1. Background
Aging is a critical period of human life, and it is a social necessity to pay attention to the needs of this stage (1). Communication skills are among the needs of this age group (2). It has been considered one of the oldest and most valuable human achievements (2). In other words, it refers to the process of sending information from one person to another and understanding it by the audience. It means transferring and sharing thoughts, ideas, and facts in such a way that the audience receives and understands them. In other words, communication is a process by which people seek to achieve common concepts by exchanging symbolic messages (3). Concerning the significance of communication in human life, some experts argue that all human development, individual harms, and human progress depend on the process of communication (4). People’s inability to communicate and maintain satisfying communication with others results in a sense of deprivation, which is seen at an older age (5). Some studies indicate that with disabilities caused by old age, social isolation, and physical problems, communication skills are negatively influenced, and their quantity and quality decrease (6, 7). Also, with the arrival of the 21st century and social, economic, medical, and health needs, the phenomenon of aging is considered one of the most fundamental problems in all countries since older people are at risk of many diseases and disabilities (8). Cardiovascular diseases, diabetes, hypertension, and many other diseases increase during the last years of people’s life. Mental and psychological disorders, including dementia and depression, are also commonly seen among the elderly and are considered the second leading cause of loss of life years due to disability (9, 10). Mental disorders with their serious symptoms, including depression, anxiety, memory loss, sleep pattern change, sense of loneliness, and social isolation, affect 15 to 25 percent of people aged over 65 (11). Several studies were conducted throughout the world, which has been reported that depression is a cause of disability at old age, and factors such as loss of a spouse, living alone, living at home, or special retirement institutions for a longer time are associated with depression in older people (12). Based on the available findings and given the global burden of diseases related to mental disorders that are predicted to increase from 10.5% in 1996 to 15% in 2020, World Health Organization (WHO) has introduced improving mental health as one of the priorities of low- and middle-income countries (13). Based on a study conducted on the burden of disease in Iran in 2003, mental and behavioral disorders were ranked second after injuries and harms (14). Several studies were carried out on the prevalence of mental disorders in Iran. The rate of psychiatric disorders was reported at 17.10% in the population aged 18 years and older, and another study reported the rate of psychiatric disorders was 21% on a population aged 15 years and older. In this regard, the rate of anxiety in these studies was reported at 8.31% and 2.3%, and the rate of depression was reported at 2.98% and 3.8%, respectively (15, 16). In a research conducted on older people living in nursing homes of Tehran, the rates of depression, anxiety, somatic disorders, and obsessive-compulsive disorder were reported at 32.5%, 18.3%, 27.5%, and 19.1%, respectively (17). In another research, it was reported that 24% of older people living in district 13 of Tehran had problems of depression and anxiety (18). Evidence indicates that a desirable level of communication skills and enhancing the level of these skills may improve mental health, enrich human relationships, and enhance the health and healthy behaviors at micro and macro levels (19). Also, communication skills, as a part of life skills, can be used both as a way to promote mental health and as a powerful tool by mental health officials in a community to empower people at social and psychological dimensions (19). The subject of interpersonal communication is a crucial subject in healthcare centers since it is dealing with health of people. The ability of people to communicate effectively is one of the crucial factors that facilitate receiving health services and improving the process of providing services, and gaining health (physical and mental health) (20).
2. Objectives
The present study aimed to investigate the association between communication skills and mental health of the elderly admitted to the teaching hospitals of Shiraz University of Medical Sciences in 2020.
