658140

research-article2016
GGMXXX10.1177/2333721416658140Gerontology & Geriatric MedicineVitorino et al.

Article
Gerontology & Geriatric Medicine

Linking Spiritual and Religious Volume 2: 1­–9

© The Author(s) 2016
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DOI: 10.1177/2333721416658140

Community-Dwelling Older Adults ggm.sagepub.com

and Nursing Home Residents

Luciano Magalhães Vitorino, BSN, MSc1, Gail Low, RN, BSN, MA, PhD2,
and Lucila Amaral Carneiro Vianna, PhD1

Abstract
Objective: This study examined the effect of Positive and Negative Spiritual and Religious Coping (SRC) upon older
Brazilian’s quality of life (QOL). Method: A secondary analysis of data collected from 77 nursing home residents
(NHRs; M age = 76.56) and 326 community-dwelling residents (CDRs; M age = 67.22 years) was conducted.
Participants had completed the Brief SRC, and the World Health Organization Quality of Life-BREF (WHOQOL-
BREF) and World Health Organization Quality of Life-OLD (WHOQOL-OLD). A General Linear Model regression
analysis was undertaken to assess the effects of SRC upon 10 aspects of participants’ QOL. Results: Positive (F = 6.714,
df = 10, p < .001) as opposed to Negative (F = 1.194, df = 10, p = .294) SRC was significantly associated with QOL.
Positive SRC was more strongly associated with NHR’s physical, psychological, and environmental QOL, and their
perceived sensory abilities, autonomy, and opportunities for intimacy. Conclusion: Positive SRC behaviors per se
were significantly associated with QOL ratings across both study samples. The effect size of Positive SRC was much
larger among NHRs across six aspects of QOL. Place of residence (POR) in relation to SRC and QOL in older age
warrants further study.

Keywords
quality of life, spirituality, religious coping, older adults, place of residence

Manuscript received: April 22, 2016; final revision received: May 31, 2016; accepted: June 10, 2016

Introduction SRC can manifest as a reappraising of God’s powers and

believing that God is punitive (Pargament et al., 2011).
Spirituality pertains to seeking meaning in life, and con- SRC is an important area of study in older age as aging
necting with a higher power or supreme-being and nature is associated with multiple physical and social losses
(Koenig, King, & Carson, 2012). “Spirituality is the aspect (Pargament, Koenig, Tarakeshwar, & Hahn, 2004). People
of humanity that refers to the way individuals seek and typically experience declines in physical functioning and
express meaning and purpose and the way they experience chronic illnesses with age (Prince et al., 2015). There are a
their connectedness to the moment, to self, to others, to growing number of studies indicating that Positive SRC
nature, and to the significant or sacred” (Puchalski et al., has health-related benefits in older age (Pargament et al.,
2009, p. 887). These attributions reflect spiritual behaviors 2004; Scandrett & Mitchell, 2009; Vitorino & Vianna,
and beliefs (Koenig, George, & Titus, 2004). Spiritual 2012). Older people also experience losses of significant
beliefs are highly personal values that become increas- others with age (Prince et al., 2015). SRC is an essential
ingly important with age (Koenig et al., 2004). Religious component of facing age-related physical and social losses
doctrines or texts prescribe how people ought to live out (Pargament et al., 2011; Pargament et al., 2000). When
their lives and treat others (Parker et al., 2003). Spiritual older people face physical and social adversities, they are
and Religious Coping (SRC) is use of spirituality and reli-
gious behaviors to overcome problems and stressful life 1
Paulista School of Nursing, Federal University of São Paulo, Brazil
events (Pargament, Feuille, & Burdzy, 2011; Pargament, 2
University of Alberta, Edmonton, Alberta, Canada
Koenig, & Perez, 2000). Nonetheless, SRC can be posi-
Corresponding Author:
tive and negative. Examples of positive SRC are solving Luciano Magalhães Vitorino, Olegário Maciel Av. Itajubá, Minas
one’s problems in collaboration with God, and searching Gerais 37504, Brazil.
for help and comfort in the religious literature. Negative Emails: [email protected]

