Spirituality and Religiosity in Elderly Adults with Chronic Disease

Espiritualidad y religiosidad en adultos mayores con enfermedad crónica

Espiritualidade e religiosidade em adultos maiores com doença crónica

Isabel Patricia Gómez Palencia¹;Dina Cantillo Banquett²;Melisa Coronado Quintana ³;Arlys López Villamizar⁴; Yecica Vergara Mendoza⁵

¹Nurse, Master's. Professor, Universidad de Cartagena –Unicartagena-. Colombia. email: ipgomezp@unicartagena.edu.co.

²Nursing student. Unicartagena. email: dinita_dinaluz@hotmail.com.

³Nursing student. Unicartagena. email: melo017@hotmail.com.

⁴Nursing student. Unicartagena. email: arlyslopez.v@hotmail.com.

⁵Nursing student. Unicartagena. email: yepavemen@hotmail.com.

Receipt date: May 27, 2014 Approval date:April 28, 2016

Article linked to research: “Mulheres solteiras e casadas e o uso do preservativo: o que sabem, pensam e praticam”, Dissertação de Mestrado apresentada ao Programa de pós-Graduação em Enfermagem, da Universidade Federal da Paraíba, Brasil, em 2014.

Conflicts of interest: none.

ABSTRACT

Objective.This work sought to explore the relationship between spirituality and religiosity in elderly adults with chronic disease. Methods. This was a cross-sectional cohort study with a representative sample of 229 elderly adults with chronic disease registered in 12 life centers in the city of Cartagena. Reed's Spiritual Perspective and Francis' Religiosity scales were applied. Results. Mean age was 74.4 years, 62.9% were women, and the most frequent occupations were: unemployed (45.9%) and housewives (44.5%); the religion most practiced was Catholicism (81.2%). Levels of spirituality and religiosity were high, showing a moderate and direct correlation (r = 0.57). Conclusion. A directly proportional relationship exists between spirituality and religiosity in elderly adults with chronic disease.

Key words: spirituality; religion; aged; chronic disease.

RESUMEN

Objetivo.Explorar la relación entre espiritualidad y religiosidad en adultos mayores con enfermedad crónica. Métodos. Estudio de corte transversal realizado con una muestra representativa de 229 adultos mayores con enfermedad crónica inscritos en 12 centros de vida de la Ciudad de Cartagena, Colombia. Se aplicaron las escalas de Perspectiva Espiritual de Reed y la de Religiosidad de Francis. Resultados. El promedio de edad 74.4 años, de los cuales un 62.9% pertenecía al sexo femenino. Por ocupación, las más frecuentes fueron desempleados (45.9%) y amas de casa (44.5%).  De otro lado, la religión  más practicada fue la católica (81.2%). El nivel de espiritualidad y religiosidad fue alto, mostrando una correlación moderada y directa (r=0.57). Conclusión. Existe una relación directamente proporcional entre espiritualidad y religiosidad en los adultos mayores con enfermedad crónica.

Palabras clave: espiritualidad; religión; anciano; enfermedad crónica.

RESUMO

Objetivo.Explorar a relação entre espiritualidade e religiosidade em adultos maiores com doença crónica. Métodos. Estudo de corte transversal realizado com uma amostra representativa de 229 adultos maiores com doença crónica inscritos em 12 centros de vida da cidade de Cartagena, Colômbia. Se aplicaram as escalas de Perspectiva Espiritual de Reed e a de Religiosidade de Francis. Resultados. A média de idade foi de 74.4 anos, um 62.9% foram mulheres, por ocupação as mais frequentes foram desempregados (45.9%) e dona-de-casa (44.5%) e a religião que mais praticada foi a católica (81.2%). O nível de espiritualidade e religiosidade foram altos, mostrando uma correlação moderada e direta (r=0.57). Conclusão. Existe uma relação diretamente proporcional entre espiritualidade e religiosidade nos adultos maiores com doença crónica.

