RELIGIOSITY AND QUALITY OF LIFE IN OLDER ADULTS: LITERATURE REVIEW

Older adults are living longer, often with one or more long-term health conditions which can impact their quality of life. In fact, a growing number of studies have shown a positive association between religion/spirituality and better quality of life for older adults. The aim of this paper is to examine the association between religiosity/spirituality and quality of life among older adults. In order to accomplish this objective, an integrative literature review will be made in which the following eletronic databases were searched: Lilacs, Scielo, Medline, and Pubmed. The inclusion criteria were: studies written in English, Portuguese or Spanish, published between 2004 and 2012, containing themes pertaining to the research question as noted above, and having full texts freely available. The exclusion criteria were literature reviews and participants under 60 years of age. Only 12 studies met the inclusion criteria. In 75% of the studies, a positive association between religion/spirituality and 1 Doutora em Ciências pela Universidade de São Paulo (USP). Bacharel em Enfermagem pela Centro Universitário Adventista de São Paulo. Docente do Programa de mestrado em Promoção da Saúde do Centro Universitário Adventista de São Paulo (Unasp). E-mail: gina.abdala@unasp.edu.br 2 Doutor em Enfermagem pela Universidade de São Paulo. Mestre em Enfermagem pela Universidade de São Paulo. Bacharel em Enfermagem pela Universidade de São Paulo. Docente associado da Universidade de São Paulo. E-mail: mikimura@usp.br. 3 Bacharel em Enfermagem e Medicina. Docente de psiquiatria e docente associado de Medicina em Duke University Medical Center, Durham. E-mail: koenig@geri.duke.edu 4 Mestre em Enfermagem pela Catholic University of America e pelo Johns Hopkins University School of Nursing. Especialista em sáude pública. E-mail: kreiner1@jhu.edu 5 Doutor em Enfermagem pelo Centre for Research in Nursing and Midwifery Education (CRNME). Docente no School of Health Sciences, University of Surrey. E-mail: k.horton@surrey.ac.uk

O ver the last few decades, the aging population has grown at an unprecedented rate worldwide. Countries such as Brazil have seen a constant change in the demographic pattern. According to estimates for 2050, the proportion of the older adult population will be around 22.71% of the total population 6 . Related to this phenomenon is the process of epidemiological transition, which is characterized by a reduction in the number of cases of infectious diseases and a rise in the number of cases of chronic non-communicable diseases and their complications (BRASIL, 2010). All these changes may compromise to varying degrees the perception of well-being and quality of life of older adults. Quality of Life (QoL) is a subjective and multi-dimensional concept that has been used with different meanings. In the absence of a conceptual consensus, terms such as life satisfaction, well-being, happiness, good life, value of life, and functional status have been used as akin to the concept of quality of life (KIMURA; SILVA, , p. 1098. The concept of health-related quality of life (HRQoL) was introduced to narrow the focus to the effects of health problems and therapeutic interventions on quality of life (MINAYO;et al., 2000, p. 7-18). HRQoL can be defined as "the value assigned to the duration of life as modified by the impairments, functional states, perceptions and social opportunities that are influenced by disease, injury, treatment or policy" (WALKER; ROSSER, 1993). Narrowing the focus on "the value assigned to duration of life," the concept of HRQoL represents a new framework in the context of health care, whose ultimate goal is not only to augment longevity, but also to provide quality to a longer survival (NETUVELI; BLANE, 2008, p. 113-126).
Evaluating HRQoL is critical in health care. A recent prospective cohort study of 2,373 participants (OTERO et al., 2010, p. 15-23), representative of the Spanish population aged 60 and older, concluded that changes in HRQoL measured by the SF-36 health questionnaire predicted mortality of older adults. This points to the importance of searching for possible determinants of a decline in HRQoL since it predicts a worse prognosis (OTERO et al., 2010, p. 15-23). Several factors are identified as determining well-being in later life, such as longevity, physical health, mental health, satisfaction, cognitive control, social competence, productivity, activity, social status, income, family and occupational roles, and social networking (NERI, 2009, p. 285).
Another factor that has been identified in a number of studies on aging, health and QoL is the protective effect of religious/spiritual beliefs and practices. An increasing number of studies have showed positive correlation between religion/spirituality and quality of life (SAWATZKY et al., 2005, p. 153-188). Besides its impact on quality of life, studies had shown that religion/spirituality has an impact on successful aging and well-being despite chronic degenerative diseases, neuropsychiatry, functionality, end of life and mortality (LUCCHETTI et al., 2011, p. 316-322).
Religious and spiritual behaviors are common in old age. The situations experienced can yield stress, hopelessness and suffering, leading to a questioning of God's existence, the meaning and purpose of life (LOTUFO et al., 2009, p. 292). Older adults tend to deeply value their religious beliefs and seek in them strategies to cope with the challenges of growing old (SOUZA, 2011).
Religion/spirituality may directly or indirectly affect health because it generally provides an extensive social support network, a reduction of unhealthy behaviors such as alcohol, smoking and drug abuse, the lowering of blood pressure and muscle tension, and the promotion of positive emotional states.
Because of that, there is a reduction of the need for health care among individuals who report a high level of religiosity or spirituality (ABDALA et al., 2010, p. 77-98). Religion is defined as "beliefs, practices, and rituals related to the Transcendent or the Divine" (KOENIG, 2011). This Transcendent can be God, Allah, HaShem, or a Higher Power (Western religious tradition) or Vishnu, Krishna, Buddha, Ultimate Truth or Reality (Eastern religious tradition). Spirituality is often viewed "positively and personally", as being focused on "individuality", as well as very broad and subjective (KOENIG, 2011). For example, there is an important need to distinguish the conceptual definition of spirituality in nursing research from that of spiritual care in a clinical environment, thus avoiding tautology in mental health outcomes, which means that spirituality can be confused with psychological positive aspects (REINERT; KOENIG, 2012KOENIG, , p. 2622KOENIG, -2634. Taking into account all the evidence above and the fact that in Brazil 95% of the population report to practice a religion and 83% consider that practice very important 2010, p. 12-15), the question used to guide this review was: is there any relationship between aspects of religiosity and quality of life among older adults?