3. Methods
3.1. Design of the Study, Participants, and Sample Size
The present study is a descriptive-analytical and cross-sectional study carried out in 2020. The statistical population of the present study included elderly patients hospitalized in hospitals affiliated to Shiraz University of Medical Sciences (including hospitals of Namazi, Shahid Dastgheib, Shahid Chamran, Khalili, Hafez, Shahid Faghihi, Ibn Sina, Zeinabieh, and Shahid Rajaei). According to the correlation between communication skills and mental health based on a pilot study in Iran (21), with a 95% confidence interval and 90% statistical power, the sample size was estimated to be 261 people (r = 0.2). In this study, 386 people were included in the study to increase accuracy and prevent bias resulting from sample loss. Distribution of these 386 patients among the hospitals was proportional to the population size of each of the studied hospitals. Accordingly, researchers referred to each of the hospitals identified total number of elderly patients (patients aged 60 years and older) hospitalized in different wards of the hospitals. After determining total number of elderly patients hospitalized in the mentioned hospitals, stratified sampling proportional to volume was used to distribute 386 samples among the hospitals. Hence, more samples were assigned to a hospital, where a higher number of elderly patients had been hospitalized. Also, in each hospital, in proportion to each of the wards (using stratified sampling in proportion to sample volume, more samples were assigned to the ward of hospital where more patients had been hospitalized), patients were selected and included in the study.
3.2. Inclusion and Exclusion Criteria
The inclusion criteria of the study included age of 60 years and older, having the ability to speak, and lack of cognitive problems. The exclusion criteria were age less than 60 years, inability to speak (answer), and having cognitive problems.
3.3. Ethics Statements
The participants were justified about the objectives of the study; the principle of confidentiality was also emphasized, and their verbal consent was obtained. Then, anonymous questionnaires without any first names and surnames were distributed among the respondents. In addition, participants were free to leave the study at any stage if they did not want to continue. Also, the protocol of the study was approved by the Ethics Committee of Shiraz University of Medical Sciences (ethics code: IR.SUMS.REC.1398.1321).
3.4. Questionnaire
A three-section questionnaire was used to collect the research data. The first section consists of demographic information of the elderly patients, including their age, gender, and marital status and level of education. The second section consists of a revised version of standardized interpersonal communication skills test. It has been designed to assess communication skills in adults. It includes 34 five-choice questions in five areas of the ability to receive and send messages (9 questions), emotional regulation (9 questions), and listening skills (6 questions), insight to communication process (5 questions), and communication with assertiveness (5 questions). In this section of the questionnaire, a 5-point Likert scale ranging from never (score 1), rarely (score 2), sometimes (score 3), often (score 4), always (score 5) was used to answer the questions. Based on the range of scores (34 to 170), the communication skills of elderly patients were assessed based on score ranges of 34 to 68 (reflecting poor communication skills), 69 to 102 (reflecting moderate communication skills), and scores above 102 (reflecting high communication skills). The questionnaire validity was examined and confirmed in a study conducted by Mojadam et al. (6). Its reliability was also confirmed in a study conducted by Chary and Fadakar (22) using Cronbach’s alpha method that was obtained at 0.69. The third section of the questionnaire has been developed to assign the mental health of the samples. This section was the standardized mental health questionnaire SCL-90-R. This questionnaire consists of 90 questions to assess nine symptoms, including depression (13 questions), anxiety (11 questions), hypochondriasis (12 questions), Obsession and coercion (11 questions), sensitivity in interpersonal relationships (12 questions), and violence (7 questions), phobia (8 questions), paranoid thoughts (6 questions), psychosis (10 questions). In this section, the questions of the questionnaire are answered on the 5-point Likert scale, ranging from no (score 0), low (score 1), to some extent (score 2), high (score 3), and strongly (score 4). Based on the range of scores (0 - 360), the mental health status of elderly patients was assessed according to score ranges of 0 - 90 (reflecting completely healthy person without symptoms), 91 - 180 (reflecting mild symptoms), 181 - 270 (reflecting moderate symptoms) and a score above 270 (reflecting severe symptoms of the disease). Its reliability and validity were examined in various domestic and foreign studies. Its reliability coefficient was reported at 0.97 using test-retest method, and the sensitivity, specificity, and efficiency of the test were reported at 0.94, 0.98, and 0.96, respectively (23, 24). The researcher referred to elderly patients’ hospitalization ward to ask the questions of the elderly patient, and he marked the patients’ answers on the questionnaire. It took an average of 20 minutes to complete each questionnaire. The questionnaires were completed from May 22 to June 30, 2020.
