Journal of Psychiatry

The Relationship between Religion/Spirituality and the General Psychological Well-Being of the Elderly Institutionalised Population in the Eastern Cape, South Africa

Anathi Ntozini^1* and Karen Walton^{2 1}Department of Psychology, University of Pretoria, South Africa
²Private Practice, South Africa
^*Correspondence: Anathi Ntozini, Department of Psychology, University of Pretoria, South Africa, Tel: +27780260328, Email:

Received: 28-May-2020 Published: 06-Jul-2020, DOI: 10.35248/2378-5756.20.23.470

Introduction

“Old age” can be considered one of humanity’s greatest social achievements as life expectancy has increased exponentially from 100 years ago, with people born in 1900 having a life expectancy of roughly 50 years [1]. However, it puts large numbers of individuals in an unfamiliar situation – never before have the elderly accounted for so many people in the world. In South Africa, the elderly comprise 10.6% of the overall population [2].

With people now reaching their 80s and beyond, this stage has been hypothesised as a new developmental stage. Erik Erikson’s psychosocial stages of development place those who are over 65 in the stage of “ego integrity versus despair”, with “wisdom” being the ego strength achieved from overcoming this stage. [3] use the writings of Joan Erikson to propose the existence of a ninth stage of development that specifically relates to those in their 80s and 90s. From Erik Erikson and his wife’s observations of their own experience of aging, they propose a final stage of “gerotranscendence”, which has found some initial support in literature and research. This final stage is characterised by a change from a materialistic perspective to a transpersonal perspective that looks beyond the individual to the future [3]. The subjects of the study could be considered to be at this developmental stage.

According to the World Health Organization (WHO), mental health can be seen as a state of well-being [4]. A shift from a treatment to prevention perspective in mental health has fuelled well-being research. It [5] sees well-being as encompassing the individual and the community – “a positive state of affairs in which the personal, relational, and collective needs and aspirations of individuals and communities are fulfilled” (p. 54). Well-being has many positive effects on individuals, with research finding that higher levels of overall well-being have positive effects on quality of life, psychological functioning and physical health of individuals [6,7] and may even increase life expectancy [8].

Increasing the quality of life and health status of the elderly has benefits for society such as being “less of a burden” on health care systems and being active and involved for longer. With a combination of an ageing population, and the unique South African situation, where mainly younger adults are affected by HIV/AIDS and there may eventually be too few younger people to care for the elderly, numbers of elderly that will need to live in institutions of some kind are set to rise. This makes well-being in the elderly population important, especially for those that do not live with their families at home.

While the elderly have been found to experience more psychological well- being than their younger counterparts [9], those in institutions [10] propose may experience less quality of life than community-residing elderly. It is not clear whether the lower satisfaction with life is due to the illness or frailty that necessitated institutionalisation or whether it is an effect of institutionalisation itself (and the type of institution the individual is placed in). Most studies on institutionalisation in the elderly focus on the cognitively impaired or extremely frail, which does not necessarily mean that this is the general experience. Institutionalisation can be conceptualised as occurring on a continuum with nursing homes and frail care centres on the one end, where residents cannot care for themselves fully, and retirement villages on the other, where residents are independent and require little care. In between these points are forms of sheltered housing where residents require lowto moderate levels of support. Broadly, institutionalisation can be defined as when elderly people are not living in their own homes (with or without spouses) but not with their children [11]. Both challenges to and opportunities for well-being have been found in institutions for the elderly [12].

The ability to adapt and make use of coping strategies may mediate the effects of institutionalisation [13]. A common coping strategy used by the elderly that is associated with higher levels of well-being is religion and spirituality [14]. This strategy is believed to have an effect on physical health and mental well-being. A person’s religious or spiritual beliefs have an effect on how that individual deals with life stressors [15], which can have either positive or negative effects. Religious beliefs where stressors are seen as punishments from God or the Devil, or that a problem is beyond God’s ability to solve, have been linked to negative effects on health and well-being, such as depression and poorer cognitive functioning [14]. However, a link between religion and well-being is a common finding in the literature [16], along with other positive findings such as lower rates of substance abuse [16], suicide [17] and anxiety [14, 18]. Its even found that those who used positive religious coping strategies showed greater improvements in health in a sample of medically ill hospitalised elderly participants.

