Introduction
Old age is usually associated with many changes, such as changes in family structure and living arrangements, changes in occupational patterns and transition to retirement, and changes in health status [1]. Due to the increasing number of the elderly population, countries should pay attention to this issue in social policies, especially in terms of reaching successful and active old age to provide a better quality of life for older people [2, 3]. Social participation is a determining factor of health and an important aspect of successful aging [4]. In this regard, and considering the importance of removing barriers and planning to facilitate the participation of the elderly in order to achieve a more dynamic society relying on successful aging, this study aims to assess the level of social participation based on health-promoting activities and investigate its factors and barriers among the elderly in Kerman, Iran.
Methods
This is a cross-sectional study that was conducted on the elderly living in Kerman city in 2020. The sample size was determined 275 using the formula. Sampling was done using a two-stage cluster sampling method. The inclusion criteria were age 60 years and older, being a resident of Kerman city, being able to communicate verbally, and being able to answer the questions. The exclusion criteria were unwillingness to participate in the study and return of incomplete questionnaires.
The data collection tool was a researcher-made social participation questionnaire based on the Canadian Community Health Survey [5]. It includes nine items assessing participation in outdoor group activities, religious activities, group sports, educational and cultural activities, activities in social centers and institutions, charity activities, and group entertainment. The questionnaire of health-promoting behaviors was also used which was designed based on the lifestyle questionnaire [6]. It has 10 subscales and 64 items [6]. The face validity of the questionnaires was examined based on the opinions of 10 experts and 20 elderly people, and their reliability were also confirmed. Cronbach’s alpha was 0.79 for the social participation questionnaire and 0.84 for the health-promoting behaviors questionnaire. 
Considering the normality of the data distribution based on the results of Kolmogorov Smirnov test, the linear regression model (univariate and multivariate analysis) was used to investigate the factors affecting social participation (facilitating and inhibiting factors). STATA software was used for univariate and multivariate regression analysis, and SPSS software, version 26 was used for other analyses.
Results
The mean age group of participants was 67.85±6.73; 69.2% of them were married; 147(53%) were men and 129(47%) were women; 15.2% were illiterate, 36.6% had lower than high school education, and 48.2% had a diploma or higher; 97.5% had children; 32.6% were employed in the government sector, 1.30% were self-employed, and the rest had other occupations. About 60% of the elderly had a chronic disease, 82% were receiving medication, and 22% had substance abuse. The most prevalent underlying diseases were high blood pressure (35%), diabetes (23%) and cardiovascular diseases (15%).
The mean score of social participation was reported as 6.71±4.01. The highest rate of participation was related in religious activities (71.7%) and outdoor group activities (70.2%), and the lowest rate of participation was related to calling TV presenters to report neighborhood problems (9.4%).The biggest barriers to social participation were illnesses (50.3%), costs (39.1%), and commuting (31.1%).Based on the results of univariate and multivariate analysis, the factors of age, marital status, educational level, suffering from chronic disease, disease prevention, physical activity, physical health, and social health were determined as influencing factors in the social participation of the elderly. Marital status, suffering from chronic disease and physical health were facilitating factors, and age, disease prevention and social health were inhibiting factors.
On average, the mean score of social participation in the elderly aged 70-79 years was lower than in those aged 60-69 years by 2.37(95% CI: -0.96-3.80). The mean score of participation in never-married elderly was more than in married elderly by 4.53(95% CI: 0.76-8.29) and the mean score of participation in divorced elderly was more than in married elderly by 6.52(95% CI: 1.96-11.07). Moreover, the mean score of participation in illiterate elderly, elderly with reading and writing literacy, and elderly with education levels lower than high school and diploma were less than those with academic degree by 4.64, 2.23, 1.81, and 3.06, respectively.
Among the health-promoting behaviors, physical activity, disease prevention and social health had a negative impact and physical health had a positive impact on the social participation of the elderly (Table 1).




Discussion
In this study, the most important barriers to the social participation of the elderly in Kerman city were illness, costs, and commuting problems. Therefore, it is recommended to plan for the management of diseases in old age, economic support and the creation of welfare and healthcare facilities to increase the social participation of the elderly. Considering the high desire of the elderly to participate in religious activities, it is necessary to consider appropriate mechanisms in the structure of neighborhoods, including the design of elderly-friendly mosques. The health-promoting behaviors including physical activity, disease prevention and social health were introduced as barriers and physical health as the facilitator of social participation. It seems that they are affected by the Covid-19 pandemic and the fear and worry about contracting the disease and quarantine at home, which need attention by policymakers and authorities, especially after the pandemic.