Method
This integrative literature review focusing on religiosity/spirituality (R/S) and quality of life among aging adults was guided by the steps of Polit and Beck (POLIT;BECK, 2006). The methodology consisted of searching published ref- This research made use of the latest definitions for the concepts it studied 718 : 1) religion: "any doctrine that requires interpretation, commitment and faith, allowing for a practice geared towards ethical, aesthetic, and emotional goals. A religion is thus characterized by a philosophy and a body of moral principles derived from it and to be followed by the faithful"; 2) spirituality: "sensitivity or attachment to religious values or to the things of the spirit as opposed to material or worldly interests"; 3) quality of life: "generic concept which reflects a concern for the modi-

Results
The initial search yielded 123 references. Of these, 118 were rejected due to a lack of clarity in relation to the age of the participants, no mentions to religion or spirituality, or no focus on quality of life or health-related quality of life. New articles were searched from the references in the five accepted articles (POLIT; BECK, 2006), and 7 more met the selection criteria mentioned above. These were added to the previous five articles completing a total of 12 publications to be reviewed ( Figure 1   For the analysis and synthesis subsequent to the selection of the publications that met the inclusion criteria a synoptic table was used considering the following aspects: authors, article title, place of origin and year of publication, study design and objective, sample size by gender, religiosity/spirituality and quality of life variables, main results and conclusions. Of these 12 articles, the majority (n=8) were studies that analyzed the relationship between religion/spirituality and HRQoL, whereas the remaining four focused on general QoL as an outcome. All reviewed articles (100%) had a cross--sectional research design with level of evidence 4 (cross-sectional and qualitative studies) (STETLER et al., 1998, p. 195-206). Nine of the studies (75%) reported a positive association between religious involvement and quality of life among older adults in various spheres of life, whereas the remaining 3 studies reported no association between religiosity/spirituality and quality of life among older adults.
The religiosity variables used in these 12 articles were organizational religious affiliation (ORA or church attendance), non-organization religious affiliation (NORA or religious activities), personal spiritual beliefs, spiritual well-being, intrinsic and extrinsic religious motivation, and religious involvement and its importance. The instruments used to measure the above variables were: SRPB-tQOL 100 (Spiritual Religious Personal The instruments used for assessing HRQoL were EUROQOL (once), WHOQOL 100 (twice), WHOQOL BREF (three times), and SF-36 (three times).
The analysis of these studies showed that in some cases the concepts of spirituality and religiosity were not clearly or consistently defined. Despite that fact, we found substantial evidence on the importance of R/S in the quality of life (QoL) of older adults, as well as in health-related quality of life (HRQoL), particularly in mental health.