3.5. Statistical Analysis
The data were analyzed using descriptive and inferential statistical methods, Pearson correlation coefficient, t-test, and ANOVA tests, and multiple linear regression in SPSS23 software at the significance level of α = 0.05.
4. Results
The mean age of the subjects was 68.62 ± 5.18 years and majority of them (43.78%) were in the age group of 60 to 70 years. Moreover, 53.89% were male and the rest were female. Most of them had primary education (33.94%) and were married (70.47%). A significant correlation was found between communication skills (and mental health) with age P = 0.02, r = 0.32 (P = 0.01, r = 0.44), gender P = 0.03, t = 1.28 (P = 0.01, t = 1.74), marital status P = 0.04, F = 1.86 (P < 0.001, F = 2.021) and level of education P < 0.001, F = 2.113 (P = 0.002, F = 1.904) (Table 1).
Table 1.Characteristics of the Study Participants
| Variables | No. (%) | P-Value Communication Skills (Mental Health) |
|---|---|---|
| Age, y | 0.02 (0.01) | |
| 60 - 70 | 169 (43.78) | |
| 71 - 80 | 128 (33.16) | |
| > 80 | 89 (23.06) | |
| Total | 386 (100) | |
| Gender | 0.03 (0.01) | |
| Man | 208 (53.89) | |
| Female | 178 (46.11) | |
| Total | 386 (100) | |
| Marital status | 0.04 (< 0.001) | |
| Single | 69 (17.87) | |
| Married | 272 (70.47) | |
| Divorced | 13 (3.37) | |
| Wife’s death | 32 (8.29) | |
| Total | 386 (100) | |
| Level of education | 0.002 (< 0.001) | |
| Illiterate | 65 (16.84) | |
| Reading and Writing | 86 (22.28) | |
| Elementary | 131 (33.94) | |
| Diploma | 56 (14.51) | |
| Bachelor’s degree and higher | 48 (12.43) | |
| Total | 386 (100) |
The mean score of general communication skills was obtained at 67.01 ± 7.36, indicating a low level of this skill among the elderly patients based on the Likert scale used in this study. Also, the mean score of total mental health of the elderly patients was obtained at 177.84 ± 9.21, indicating mild symptoms of mental disorders among the elderly patients studied (Table 2).
Table 2.Mean of Communication Skills and Mental Health of the Study Participants
| Area | Mean ± SD |
|---|---|
| Communication skills | |
| Listening | 15.11 ± 2.46 |
| Emotional control | 15.36 ± 3.61 |
| Understand the message | 11.24 ± 2.54 |
| Insight | 13.09 ± 2.39 |
| Assertiveness | 12.21 ± 3.41 |
| Total | 67.01 ± 7.36 |
| (Disorders) mental health | |
| Depression | 23.21 ± 3.21 |
| Anxiety | 21.42 ± 3.32 |
| Hypochondriasis | 18.22 ± 2.29 |
| Obsession and coercion | 23.03 ± 4.03 |
| Sensitivity in interpersonal relationships | 19.06 ± 4.11 |
| Violence | 21.12 ± 3.19 |
| Phobia | 18.02 ± 2.51 |
| Paranoid thoughts | 16.24 ± 4.08 |
| Psychosis | 17.52 ± 4.13 |
| Total | 177.84 ± 9.21 |
The results of the present study revealed a significant correlation between communication skills and mental health of the elderly patients (P < 0.001, r = -0.631), indicating that increasing communication skills was associated with a reduced level of mental health disorders (Table 3).