Religious affiliation and membership are not routinely measured as part of census information in South Africa. In the 2001 Census it was found that about 85% of the South African population identifies with a religion or spiritual affiliation [19] and [20] estimates that in African countries more than 90% of the population on average are religious.

The latest General Household Survey [21] found that 95% of South Africans identified with some religion, with the majority being Christians (up to 88% in some provinces). The elderly as a population group are commonly considered to be more religious than their younger counterparts [22,23].

With the possible benefits associated with religiosity and spirituality in the elderly, it is worth investigating whether the relationship between psychological well-being and religiosity/spirituality is also found in the elderly in the South African context. This leads to the guiding research question for this study: What type of correlation exists between religiosity/spirituality and psychological well- being amongst the elderly institutionalized population?

Positive psychology was used as the theoretical framework for the study [24]. To define positive psychology as the scientific study of positive human functioning and flourishing on many levels, which encompass the personal, relational, biological, institutional, cultural and global dimensions of life. Positive psychology looks to complement traditional and established theories and encourage focus not merely on what is wrong but also what is right [25,26], taking a preventative and promotional approach to mental health [27].

The concept of well-being clearly falls within the theoretical framework of positive psychology. According to [28], well-being is central to positive psychology, with positive emotions, positive relationships, engagement, achievement and living lives of meaning as the most important indicators of well-being. Emotional, psychological and social well-being can be seen as vital ingredients of mental health [26,29].

From the perspective of positive psychology, spirituality and religion are seen as a search for the sacred [30,31], with religion and religious practices seen as the ways the search becomes organised and socially acceptable [30,32]. It is highlighted that universal nature of spirituality, where, although the content of specific belief differs, “all cultures have a concept of an ultimate, transcendent, sacred and divine force”.

Method

The study used a non-experimental quantitative research design.

Participants

The study population consisted of elderly residents in elderly institutions in Buffalo City Metropolitan area, South Africa and the local surrounding areas. The elderly population of this area is estimated to be 6% of the total population [33]. According to the [34], the number of elderly people resident in institutional settings in Buffalo City is 2,438. The sample was obtained using nonprobability convenience sampling, which makes use of volunteers to participate in a study. This mode of sampling was seen to be appropriate as the particular characteristics of this population (e.g. cognitive impairments, which are often a major reason for institutionalisation) made randomised sampling unsuitable.

A number of criteria were set out for participation:

• must be 65 years and older

• currently residing in an “old age home”

• not have any currently diagnosed psychiatric disorders

• no current dementia or other disorders which severely affect memory

Staff at the institutions where sampling took place screened possible participants for exclusionary criteria and approached suitable candidates about participating in the study.

The sample size was calculated with a confidence level of 95% and a confidence interval of 5, leading to a calculation of 332 individuals. It became apparent during the course of the study that many people from previously disadvantaged groups did not reside in “old age homes” but were more often still cared for at home, which meant that there were few black and colored people. The researcher attempted to include as many from these groups as possible. Other limitations were that all of the participants lived in urban areas; differences may be found with rural elderly.

It became apparent in the data collection that many of the target population were unable to participate due to illness or disability. Many were also highly suspicious of filling in forms, even when assured of confidentiality. This meant that the researcher had to expand the area of data collection from just Buffalo City Metropolitan area to four nearby municipalities. The majority of the data, however, was collected within the area of Buffalo City. In total, 336 questionnaires were collected, which was a statistically significant sample size and a particular strength of the data.

Instruments

Two instruments were used in this study:

• The General Psychological Well-being Scale (GPWBS); and

• The Assessment of Spirituality and Religious Sentiments– Short Form (ASPIRES – SF).

The GPWBS is seen to capture the holistic and multifaceted approach to psychological well-being [35]. It was developed in the South African context and has been found to be a good measure of general psychological well-being. The GPWBS is a 20-item questionnaire using a 7-point Likert scale with options varying from 1 “strongly disagree” to 7 “strongly agree”.