Results from association between R/S and QoL as an outcome
Four of the 12 studies demonstrated a positive association between religion/spirituality and QoL as an outcome (satisfaction with life and psychosocial QoL). Older adults (N=3,387) in these studies self reported that religion played an important role in their general quality of life. 21,22,23,24 In a study exploring whether participation in religious activities are related to satisfaction with life and depression, a convenience sample of community-dwelling older adults (N=489) in Nepal reported that these activities helped them coping with depression, increased sociability and decreased levels of depression in men who prayed more (GAUTAM et al., 2007).
In a large study of a probabilistic older adult (N=2,143) sample in Sao Paulo, Brazil, belonging to a religion (97.6%) and valuing it (88.6%) appear to be important mechanisms of support for older adults, helping them cope with difficulties, contributing to greater life satisfaction and lowering helplessness and hopelessness (DUARTE et al., 2008, p. 173-177). Religious involvement seems to have a significant effect on physical and emotional well-being, specially among widowed and terminally ill older adults (DUARTE et al., 2008, p. 173-177). Similarly, in Rio de Janeiro, Brazil, a survey with 256 older adults to investigate the association between religious involvement and subjective well-being found that only subjective religiosity had a positive and significant relationship with life satisfaction (CARDOSO; FERREIRA, 2009, p. 380-393).
The fourth study in New Haven-NC-USA reported that among 499 older adults, those with deep religious commitment showed greater sociability (62%), better health (51%), lower depression scores (63%), and found life more exciting (49%) compared with less religious participants (IDLER;et al.,. Physically disabled participants benefited more from both public and subjective religious involvement than those who were not (IDLER et al., 2009, p. 528-37). See Chart 1.

Study design and objective
Cross-sectional, survey.
Aim: to explore whether participation in religious activities are related to depression and satisfaction with life.

Main results and conclusions
Among specific leisure and religious activities, saying prayers (B = -2.75; p < 0.005) was correlated to lower depression for older men, but only watching television and listening to the radio (B= -2.68; p <0.005) related to lower rates of depression for women.

Article title
Source and year of publication

Religious and QoL variables
Religious belief, importance of religion in life, satisfaction of life, despair, helplesness.

Main results and conclusions
Belonging to a religion (97.6%) and valuing it (88.6%) appear to be important mechanisms of support for older adults who face everyday problems, contributing to greater life satisfaction (82.3%), less helplessness (87.5%) and less despair (80.1%). Religious involvement seems to have a significant effect on the physical and emotional well-being of people. Rio de Janeiro, Brazil.

Study design and objective
Cross-sectional study.
Aim: to investigate the relationship between religious involvement and the subjective well-being of older adults.

M=male F=female
Sample: 256 older adults.

Study design and objective
Cross-sectional from a prospective cohort.
Aim: to compare the quality of life of those who are religiously involved with that of those who are not.

F=female
Sample of 499 older adults, following an annual interview (EPESE).

Religious and QoL variables
Public and subjective religious involvement, indicators of health-related and psychosocial QoL.

Main results and conclusions
In a logistic regression model, the more deeply religious respondents were, the more likely they were to visit with friends (62%), and have better self-rated health (51%), fewer depressive feelings (63%), and to find life more exciting (49%) compared with the less religious.
Disabled participants benefited more from both public and subjective religious involvement than those who were not.

Results from the association between R/S and HRQoL as an outcome (positive association)
Five studies (of the 12) reported a positive association between religion/ spirituality and HRQoL as an outcome among a total of 2,455 older adults from several sites. In one study from a cohort study in Chaperl Hill-USA (N=277), the term spirituality (Spirituality Index of Well-Being -SIWB) was a predictor for HRQoL in older adults, but not religiosity. The participants stated that the higher their level of spirituality, the more comfort and strength they had through faith and belief in God (DAALEMAN et al., 2004, p. 49-53). However, this can be considered a tautological effect (REINERT; KOENIG, 2012, p. 2622-2634) since the use of a measure of spirituality can have a confounding effect on the mental health outcomes.
In another study with 50 older adults in Sao Paulo-Brazil, religion was considered to be extremely/very important, bringing the participants comfort, security and strength to overcome problems, loss and grief (MORAES; WIT-TER, 2007, p. 215-238). Interestingly, in a cross sectional study of 1958 with aged people in Rio de Janeiro, Brazil, it was noted that (older, evangelical, less educated) women obtained lower scores than men in all domains of quality of life. Individuals from the Catholic faith obtained better scores than Evangelicals for physical fitness (82.2%, CI=78.5-85.9) and vitality (65.2%, CI=63.2-67.1), even adjusting for gender, age, income and schooling. A detailed understanding of cultural variability from one country to another, or even from one state to another in the same country, is in fact critical to explain differences observed in dissimilar faith groups (LIMA et al., 2009(LIMA et al., , p. 2159(LIMA et al., -2167. In another Brazilian study, after controlling for confounding variables in a convenience sample of 110 outpatients in a rehabilitation setting in Sao Paulo-Brazil, religiousness was inversely correlated with depressive symptoms and pain rating, and was positively correlated with quality of life and cognitive functioning (LUCCHETTI et al., 2011, p. 159-167).
In another study, religion/spirituality also had a positive influence in the mental health of 60 active older adults. Trying to identify if religious orientation had any impact on the HRQoL of seniors (BARRICELLI et al., 2012, p. 505-515).
Found that intrinsic religiosity also related to the general health of men (p<0.05) (BARRICELLI et al., 2012, p. 505-515