Ethical Considerations
Compliance with ethical guidelines
It was approved by the Ethics Committee of Kerman University of Medical Sciences (Code: IR.KMU.REC.1398.636). 

Funding
This study was funded by Kerman University of Medical Sciences.

Authors' contributions
Conceptualization: Mina Sharafi and Vahid Reza Borhaninejad; Investigation: All authors; Editing & review: Vahid Reza Borhaninejad

Conflicts of interest
The authors declare no conflict of interest

Acknowledgements
The authors would like to thank all seniors participated in this study.


References

1. Forster P, Morris M. Successful transition to retirement in Australia. Social Sciences Directory. 2012; 1(1):4-12. [Link]
2. Moradi S, Fekrazad H, Mousavi MT, Arshi M. [The study of relationship between Social Participation and quality of life of old people who are member of senior association of Tehran City in 2011 (Persian)]. Salmand: Iranian Journal of Ageing. 2013; 7(4):41-6. [Link]
3. Zanjari N, Sharifian Sani M, Hosseini Chavoshi M, Rafiey H, Mohammadi Shahboulaghi F. [Comparison of experts and older adults’ viewpoints on successful ageing (Persian)]. Journal of North Khorasan Univ Med Sci. 2017; 9(2):279-90. [DOI:10.18869/acadpub.jnkums.9.2.279]
4. Levasseur M, Richard L, Gauvin L, Raymond E. Inventory and analysis of definitions of social participation found in the aging literature: Proposed taxonomy of social activities. Social Science & Medicine. 2010; 71(12):2141-9. [PMID]
5. Mansouri T, Farhadi A, Borhaninejad VR, Kojaie Bidgoli A, Navvabi Rigi SD, Hosseinabadi R. [Factors and barriers affecting the social participation of older people (Persian)]. Journal of North Khorasan University of Medical Sciences. 2018; 9(4):66-73. [Link]
6. Bourassa KJ, Memel M, Woolverton C, Sbarra DA. Social participation predicts cognitive functioning in aging adults over time: Comparisons with physical health, depression, and physical activity. Aging & Mental Health. 2017; 21(2):133-46. [PMID]
7. Bukov A, Maas I, Lampert T. Social participation in very old age: Cross-sectional and longitudinal findings from BASE. Berlin Aging Study. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences. 2002; 57(6):P510-7. [PMID]
8. Richard L, Gauvin L, Gosselin C, Laforest S. Staying connected: Neighbourhood correlates of social participation among older adults living in an urban environment in Montréal, Quebec. Health Promotion International. 2009; 24(1):46-57. [PMID]
9. Saber M, Rashedi V, FadakarDavarani MM, Borhaninejad V, et al. Social support, happiness, and self-rated health among older adults: A population-based study. Advances in Gerontology. 2021; 11:22-8 [DOI:10.1134/S2079057021010471]
10. Lee HY, Jang SN, Lee S, Cho SI, Park EO. The relationship between social participation and self-rated health by sex and age: A cross-sectional survey. International Journal of Nursing Studies. 2008; 45(7):1042-54. [PMID]
11. Ahmad K, Hafeez M. Factors affecting social participation of elderly people: A study in Lahore. The Journal of Animal & Plant Sciences. 2011; 21(2):283-9. [Link]
12. Holmes WR, Joseph J. Social participation and healthy ageing: a neglected, significant protective factor for chronic non communicable conditions. Global Health. 2011; 7:43. [PMID]
13. Katagiri K, Kim JH. Factors determining the social participation of older adults: A comparison between Japan and Korea using EASS 2012. PloS One. 2018; 13(4):e0194703. [PMID]
14. Rodriguez Añez CR, Reis RS, Petroski EL. Brazilian version of a lifestyle questionnaire: Translation and validation for young adults. Arquivos Brasileiros de Cardiologia. 2008; 91(2):92-8. [PMID]