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2 Gerontology & Geriatric Medicine

more likely than are younger people to rely on SRC Research Question 2: When Positive and Negative
(Koenig, 2012; Lucchetti, Lucchetti, Peres, Moreira- SRC affects the same aspects of QOL, are SRC effect
Almeida, & Koenig, 2012; Pargament et al., 2011). sizes the same or significantly different?
Spiritual and religious beliefs are important compo-
nents of quality of life (QOL) at any age (Lee, Nezu, &
Method
Nezu, 2014; Skevington, Gunson, & O’Connell, 2013;
Vitorino et al., 2015). Positive SRC has enhanced the Design and Participants
overall QOL of community-dwelling adults of all ages
with dementia (Agli, Bailly, & Ferrand, 2015). Adults The study is a secondary analysis of cross-sectional sur-
with schizophrenia who use more positive than negative vey data. Data were collected from NHRs in two geo-
SRC report better psychological QOL (Nolan et al., graphic regions between June and July 2010 (Vitorino &
2012). Adults with the human immunodeficiency virus Vianna, 2012). Nursing homes were not under any par-
who use negative SRC report major depressive symp- ticular religious ownership, and religious practices were
toms and impairments in QOL (Lee et al., 2014). not a criterion for admission. Inclusion criteria were
Otherwise religious coping has enhanced QOL among being 60 and older, and a 6-month residency. The exclu-
older Muslims in terms of their mental health and social sion criterion was having significant cognitive impair-
functioning (Heydari-Fard, Bagheri-Nesami, Shirvani, ment. Registered Nurses identified 77 potential
& Mohammadpour, 2014). As people age, where they participants who met the participation criteria. All 77
live becomes an especially important aspect of QOL consented to participate. Data were collected from the
(Power, Quinn, Schmidt, & WHOQOL Group, 2005; randomly selected CDRs within the same two geo-
Skevington et al., 2013). Studies of the QOL benefits of graphic regions between September 2013 and March
SRC among nursing home residents (NHRs) are lacking 2014. Inclusion criteria were being 60 and older, and a
(Vitorino et al., 2015). There are also no published stud- household resident. The exclusion criterion was having
ies comparing the effects of SRC upon the QOL of a Mini Mental State Examination score of <13 with no
NHRs and community-dwelling residents (CDRs). formal education, <18 with 1 to 8 years of education,
Brazil is a top-five country for numbers of older and <26 with 9 or more years of education (Brucki,
adults, particularly those 80 and older (United Nations, Nitrini, Caramelli, Bertocci, & Okamoto, 2003). Of the
Department of Economic and Social Affairs, Population 452 CDRs who were approached, 326 met the participa-
Division, 2013). In 1940, people 60 and older repre- tion criteria and consented to participate.
sented 4.1% (1.7 million) of the general population. In
2013, this proportion reached 13% (26.19 million), Measures
among which 3.2 million were 80+ years of age (United
Nations, Department of Economic and Social Affairs, The following instruments were used for data collection:
Population Division, 2013). Brazilians of all ages have
a strong faith in God and see themselves as spiritual •• Demographic data were collected: age (Pargament
beings (Neri, 2011). Among those 60+ years of age, et al., 2004; Vitorino & Vianna, 2012), gender,
nearly all (96%) consider religion a very important education, and marital status (Pargament et al.,
aspect of everyday life (Neri, 2011). Little is known 2011; Vitorino et al., 2015), having a religion
about how SRC affects older Brazilians’ QOL. Spiritual, (Power et al., 2005), propensities for leisure and
religious, and personal beliefs have improved the QOL physical activities (Sun, Norman, & While,
of well and ill persons below 60 years of age who were 2013), and comorbidities and perceived health
living in their own home (Parker et al., 2003). Aspects (Power et al., 2005; Vitorino & Vianna, 2012).
of QOL were psychological, social, environmental, and •• SRC was assessed using the Brief SRC scale
global. Positive SRC has also enhanced NHR’s auton- (Panzini & Bandeira, 2005). Positive SRC subdi-
omy, opportunities for intimacy, and fears about death mensions are as follows: Transformation of Self,
and dying (Vitorino et al., 2015). Spiritual Help, Helping Another Person, Positive
Position Before God, Other Institutional,
Distancing Through God, and Spiritual
Aim of This Study Knowledge. Negative subdimensions are as fol-
The aim of this Brazilian study was to compare the lows: Negative Revaluation of God, Negative
effects of Positive and Negative SRC upon the QOL of Position Before God, and Dissatisfaction and
older CDRs and NHRs. Our study is the first study to Reassessment of Meaning. All items are mea-
focus on the role of place of residence (POR). Our sured on a 5-point Likert-type scale ranging from
research questions were as follows: 1 (not at all) to 5 (very much; Panzini & Bandeira,
2005). Positive SRC Cronbach’s alpha coeffi-
Research Question 1: Would Positive and Negative cients for CDRs and NHRs were α = .809 and α =
SRC significantly affect the same or different aspects .952 and, respectively. Negative SRC coefficients
of QOL among CDRs and NHRs? were α = .785 and α = .671, respectively.
Vitorino et al. 3