A 2010 study by Khumalo, Temane and Wissing found the GPWBS to have a Cronbach’s Alpha coefficient of 0.87, which suggests high internal consistency of test items. The scale was also found to have criterion-related validity and to correlate positively with a number of other well-known measures of psychological wellbeing and negatively with measures of psychological ill- health [36].

In a 2012 study by [35] factor analysis led to three major factors emerging: “positive affect and meaningful satisfaction”, “negative affect and poor coping”, and “positive meaningful relatedness and vitality”. “Positive affect and meaningful satisfaction” relate to the interconnectedness between subjective happiness and a feeling of meaningfulness – that people thrive when they are able to engage in activities they find meaningful. The second factor of “negative affect and poor coping” links negative affect and perception of a lack of social support. Social support is recognised as a positive resource for well- being [36]. The emergence of this factor also lends support to [29] assertion that health and illness do not occur on the same continuum but are correlated. The last factor of “positive meaningful relatedness and vitality” refers to a restorative state associated with energy and enthusiasm, which occurs in a social and spiritual context of relatedness. Factor 1 consists of eight items, factor 2 of three and factor 3 of nine items.

The scores for the GPWBS range from a minimum of 29 to a maximum 140, with the different scores related to the constructs of languishing, moderate mental health and flourishing. The ASPIRES instrument was developed as a measure that demonstrates acceptable psychometric properties. The original ASPIRES measures on two broad domains – “religious sentiments” and “spiritual transcendence”. The“religious sentiments” domain has two sub-domains, “religious involvement” and “religious crisis”. The “spiritual transcendence” domain is a motivational construct that focuses on the creation of personal meaning in an individual’s life [37]. A major strength of the ASPIRES is its robustness across culture and faith groups. It appears to measure universal aspects of spirituality and religion that exist in all human cultures, which allows it to be used effectively across cultures, faiths and religious traditions [37].

The ASPIRES has shown acceptable levels of internal consistency, with an alpha coefficient of 0.89 on the spiritual transcendence domain and 0.89 on religious sentiments on the self-report measure. The ASPIRES also shows evidence of discriminant, construct and incremental validity.

The short form version of the ASPIRES was used in the study. This is a 13-item measure that is often indicated where the full format may be overly long and is most often used with professionals and the elderly [37].

Only four items from the “religious sentiments” domain (which assesses how involved an individual is in participating in ceremonies, rituals and activities associated with their faith) are included and the sub-domain of “religious” crisis” is not included in this scale. For the “spiritual transcendence” domain, three questions are used out of each of the three sub-domains: “prayer fulfillment”, “universality” and “connectedness”. Prayer fulfillment is defined by [38] as “feelings of joy and contentment that result from encounters with a transcendent reality”, universality as “a belief in the unitive nature of life”, and connectedness as “a belief that one is part of a larger human orchestra whose contribution is indispensable in creating life’s continuing harmony” (p. 989). The short form has been shown to have an acceptable level of internal consistency and to correlate well with the long form, showing that it captures information that is largely the same as the long form [37].

Procedure

The data was collected from 26 centers that offered a range of options along the institutionalization continuum. The majority of the questionnaires were administered individually to participants or in small groups where the researcher was able to assist with participants’ questions and to check that all questionnaires were completed.

Certain problems were encountered with the data collection and overcome. Some confusion was noted with items on the ASPIRES and GPWBS that were reverse scored. It was found that alerting participants to the fact that some people struggle with particular questions helped to prepare them for those difficult items. The language on the ASPIRES was a problem for certain participants who found terminology such as “higher plane of consciousness “outside their everyday language use. A number felt the terminology was too “New Age”, felt that Christianity was the only way and so struggled to see the concepts of the ASPIRES as universal determinants.