Palavras chave:espiritualidade; religião; idoso; doença crônica

INTRODUCTION

Chronic diseases are long-term illnesses and generally of slow progression. Heart disease, stroke, cancer, respiratory disease, and diabetes are the main causes of mortality throughout the world, responsible for 63% of deaths.¹ in elderly adults, chronic disease triggers a series of events that unbalance the general state of health, causing progressive deterioration in the different dimensions of the human being, like the physical and psychological; during this experience is when patients look to their spirituality and seek support on a superior being.² Likewise, Reed argues in her theory that in moments of disease of advanced age and upon vitally stressful events vulnerability increases, that is, awareness of mortality that leads to self-transcendence, i.e., to the extension self-conceptual limits with oneself, with the world, and with others.³ Thus, spirituality and religiosity gain importance, given that these are fundamental dimensions in the lives of humans, representing in elderly adults, especially in those enduring chronic diseases, a means to confront the anguish and difficulties according to their practices and beliefs.^4,5Reed⁶ describes spirituality as ''the inclination to find meaning in life through a sense of connectedness with something greater, which transcends the ego and strengthens it, hence, differences exist in behavioral and physiological adaptive responses during moments of anxiety experienced by the individual'', which indicates that elderly adults, upon difficult situations like suffering from a chronic disease, react in such a way that it affects the physical and mental health. Also, Whetsell,⁷ in a study with elderly adults, demonstrated how the integration between fortitude and spiritual wellbeing markedly influence the health of elderly adults upon confronting a stressful situation. Religiosity is by nature essentially social; it is structured as a body of knowledge, behaviors, rights, norms, and values that govern the lives of subjects interested in being involved with the divine. Religiosity has a directive nature, upon providing the subject with the necessary fundamental knowledge to seek the divine through indoctrination and congregation with others.⁸ Religion is determined by multiple reasons, one of them and the most frequent is that of being ill or under health threat, and it is here where the approach to religion takes place or the development of previously existing religiosity as a way of coping with stressful situations, permitting to adopt a sense of coherence that as a general resource of existence favors one's health.⁹

Spirituality and religiosity may be related to diverse elements that influence significantly upon the disease process been endured by the individual.⁷ These are of great help in the satisfaction of life, whatever situation in individual presents; it supports the adaptation of impediments arising upon having a chronic disease. Religiosity permits enjoyment of good physical and mental health, in spite of the chronic disease affecting an individual. Care of chronic diseases in elderly adults centers not only on the physical, but also on the spiritual and it has been the concern of healthcare staff, given that these aspects are not directly assumed.¹⁰ The aim of this study was to explore the relationship between spirituality and religiosity in elderly adults with chronic disease.

METHODOLOGY

In 2014, a cross-sectional cohort study was conducted with the participation of elderly adults with chronic diseases coming from the life centers located in the city of Cartagena (Colombia). The sample size was calculated based on an expected 50% prevalence, with 4% margin of error and 95% confidence level. Random sampling was used through conglomerates constituted by the 24 life centers and, thereafter, a systematic random sampling was made to select the elderly adults. The selection criteria included the following: patients of both genders from 65 to 80 years of age who regularly attended the life centers in the city of Cartagena, who had been diagnosed with any chronic disease, and who had preserved mental abilities; the sample size calculated was 246 subjects.

Regarding data collection, sociodemographic information was taken (age, sex, schooling, marital status, place of origin, occupation, religion, and socioeconomic level) and two scales were used to evaluate spirituality and religiosity. To measure spirituality, the Spiritual Perspective Scale by Pamela Reed was used,¹¹ which has two components: practices and beliefs; with respect to spiritual practices, it has four items, which are evaluated from six criteria with a score from 1 to 6, with 1 = never or 6 = more or less once a day. The spiritual beliefs have six items, evaluated with six criteria, using the same previous scoring, with 1 = extremely disagree and 6 = extremely agree. This instrument has been used in Colombia, has Cronbach's alpha with values between 0.85 and 0.90, which indicates its high reliability.^12-14

To assess religiosity, this work applied the five-item version of the Francis Scale of Attitude toward Christianity¹⁵ that evaluates the affective response upon God, Jesus, and prayer. Each item has the following options: 0 = strongly disagree, 1 = disagree, 2 = not sure, 3 = agree, 4 = strongly agree. The total score is the sum of the scores of the five items, with 20 being the maximum. This instrument showed a Cronbach's alpha of 0.88, when used on high school students in Cartagena, Colombia.¹⁶ This is a unidimensional scale without a pre-established cut-off point. Higher scores indicate more favorable attitude toward religion.

The researchers provided explanations to the subjects, who consented to participate after being notified in writing on the purpose of the study. The participants answered both instruments applied from the reading made by the research group. Upon obtaining and analyzing the information, the results were shared with each of the persons in charge of the life centers and with all those who were part of the research, through the guarantee granted by the Mayor's office of Cartagena.

