symptoms with regular leisure activity and family social support among Japanese workers. Industrial Health. 2007; 45(1):181-5. [DOI:10.2486/indhealth.45.181] [PMID]
17. Wakui T, Saito T, Agree EM, Kai I. Effects of home, outside leisure, social, and peer activity on psychological health among Japanese family caregivers. Aging & Mental Health. 2012; 16(4):500-6. [DOI:10.1080/13607863.2011.644263] [PMID] [PMCID]
18. Li Y, Ferraro KF. Volunteering and depression in later life: Social benefit or selection processes? Journal of Health and Social Behavior. 2005; 46(1):68-84. [DOI:10.1177/002214650504600106] [PMID]
19. Rahimi A, Anoosheh M, Ahmadi F, Foroughan M. [Tehranian elderly people’s experiences about leisure time activities and recreations (Persian)]. Salmand: Iranian Journal of Ageing. 2010; 5(1):61-77. http://salmandj.uswr.ac.ir/article-1-295-en.html
20. Seyfzadeh A, Hagighatian M, Mohajerani AA. [The relationship between social isolation and health among the Tehranian elderly (Persian)]. Journal of Education and Community Health. 2017; 4(3):19-25. [DOI:10.21859/jech.4.3.19]
21. Tajvar M, Grundy E, Fletcher A. Social support and mental health status of older people: A population-based study in Iran-Tehran. Aging & Mental Health. 2018; 22(3):344-53. [DOI:10.1080/13607863.2016.1261800] [PMID]
22. Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health Survey (SF-36): Translation and validation study of the Iranian version. Quality of Life Research. 2005; 14(3):875-82. [DOI:10.1007/s11136-004-1014-5] [PMID]
23. Saberian M, Haji Aghajani S, Ghorbani R. [Study of the mental status of the elderly and its relationship with leisure time activities (Persian)]. Journal of Sabzevar University of Medical Sciences. 2004; 10(4):53-60. https://www.sid.ir/fa/journal/ViewPaper.aspx?ID=32870
24. Ilali ES, Bashkani M, Jahanbakhsh F. [A review of the effect of leisure on depression in the elderly (Persian)]. Clinical Excellence. 2018; 8(2):50-60. http://ce.mazums.ac.ir/article-1-411-en.html
25. Conde MD. Leisure patterns and needs of the elderly in rural Galicia (Spain). Educational Gerontology. 2012; 38(2):138-45. [DOI:10.1080/03601277.2010.515894]
26. Lee JH, Lee JH, Park SH. Leisure activity participation as predictor of quality of life in Korean Urban‐dwelling elderly. Occupational Therapy International. 2014; 21(3):124-32. [DOI:10.1002/oti.1371] [PMID]
27. Krantz-Kent R, Stewart J. How do older Americans spend their time? Monthly Labor Review. 2007; 130:8. https://heinonline.org/hol-cgi-bin/get_pdf.cgi?handle=hein.journals/month130§ion=41
28. Triadó C, Villar F, Solé C, Celdrán M, Osuna MJ. Daily activity and life satisfaction in older people living in rural contexts. The Spanish Journal of Psychology. 2009; 12(1):236-45. [DOI:10.1017/S1138741600001645] [PMID]
29. Deslandes A, Moraes H, Ferreira C, Veiga H, Silveira H, Mouta R, et al. Exercise and mental health: Many reasons to move. Neuropsychobiology. 2009; 59(4):191-8. [DOI:10.1159/000223730] [PMID]
30. Tudor-Locke C, Bassett DR Jr. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Medicine. 2004; 34(1):1-8. [DOI:10.2165/00007256-200434010-00001] [PMID]
31. Madah SB, Emami A, Rahgozar M, Foroughan M, Norouzi Tabrizi K, Mohammadi F, et al. [The status of social and leisure time activities in the elderly residing in Iran and Sweden (Persian)]. Salmand: Iranian Journal of Ageing. 2008; 3(2):597-606. http://salmandj.uswr.ac.ir/article-1-95-en.html
32. Cheung MC, Ting W, Chan LY, Ho KS, Chan WM. Leisure participation and health-related quality of life of community dwelling elders in Hong Kong. Asian Journal of Gerontology & Geriatrics. 2009; 4(1):15-23. http://www.hkag.org/Publications/AJGG/V4N1/p15_2009-46-OA.pdf
33. Norouzi Tabrizi K. [Design, implementation and evaluation of a care model on the community of elderly people living in Tehran (Persian)] [PhD. dissertation]. Tehran: Tarbiat Modares University; 2006.
34. Paillard-Borg S, Wang HX, Winblad B, Fratiglioni L. Pattern of participation in leisure activities among older people in relation to their health conditions and contextual factors: A survey in a Swedish urban area. Ageing & Society. 2009; 29(5):803-21. [DOI:10.1017/S0144686X08008337]
35. Gilmour H. Social participation and the health and well-being of Canadian seniors. Health Reports. 2012; 23(4):23-32. [PMID]
36. Goll JC, Charlesworth G, Scior K, Stott J. Correction: Barriers to social participation among lonely older adults: The influence of social fears and identity. PLoS One. 2018; 13(7):e0201510. [DOI:10.1371/journal.pone.0201510] [PMID] [PMCID]
37. Darvishpoor Kakhki A, Abed Saeedi Z, Abbaszadeh A. [Social participation, barriers, and related factors in older people in Tehran (Persian)]. Journal of Health Promotion Management. 2014; 3(4):65-73. http://jhpm.ir/article-1-346-en.html
38. Ebrahimi GA, Razeghi N, Moslemi Ptrod R. [Social factors affecting leisure A case study of the 15-64 year- old in the city of Jouybar, Mazandaran, Iran (Persian)]. Journal of Applied Sociology. 2012; 22(4):71-98. https://jas.ui.ac.ir/article_18244.html?lang=en
39. Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist. 1969; 9(3 Pt 1):179-86. [DOI:10.1093/geront/9.3_Part_1.179] [PMID]
40. Tessier S, Vuillemin A, Bertrais S, Boini S, Le Bihan E, Oppert JM, et al. Association between leisure-time physical activity and health-related quality of life changes over time. Preventive Medicine. 2007; 44(3):202-8. [DOI:10.1016/j.ypmed.2006.11.012] [PMID]
41. Melzer I, Benjuya N, Kaplanski J. Effects of regular walking on postural stability in the elderly. Gerontology. 2003; 49(4):240-5. [DOI:10.1159/000070404] [PMID]
42. Holstila A, Mänty M, Rahkonen O, Lahelma E, Lahti J. Changes in leisure‐time physical activity and physical and mental health functioning: A follow‐up study. Scandinavian Journal of Medicine & Science in Sports. 2017; 27(12):1785-92. [DOI:10.1111/sms.12758] [PMID]