A significant problem was that some participants were unable to read or write because of a lack of education or not possessing glasses or having forgotten them in their rooms. Research assistants administered their questionnaires and recorded the information, which assisted in ensuring that educational level was not a barrier to participation. Some participants were not able to speak English and so research assistants were trained as interpreters. Another problem was that participants tended not to want to disagree. This was overcome by explaining to everyone that there are no right or wrong answers and that some questions required disagreement. Overcoming the suspicions of many participants was a challenge – they were wary of signing the informed consent form, despite reading it themselves and having it explained verbally to them. To combat the possibility that centre managers would only approach those who would traditionally be considered religious, it was emphasized that everyone’s view point was important in the study. The questionnaires were of a length that was manageable for the majority of the elderly. Some concentration difficulties were noticed with many of the elderly. As the researcher’s familiarity with the questions increased, however, it became quicker to administer and fewer problems were encountered.

Ethical considerations

The University of Fort Hare’s Ethics Committee granted ethical approval for the study to be undertaken. Entry into old age homes and access to participants were gained through the institutions’ management, whose assistance was also sought in sourcing participants who fulfilled the inclusion criteria.

The aims, purpose, duration and process of the study were explained to participants and they were informed that participation was voluntary and that they could withdraw at any time. Participant confidentiality was respected; participants were given a code and no identifying information was gathered. Assistance was made available through Lifeline to any participant who was distressed by questions in the study and participants were informed of this service verbally and in writing.

Data analysis

The data was coded, scored and entered into the SPSS program. Frequency tables were created to first uncover the means and standard deviations of the different variables. The Cronbach Alpha coefficient was calculated for the questionnaires and subscales within them to determine reliability of the measures for the sample used. The Shapiro-Wilk test for normality of data was also used to ascertain whether the data was normally distributed. This consideration affected decisions about whether to use nonparametric tests to confirm findings of the parametric tests. The t-test was considered an appropriate statistical technique for ascertaining whether a correlation exists between variables, in particular where variables are normally distributed and the sample size exceeds 30 participants [39]. The two-tailed t-test is used to discover relationships but not necessarily the direction of the relationship. A Kruskal Wallis Test for independent samples was also run to confirm the results of the parametric t-tests.

To discover whether a correlation exists between psychological wellbeing and religiosity/spirituality, a number of assumptions about the data were investigated. Pearson’s product moment correlation coefficient assumes that variables are measured either at the ratio or interval scale, have a linear relationship and have no significant outliers, and that the data is normally distributed. Spearman’s rank order correlation coefficient is a non-parametric test that gives an indication of monotonic relationships between variables.

Spearman’s rho does not require normally distributed data nor is it so sensitive to the presence of outliers in the data. These considerations were investigated to determine the most appropriate statistic for the data.

Results

To establish whether a link exists between psychological well-being and religiosity, Pearson’s product moment correlation coefficient was calculated. While scatterplots showed a linear relationship among the variables, which is an assumption for using Pearson’s product moment correlation, a number of outliers were found and it was decided to make use of Spearman’s rho instead.

The findings are presented in Table 1 (GPWBS and religious sentiments) and Table 2 (GPWBS and spiritual transcendence).

Table 1: Correlations for Spearman’s rho for the GPWBS and religious sentiments scale.

Table 2: Correlations for Spearman’s rho for the GPWBS and spiritual transcendence scale.

As seen from Table 1, a significant correlation exists between psychological well-being, as measured using the GPWBS, and religious sentiments, as measured using the ASPIRES. The correlation can be considered a weak positive correlation with the findings being reported rs = 0.239, n = 336 and p <0.001. For the correlation between psychological well-being and spiritual transcendence rs = 0.189, n = 336 and p < 0.001 (Table 2). This indicates a very weak positive relationship. However, both results are significant at the 0.001 level.

Owing to the poor Cronbach alpha of the factors of the spiritual transcendence scale, correlations for the individual factors of this sub-scale with psychological well-being were also investigated. These are summarised in Table 3.

Table 3: Correlations for Pearson’s r for the GPWBS and the three factors of the spiritual transcendence scale.

Table 3 shows the correlation between the factors on the spiritual transcendence scale and psychological well-being, as well as the correlations that exist between the factors themselves. Both prayer fulfilment (factor one) and universality (factor two) attained significant correlations with psychological well-being at the 0.01 (1%) level. Prayer fulfilment attained rs = 0.117, n = 336 and p = 0.001(p < 0.01) with psychological well-being, which signifies a very weak positive relationship. Universality attained rs = 0.224, n = 336 and p =0.000 (p < 0.001), representing a weak positive correlation. Connectedness (factor three) and psychological well-being did not attain a significant correlation, with rs = -0.007, n = 336 and p = 0.895 (p > 0.001).