Table 3.Correlation Between Communication Skills and Mental Health
| Dimensions of Mental Health | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Dimensions of Communication Skills | Depression | Anxiety | Hypochondriasis | Obsession and Coercion | Sensitivity in Interpersonal Relationships | Violence | Phobia | Paranoid Thoughts | Psychosis | (Disorders) Total Mental Health |
| Listening | r = -0.340 (P < 0.001) | r = -0.676 (P < 0.001) | r = -0.287 (P < 0.001) | r = -0.423 (P < 0.001) | r = -0.301 (P < 0.001) | r = -0.394 (P < 0.001) | r = -0.227 (P < 0.001) | r = -0.231 (P = 0.011) | r = -0.216 (P = 0.011) | r = -0.597 (P < 0.001) |
| Emotional control | r = -0.401 (P < 0.001) | r = -0.428 (P < 0.001) | r = -0.276 (P < 0.001) | r = -0.462 (P = 0.002) | r = -0.381 (P < 0.001) | r = -0.494 (P < 0.001) | r = -0.369 (P = 0.007) | r = -0.431 (P = 0.003) | r = -0.501 (P = 0.003) | r = -0.617 (P < 0.001) |
| Understand the message | r = -0.470 (P < 0.001) | r = -0.432 (P < 0.001) | r = -0.373 (P = 0.002) | r = -0.424 (P < 0.001) | r = -0.272 (P < 0.001) | r = -0.364 (P < 0.001) | r = -0.289 (P < 0.001) | r = -0.413 (P < 0.001) | r = -0.511 (P < 0.001) | r = -0.661 (P < 0.001) |
| Insight | r = -0.531 (P < 0.001) | r = -0.489 (P < 0.001) | r = -0.366 (P = 0.023) | r = -0.379 (P = 0.002) | r = -0.265 (P < 0.001) | r = -0.421 (P < 0.001) | r = -0.306 (P = 0.003) | r = -0.261 (P < 0.001) | r = -0.276 (P = 0.023) | r = -0.610 (P = 0.006) |
| Assertiveness | r = -0.512 (P = 0.006) | r = -0.509 (P < 0.001) | r = -0.346 (P = 0.002) | r = -0.406 (P = 0.005) | r = -0.446 (P < 0.001) | r = -0.394 (P < 0.001) | r = -0.325 (P = 0.006) | r = -0.401 (P = 0.007) | r = -0.372 (P = 0.004) | r = -0.566 (P = 0.005) |
| Total Communication Skills | r = -0.578 (P < 0.001) | r = -0.598 (P < 0.001) | r = -0.413 (P < 0.001) | r = -0.212 (P < 0.001) | r = -0.462 (P < 0.001) | r = -0.481 (P < 0.001) | r = -0.462 (P < 0.001) | r = -0.376 (P < 0.001) | r = -0.369 (P < 0.001) | r = -0.631 (P < 0.001) |
The results of multiple linear regression analysis used to assess the simultaneous effect of different dimensions of communication skills on the mental health of the elderly patients revealed that the significant variables of the model that were determined using the Enter method included understanding the message, emotional control, listening, assertiveness, and insight, respectively, in terms of importance. Table 4 presents the β values of the influential variables that indicate the priority of affecting mental health. This test also indicated that the coefficient of determination (R2 adjusted) of the model was 0.51, meaning that 51% of the variations in the mental health score can be explained by the variables of the model.
Table 4.Factors Affecting Mental Health Disorders Using Multiple Linear Regression Model
| Variables | Unstandardized Coefficients | Standardized Coefficient β | t Statistics | P-Value | |
|---|---|---|---|---|---|
| Std. Error | Coefficient β | ||||
| Understand the message | 0.063 | - 0.345 | - 0.323 | - 3.571 | < 0.001 |
| Emotional control | 0.072 | - 0.275 | - 0.261 | - 2.264 | 0.001 |
| Listening | 0.069 | - 0.225 | - 0.198 | - 2.301 | 0.001 |
| Assertiveness | 0.101 | - 0.201 | - 0.188 | - 2.238 | 0.005 |
| Insight | 0.110 | - 0.197 | - 0.184 | - 1.187 | 0.006 |
5. Discussion
The findings of the present study revealed that communication skills had a reverse and significant association with mental health disorders and their dimensions among the elderly patients. It means that the score of mental disorder decreases with increasing communication skills. The results of studies carried out by Amini et al. (25), Mostafa-Nezhad and Dortag (26, 27). Sahebdel and Asadi (27), Gheirati et al. (21), Solati (28), and Herbert et al. (29) in investigating the impact of communication skills training on mental health showed that communication skills had a significant impact on mental health, and training and improving this skill were an effective method to improve mental health and decrease mental disorders. The results of studies conducted by Johnsson et al. (30), Hoglander et al. (31), and Tsai et al. (32) also revealed that communication skills significantly correlated with mental health, and it is in line with the results of the present study. Also, the results of a research carried out by Mirdarikvand et al. (7) revealed that communication skills were one of the variables predicting sense of loneliness as one of the causes of mental disorders. Furthermore, the results of a study conducted by Dong and Simon (33) showed that the autocracy of the elderly patients and their inability to establish social communication were significantly associated with poor health status and low cognitive function, and depression symptoms. It seems that desirable level of communication skills creates a set of abilities in the older people that are effective in social adjustment, showing positive behaviors, and improving mental health. Also, older people probably experience fewer mental disorders such as stress, anxiety, and