RESULTS

A total of 229 elderly adults participated in the study. The main socio-demographic characteristics were: mean age was 74.4 ± 5 years, 63.8% were women; regarding marital status, widowers/widows prevailed (42.8%), followed by single and married (25.3% each) and by common-law marriages (6.6%). The most-practiced religion was Catholicism (81.2%), followed by Evangelist (15.7%) and Mormon and Adventist (0.4% each). With respect to schooling, it was found that 43.7% had incomplete primary school, 23.6% were illiterate, 4.8% had complete high school, and only 1.3% had technical education. The most frequent socio-economic stratum was 1 (66.8%), followed by 2 (27.9%) and, lastly by 3 (5.2%). In terms of place of origin, 53.3% were from the rural area. Lastly, with respect to occupation, it was found that 45.9% were unemployed, 44.5% were housewives, and finding in lower proportion retirees (1.3%) and those gainfully employed (0.4%).

Moving on to the results in the measurement of the scales, the average obtained from the scale of spiritual perspective was 54.7 ± 3.7 points, with a maximum score of 60. In the component of Spiritual Practices, the average was 22 ± 2.2 points. Table 1 shows that the five practices are performed most frequently on a daily basis, with this proportion being higher in the practices of praying or meditating (97.8%) and talking about spirituality (73.8%).

Table 1.

The average obtained in the component of spiritual beliefs was 32.7 ± 23 points. As noted in Table 2, in the seven beliefs almost all the participants agreed (sum of the categories agree more than disagree, agree and extremely agree). A similar situation was observed in the Francis Religiosity Scale Table 3.

Table 2.

Table 3.

Association between spirituality and religiosity was explored in the group of elderly adults with chronic disease participating in this study, finding that the correlation between religiosity and spirituality is moderate (r = 0.57). The same occurred with the relationship between religiosity and the component of spiritual beliefs (r = 0.61), while the correlation of religiosity with the component of spiritual practices is low (r = 0.22). All these correlations had a p value of <0.001.

DISCUSSION

The positive relationship found between the levels of spirituality and religiosity of elderly adults with chronic disease who attend life centers in the city of Cartagena indicates the importance of spirituality as a dimension with transcendence on the human being. The study shows a median relationship between religiosity and spiritual beliefs; and a low relationship between religiosity and spiritual practices, which is why there may be individuals who are more religious than spiritual or others who are more spiritual than religious. These two aspects are enhanced when suffering a chronic disease. Currently, several studies have been done on the theme and it has been related to improved physical and mental health in all types of disease.¹⁷ In their study, Martínez et al.,²⁴ reveal the relationship between the variables of religiosity and spirituality, confirming spiritual growth with breast cancer and cancer in the female genitourinary system. Also, Quiceno and Vinaccia⁹ show that adults use spiritual and religious tools (read religious books, spiritual symbols, etc.) to endure their chronic disease.

The most prevalent religion was Catholicism, coinciding with the research by Barboza and Forero¹⁸ in patients with breast cancer in which 76.3% were Catholic; likewise, with the study by Rivera and Montero⁸ on spirituality and religiosity in Mexican elderly adults, where Catholicism prevailed with 74%. This indicates that, currently, most people still practice the Catholic religion. A study by Bell J. et al.,¹⁹ indicates that during most of the 20^th century (1900 to 1960) at least 90% of the population in Latin America was Catholic. Now, the survey implemented by this research group in 18 countries in Latin America and one territory of the United States (Puerto Rico) yielded as a result that 62% of adults identify themselves as Catholic.

Whetsell et al.,⁷ demonstrated that health related to fortitude and spiritual wellbeing are significant dimensions that help to maintain the elderly healthy. In adult individuals, spirituality seems to promote a proactive attitude against adversity; that is, it promotes the consolidation of vital projects, like: health, family stability, and professional success. In addition, spirituality favors strengthening self-esteem and identity in the case of those who suffer discrimination or exclusion due to cultural, ethnic, or religious reasons.²⁰

Moreover, it is quite important for the elderly to belong to a social group (life center), where they share the same religious beliefs. Through these beliefs, they find refuge in a higher being during difficult moments, which helps them to cope with their disease process; this coincides with the study by Quiceno²¹, which stresses the importance of belonging to a group that shares the same beliefs as a means of social support that provides them help and approval or comfort during moments of difficulty. Similarly, as strategies to endure the diseases, it is fundamental for them to have spiritual objects and symbols, listen to religious music, read books or texts on spiritual-religious inspiration (Bible), attend and participate in church celebrations and receive communion. In this respect, Reed³ argues that during moments of disease, advanced age, and upon vitally stressful events vulnerability increases, that is, awareness of mortality that leads to self-transcendence, or to extending the self-conceptual limits with oneself, the world, and others.