Study design and objective
Cross-sectional Aim: to examine the interaction of religion and spirituality with health-related quality of life in a community-dwelling geriatric population.

M=male
F=female 277 aged patients from a cohort study

Main results and conclusions
After univariate and multivariate analysis, quality of life and spirituality (p <.01) were all associated with HRQoL, but religiosity was not (p= .12). In a model adjusted for all covariates, however, spirituality remained independently associated with self-appraised good health (p=.01). Spirituality may be an important explanatory factor of subjective health status in older adults.

Source and year of publication
Moraes NAS, Witter GP.
Old age: intrinsic and extrinsic life quality.

Study design and objective
Cross-sectional.
Aim: to investigate several aspects of (intrinsic and extrinsic) quality of life according to the opinions of older adults.

Religious and HRQoL variables
Importance of religion and the practice of religious activities, WHOQoL -bref, and another instrument elaborated for the research.

Main results and conclusions
HRQoL, as measured by the WHOQoL-bref, was positively evaluated by 50 subjects (ages between 65 and 86 years).
Religion was considered to be extremely/very important (χ2 = 7.82; p ≤ 0.05; df=3). Contact with the Divine is important since it brings participants security and gives them spiritual comfort. Practice of religious activities was n o . 1 in leisure preference by older adults.

Authors, Article title
Source and year of publication

Study design and objective
Cross-sectional.
Aim: to analyze the influence of different demographic and socioeconomic factors on the quality of life profile of the elderly Sample,

M=male F=female
A two-stage stratified cluster sample was obtained from 1958 elderly people.

Main results and conclusions
Women obtained lower scores than men in all the domains of QOL. Using a multiple linear regression model, individuals from the Catholic faith obtained better scores than Evangelicals for physical fitness (82.2%, CI=78.5-85.9) and vitality (65.2%, CI=63.2-67.1), even adjusting for gender, age, income and schooling.

Study design and objective
Cross-sectional study Aim: to evaluate the relationship between religiousness and mental health, hospitalization, pain, disability and QOL in older adults.

F=female
Convenience sample of 110 outpatients in a rehabilitation setting. M=29, F=81.

Religious and HRQoL variables
Private and social Religious Practice Scale (religious attendance and its importance in life) + Whoqol bref + GDS-15

Main results and conclusions
In a logistic and/or linear regression analysis, after controlling for confounding variables, religiousness was inversely correlated with depressive symptoms (OR=3.587 95%CI=1.045-12.312, p=0.042) and pain rating B=-1.065, p=0.045); and was positively correlated with HRQoL (OR=0.373 CI=0.149-0.933, p=0.035) and cognitive functioning (B=2.029, p=0.018). Clinicians should ensure that spiritual needs are addressed among older patients in rehabilitation settings.

Authors, Article title
Source and year of publication

Study design and objective
Cross sectional.
Aim: to identify forms of religious orientations, if intrinsic or extrinsic, and possible relation to the quality of life for active seniors.

Religious and HRQoL variables
Hoge Scale -Intrinsic Religious Motivation Scale + SF-36

Main results and conclusions
There was no statistically significant difference in all areas of the SF-36 among women with intrinsic and extrinsic religiosity. Statistically significant difference was only found among men in the field of "General Health", which was considered better among those with intrinsic religiosity (p<0.05) Results from association between R/S and HRQoL (lack of association) Even though religiosity may exert a protective effect on one's quality of life, some studies have demonstrated a negative association or even a lack of association, highlighting the need for more research in this area (ALVES et al., 2009(ALVES et al., , p. 2105(ALVES et al., -2111. A total of 2,450 older adults from Canada, Brazil and the U.S. participated in a survey concerning the relationship between religion/spirituality and HRQoL in three studies. These studies did not find any association between religiosity/spirituality and HRQoL nor any form of negative association (MOLZAHN, 2007, p. 32-9;FLORIANO;DALGALARRONDO, 2007, p. 162-170;VAHIA et al., 2011, p. 97-102). In one of them, a convenience sample (N=426) of older adults listed the strongest predictors of overall HRQoL as social support and health satisfaction, but not spirituality, in a secondary analysis of Canadian community-based data (MOLZAHN, 2007, p. 32-39).
Another study compared members of an Evangelical church with Catholics. In the study, religiosity/spirituality was significantly associated to the worst