depression due to stronger communication skills and thus having the ability to ask for help and support from others. In the present study, a significant association was found between communication skills and mental health and the variables of age, gender, marital status, and level of education. In the studies carried out by Mojadam et al. (6), Peyman et al. (34), and Yorkston et al. (35), a significant correlation was reported between communication skills and demographic variables, which is in line with the results of the present study. Riviere et al. reported a significant association between mental health and demographic variables of age and gender (36), which was in line with the results of the present study. Arasteh et al. (37) also reported a significant association between mental health and the variables of gender, income level, and level of education. The results of studies carried out by Gheirati et al. (21) and Ansari et al. (38) also revealed a significant association between mental health and the variables of gender and marital status, which is in line with the results of the present study. According to the results of the present study, among the dimensions of communication skills, understanding message, emotional regulation, listening, assertiveness, and insight, respectively, had a significant and inverse effect on mental health disorders. The multiple linear regression results also revealed that the component of “understanding message” had the highest impact on the mental health of the elderly patients. It means that the mental health of elderly patients increases with increasing the level of understanding of messages (the ability to receive and send messages). In the research carried out by Amini et al. (39), understanding verbal and nonverbal messages was found to be one of the predictors of general health. The ability to send and receive verbal and nonverbal messages is one of the most important factors promoting mental health since it enables older people to transfer their desired needs to others; so meeting these needs will result in a desirable level of mental health in them. According to the results of the present study, emotional regulation was another component of communication skills affecting mental health so that with increasing the emotional regulation, the level of mental health of the older people increases. This result was in line with the results of a study conducted by Amini et al. (39). It can be stated that with increasing emotional regulation ability, the older people will be able to resist against psychological pressures such as stress, anxiety, and depression and maintain their mental health at an acceptable level. The results also indicated that "listening" was another component of communication skills affecting mental health so that with increasing the level of listening skills, the mental health of the older people increases. Dalvandi et al. (40) also showed that listening had a significant impact on mental health so that implementation of listening programs was associated with improved mental health of older people. Listening is one of the most important factors in interpersonal communication that can improve mental health. It can be justified by the fact that by improving and strengthening the listening skill, the older people will be able to eliminate their possible misunderstandings in the relationship with others and be protected from psychological harm. The present study also revealed that “communication with assertiveness” and “insight to communication” were other components of communication skills affecting mental health. It indicates that improving the ability to establish communication with assertiveness and having right insight into the communication will increase the mental health of the older people. Tsai et al. (32) and Amini et al. (39) also reported that two variables of assertiveness and insight predicted the mental health of people. It can be stated that having assertiveness and right insight in communication maintains human dignity, self-esteem, and self-confidence, and helps people have a correct perception of communication.
5.1. Study Limitations
The present study has some limitations. One of its limitations is cross-sectional nature of the study, making it difficult to determine causal relationships in this type of study. Additionally, only a questionnaire was used in the present study to assess the impact of communication skills, so it is recommended further studies should be conducted longitudinally using different data collection methods.
5.2. Conclusions
There was a significant correlation between communication skills and the mental health of elderly patients. Also, proper communication skills play an important role in promoting elderly patient’s mental health. It is recommended to develop and use supportive programs to improve communication skills in the form of elderly health programs, given the role and impact of communication skills and their dimensions on the mental health of the older people and to improve their health status.