Prayer fulfilment attained significant correlations with universality and connectedness. Respectively they attained rs = 0.365, n = 336 and p = 0.000 (p< 0.01), which is a weak positive correlation (universality), and rs = 0.155, n = 336 and p = 0.004 (p < 0.01), which is a very weak positive correlation (connectedness). Universality attained a weak positive correlation with connectedness, with rs = 0.217, n = 336 and p = 0.000 (p < 0.001). It is therefore apparent that although the factors of the spiritual transcendence scale do not show strong correlations with one another, the correlations are significant.

Discussion

The relationship between psychological well-being and religiosity/ spirituality was explored by linking the findings with existing literature, using a positive psychology framework. The finding of a significant relationship between religiosity/ spirituality and psychological well-being was not surprising, given that religion can be considered very important to the elderly, who have the highest levels of religious participation [40]. Religion and the religious community form one of the largest sources of social support outside of the family system. This relationship has consistently been found in the literature [41-48].

A weak but significant positive relationship was found between the variables of religious sentiments and psychological well-being and between spiritual transcendence and psychological well-being. A literature review by [49] found that the majority of studies reported weak but significant positive correlations between these variables, which have also been found in later studies [47], reviewed literature published specifically within the positive psychology perspective. These authors propose that religion has a positive effect on wellbeing, which is mediated through meaning and purpose in life and through social relationships, which are in fact considered to be building blocks of well-being by [28]. Meaning in life has been found to be the most consistent predictor of well-being across the lifespan [50].

Studies have found four categories of meaning that contribute positively to well-being: achievements, relationships, religion/ spirituality and self- transcendence/generativity. All of these dimensions can be fulfilled through religious practice for the elderly. The elderly are the most active in religious participation, which may provide a sense of achievement when they perceive what they are doing as worthwhile. Religion may also expose them to relationships, with an emphasis on being altruistic and kind to others. Spiritual or religious meaning comes with the sense of belonging to something greater than oneself [51]. Generativity can be fulfilled through religious participation by being involved in an organisation that a person believes will leave a legacy [52].

Link positive emotions with encouraging spirituality. They use Fredrickson’s (1998, 2001) broaden-and- build theory of positive emotions as a conceptual framework. The experience of perceiving oneself as spiritual leads one to see one’s life and the lives of others as interconnected and purposeful, which are the fundamental building blocks of Fredrickson’s theory. The importance of connectedness and positive meaning is also echoed in Ryff’s theory of well-being [53] and in [28] conception of happiness. The experience of positive emotions is also interconnected with meaning and purpose in life [51].

Relationships are seen in many different fields as the most important survival strategy [54]. Psychologically, humans appear to have a “need to belong” that is fulfilled by interactions with others. For these interactions to lead to positive emotions, they should take place within a framework of mutual concern for one another [55].

According to [56], the elderly have more positive relationships than younger adults. They hypothesise that, during later life, a shift occurs towards emotional well-being due to diminished temporal horizons, which lead the elderly to seek relationships that nurture well-being with individuals most meaningful to them and minimise conflict with problematic social ties. As religious communities are often the biggest source of social support for the elderly, aside from their immediate family, it can be seen how having a religious or spiritual orientation can nurture well-being. According to Krause [57] ties that the elderly have to their specific congregation strengthen in late adulthood, while ties to work and other activities tend to decline.

Conclusion

Psychological well-being was shown to have a positive relationship with religiosity/spirituality in elderly institutionalized population. Explanations for this finding were situated within the positive psychology literature, which suggests that this relationship operates through factors such as positive emotions, meaning and purpose in life, and support. When looking at how religious/spiritual the South African elderly are in comparison to norms provided on the ASPIRES, it was found that the elderly tend to be more religious than their younger counterparts. No norm group was available for the over 65 years of age group specifically, however, and hence this finding needs to be treated with caution.

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