15. Darvishpoor Kakhki A, Abed Saeedi ZH, Abbaszadeh A. [Social participation, barriers, and related factors in older people in Tehran (Persian)]. Journal of Health Promotion Management. 2014; 3(4):65-73. [Link]
16. Wilkie R, Peat G, Thomas E, Croft P. Factors associated with participation restriction in community-dwelling adults aged 50 years and over. Quality of Life Research. 2007; 16(7):1147-56.  [PMID]
17. Pinto JM, Neri AL. Trajectories of social participation in old age: A systematic literature review. Revista Brasileira de Geriatria e Gerontologia. 2017; 20(2):259-72. [DOI:10.1590/1981-22562017020.160077]
18. Borhaninejad V, Nabvi S, Lotfalinezhad E, Amini F, Mansouri T. [Relationship between social participation and life satisfaction among older people (Persian)]. Journal of North Khorasan University of Medical Sciences. 2017; 8(4):701-11. [DOI:10.18869/acadpub.jnkums.8.4.701]
19. Lali M, Abedi A, Kajbaf MB. Construction and validation of the lifestyle questionnaire (LSQ). Psychological Research. 2012; 15(1):29. [Link]
20. Sasaki S, Sato A, Tanabe Y, Matsuoka S, Adachi A, Kayano T, et al. Associations between socioeconomic status, social participation, and physical activity in older people during the COVID-19 pandemic: A cross-sectional study in a Northern Japanese city. International Journal of Environmental Research and Public Health. 2021; 18(4):1477. [PMID]
21. Aliakbari Dehkordi M, Peymanfar E, Mohtashami T, Borjali A. [The comparison of different levels of religious attitude on sense of meaning, loneliness and happiness in life of elderly persons under cover of Social Wlfare Organisation of Urmia city (Persian)]. Salmand: Iranian Journal of Ageing. 2015; 9(4):297-305. [Link]
22. Gilmour H. Social participation and the health and well-being of Canadian seniors. Health Reports. 2012; 23(4):23-32. [Link]
23. Andonian L, MacRae A. Well older adults within an urban context: Strategies to create and maintain social participation. British Journal of Occupational Therapy. 2011; 74(1):2-11. [Link]
24. Levasseur M, Généreux M, Bruneau JF, Vanasse A, Chabot É, Beaulac C, et al. Importance of proximity to resources, social support, transportation and neighborhood security for mobility and social participation in older adults: Results from a scoping study. BMC Public Health. 2015; 15:503. [PMID]
25. Borhaninejad V, Shati M, Bhalla D, Iranpour A, Fadayevatan R. A population-based survey to determine association of perceived social support and self-efficacy with self-care among elderly with Diabetes Mellitus (Kerman City, Iran). International Journal of Aging & Human Development. 2017; 85(4):504-17. [PMID]
26. Khodadadi S, Pourhadi S, Hosseini SR, Sum S, Kheirkhah F, Mohammadi Z. [Investigating the relationship between social support, cognitive status, and depression with daily life activities of the elderly in Amirkola City (Persian)]. Salmand: Iranian Journal of Ageing. 2022; 17(1):2-15. [Link]
27. Larijani M, Tajmazinani AA. [A Study of factors influencing social exclusion of the elderly in Varamin city (Persian)]. Journal of Applied Sociology. 2015; 26(3):57-74. [Link]
28. Feng Z, Cramm JM, Nieboer AP. Social participation is an important health behaviour for health and quality of life among chronically ill older Chinese people. BMC Geriatrics. 2020; 20(1):299. [PMID]
29. Tomioka K, Kurumatani N, Hosoi H. Age and gender differences in the association between social participation and instrumental activities of daily living among community-dwelling elderly. BMC Geriatrics. 2017; 17(1):99. [PMID]
30. Zare B, Kavehfirouz Z, Soltani MR. Capital-related determinants of the elderly’s life style in the city of Tehran. Journal of Population Association of Iran. 2014; 8(16):117-38. [Link]
31. Dawson-Townsend K. Social participation patterns and their associations with health and well-being for older adults. SSM-Population Health. 2019; 8:100424. [PMID]
32. Ma X, Piao X, Oshio T. Impact of social participation on health among middle-aged and elderly adults: Evidence from longitudinal survey data in China. BMC Public Health. 2020; 20(1):502. [PMID]
33. Choi E, Han KM, Chang J, Lee YJ, Choi KW, Han C, et al. Social participation and depressive symptoms in community-dwelling older adults: Emotional social support as a mediator. Journal of Psychiatric Research. 2021; 137:589-596. [PMID]