This study shows high levels of religiosity in elderly adults when they suffer chronic disease, where the fact of belonging to and/or attending a congregation group, without regard to the type, offers much strength, aid, and support for their disease process. Evidence-based research propose that although people are not very religious in their daily living, they can be during moments of disease, given that the experience of losing personal control leads to the search for a higher power or a God to find the purpose of life and confront stressful situations. This is how religious and existential coping strategies can help people to encounter chronic diseases over time; hence, it may be stated that the religious and existential experience becomes more experiential and gains meaning during moments of crisis and when perceiving that control over life is uncertain.^22,23

Religious life is important for the elderly; however, a study by Rivera and Montero⁸ on spirituality and religiosity in Mexican elderly adults reported that this variable does not seem to benefit the mental health of the elderly, when it is defined by the degree of depression and solitude experienced. In addition, the study by Ocampo et al.,²² states that there is association of religion with the physical and mental health of individuals. Koenig²⁴ reported that ambulatory elderly believed in God, prayed regularly, and believed that religious activities helped them during critical periods. Likewise, the study found that all elderly adults practiced a religion as stated that prayer was of great help and that God was very close to them.

Results show that religiosity and spirituality have a directly proportional relationship; these two aspects play an important role in the elderly to overcome their chronic disease process. Furthermore, sharing the same religious beliefs strengthens the spiritual and religious levels of these elderly adults, thus, improving the disease process and adaptation to it. Using spiritual and religious resources constitutes a coping strategy frequently used by the elderly, and it is associated to adjusting to situations of loss, changes, or disease during aging;⁴ however, it has also been proposed that spirituality and religiosity are not only a source of support and benefits, but can also be a source of conflict and suffering, which is why in profoundly spiritual individuals strong feelings of guilt, despair, anger, and lack of sense may emerge.²⁵

Upon comparing the findings of this study with the results from other research works, it may be determined that levels of spirituality and religiosity of elderly adults with chronic disease are high; similar to the study by Martínez et al²⁶., which considers that spirituality is related to religiosity, given that patients with chronic disease, like cancer, are as spiritual as they are religious; so that the habit of praying, the frequency of attending temples, the importance of the spiritual life for the subject before and after becoming elderly are associated significantly to the spiritual conviction.⁸

Spirituality and religiosity in Nursing play an important role within the health-disease process in caring for the elderly, who are individuals with a great number of physiological and emotional problems related to age and characteristic lifestyles, and who, upon confronting health situations that bring them closer to death, seek religious practices and beliefs where they feel strengthened and full of hope in their recovery or in accepting their condition in a positively. This is where Nursing, based on its knowledge, intervenes in caring in a holistic manner, bearing in mind all those dimensions of the being that can be strengthened through interventions that aim at the well-being of the elderly. These Nursing actions toward spiritual caring are ratified in research that evidences the need to train all nurses in this area for care to be more comprehensive.²⁷

In conclusion, a directly proportional relationship exists between spirituality and religiosity in elderly adults, which is evidenced in the beliefs and practices of the people surveyed, according to that evaluated by the instruments of the spirituality scale by Pamela Reed and the scale of religiosity by Francis. Elderly adults with chronic disease registered in life centers in the city of Cartagena present the need to approach a higher being, which offers them strength during moments of difficulty. Thereby, Nursing, from its particular work, will manage to maintain a balance between the variables of spirituality and religiosity because it provides a better state of health that could influence upon the quality of life of this population.

REFERENCES

2. Pinto N. Percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos. Aquichan. 2011; 11(3):276-81.         [ Links ]

3. Reed P. Theory of self-transcendence. In: Smith MJ, Liehr PR. Middle range theory for nursing. 3th Ed. New York: Springer Publishing Company; 2014. P:109-15.         [ Links ]