Main results and conclusions
Results show that spirituality was not a significant factor contributing to HRQoL in this communitybased sample (r=0.19), and that the strongest predictors of overall HRQoL were social support (t =9.87, p < .001), and health satisfaction (t = 6.854, p< .001).

Authors, Article title
Source and year of publication

Study design and objective
Cross-sectional.
Aim: to evaluate the relationship between different dimensions in socio-cultural life: social support, religion, mental health and QOL.

M=male F=female
Systematic sample of 82 older adults.

Religious and QoL variables
Religious affiliation, frequency at church services, personal involvement, WHOQOL bref.

Main results and conclusions
In a sample of 82 older adults belonging to an Evangelical church religiosity/spirituality was significantly associated with worse HRQoL in the four domains of the WHOQOL-bref instrument. In logistic regression models, the Evangelicals presented greater risk for worse social, environmental, physical and psychological QoL than the Catholics (6, 8, 5 and 4 times, respectively).

Authors, Article title
Source and year of publication

Study design and objective
Cross-sectional survey Aim: to examine the association between spirituality and optimism, resilience, depression, and health-related quality of life (HRQoL)

M=male
F=female 1942 older women, between 60 and 91 years of age. F=1942.

Religious and QoL variables
2 items from Bref Multid. Measure of Relig/Spirit Scale and 3 items from Hodge's Intrinsic Rel Motivation Scale, SF36.

Main results and conclusions
Spirituality was not associated with self-rated successful aging of 1,942 older women, 60-91 years of age; however, greater spirituality correlated with higher resilience (CD RISC, Rho =0.282, p<0.001) and higher optimism (LOT, Rho=0.106, p<0.001).

Discussion
Some of the most important findings in this scientific review focusing on QoL as an outcome are: 1) involvement in religious activities,especifically saying prayers, was related to less depression for men; 2) belonging to a religion and valuing it was related to greater life satisfaction; 3) being deeply religious was related to a greater likelihood of having more friends and better self-rated health; 4) religious participants found life more exciting when compared to less religious people; and, finally: 5) religiosity motivated and brought encouragement to older adults who were suffering from depression, helplessness and loneliness at the end of their lives, specially the widowed and terminally ill. In terms of HRQoL as an outcome, the most important finding was that spirituality was associated with HRQoL, especially better physical fitness and vitality for Catholics. Intrinsic religiosity (how important religion is) was related with good general health for older men. Religiosity was also related with less depressive symptoms, less pain rating, better HRQoL and lower cognitive impairment. The above findings have implications for maintenance and enhancement of the mental and physical health quality of life of older adults. Increasing evidence suggests in fact that greater adherence to religious beliefs can influence the population's physical and mental health (SILVA et al., , p. 1187(SILVA et al., -1192. There are several instruments that can assess spiritual suffering of patients in the clinical environment. These are suited and conducive to the formulation of spiritual diagnosis for clinical care (Spirituality Rating Scale; Pinto and Pais-Ribeiro's Spirituality Scale; and Spiritual Well-being Scale) (CHAVES et al., 2011).

Review limitations
In three out of the 12 studies, the sample size was the convenience type, instead of a probability sample. This suggests that there was bias in the sampling, although justifiable due to the difficulty of finding severely ill patients suited for these studies (patients with depression, elderly volunteers, institutionalized and rehabilitation patients). and physical). Religiosity has been found to help older adults to face problems, cope with losses and overcome struggles, bringing security and spiritual comfort in their times of need. The practice of prayer was associated with less depression in older men. Belonging to a religion and valuing it was associated with greater satisfaction with life. Even after controlling confounding variables, religiosity was inversely correlated with levels of depressive symptoms and pain, and positively correlated with cognitive function and health-related quality of life. Current studies have a predominance of cross-sectional designs, which provide a low level of evidence and do not allow for causal relationships between the variables.
Finally, aging is a growing demographic reality. Public health systems for this population face many challenges, and religion/spirituality may be a positive strategy to help the healing process at no significant cost for the government. Religion can be a powerful resource for the health care of older adults, leading them to improved quality of life.