•• QOL was assessed using the Brazilian version of significantly enhanced the very same aspects of QOL
the WHOQOL-BREF ( Fleck et al., 2000; across both study samples. All observed effect sizes
WHOQOL Group, 1998) and WHOQOL-OLD were significantly larger among NHRs.
(Fleck, Chachamovich, & Trentini, 2006; Power In this study, Positive SRC was significantly posi-
et al., 2005). Cronbach’s alpha coefficients for tively associated with physical QOL across both study
CDRs and NHRs, respectively, were as follows: samples that corroborates others’ findings on physical
Physical Health (α = .730; α = .859), Psychological health and SRC (Pargament et al, 2011; Parker et al.,
(α = .706; α = .750), Social Relationships (α = 2003; Sturz & Zografos, 2014; Vitorino et al., 2015).
.723; α = .724), and Environment (α = .635; α = Spirituality and religion have been found to buffer older
.776). For the WHOQOL-OLD (Power et al., adults’ health-related stress (Pargament et al., 2004).
2005), these were as follows: Sensory Abilities (α Older adults engaging in positive SRC usually see them-
= .624; α = .852); Autonomy (α = .702; α = .811); selves as physically healthy (Vitorino & Vianna, 2012)
Past, Present, and Future (α = .740; α = .762); and have a lower risk of physical illness and disability
Social Participation (α = .726; α = .845); Death (Parker et al., 2003). Positive SRC can also simultane-
and Dying (α = .730; α = .712); and Intimacy (α = ously enhance physical health and QOL (Vitorino et al.,
.725; α = .863). All WHOQOL ratings are based 2015). Positive SRC is an important coping strategy for
on assessments over the past 2 weeks and scored older adults with physical illnesses (Heydari-Fard et al.,
on a 5-point Likert-type scale. 2014; Pargament, 2011; Pargament et al., 2004). Positive
SRC helps older people better adhere to prescribed med-
ical treatments (Koenig et al., 2004). Spiritual and reli-
Statistical Analysis
gious behavior help older people manage physical
Absolute and relative frequency counts, means, and illnesses (Koenig, 2012; Koenig et al., 2004; Pargament
standard deviations were used to describe the sociode- et al., 2004) through, for example, encouraging healthier
mographic characteristics, and WHOQOL-BREF lifestyles and promoting longevity (Koenig, 2012). For
domains and WHOQOL-OLD facets among the CDR NHRs, Positive SRC carried more weight for physical
and NHR study samples. In the multivariate analysis, a QOL. NHRs tend to be older and more physically or
General Linear Model (GLM; A. Taylor, 2011) was used mentally frail than CDRs, and less able to care for them-
to compare the effects of Positive and Negative SRC selves (Europe Union, 2012; Gilleard & Higgs, 2010;
upon the QOL of CDRs and NHRs. Sociodemographic Turcotte & Sawaya, 2015). Nursing home admissions
characteristics were entered into the GLM as covariates; have been likened to an “event horizon” marked by
doing so permits covariate-adjusted mean scores for the advanced age and the lesser ability or inability to act on
WHOQOL-BREF and WHOQOL-OLD. In the GLM, one’s own behalf (Gilleard & Higgs, 2010). NHRs
Positive and Negative SRC was also permitted to inter- required around-the-clock assistance from health care
act with POR. providers and were, on average, 10 years older and a far
larger proportion reported being in poor health than did
CDRs. Being able to engage in limited or no physical
Results
activity, and functional disability with feeding, bathing,
Table 1 shows the sociodemographic characteristics of dressing, toileting, continence, and transferring are very
CDR and NHR participants. In the multivariate GLM, strong predictors of long-stay institutionalization in
Positive SRC × POR (F = 6.714, df = 10, p < .001) had Brazil (Del Duca, Silva, Thumé, Santos, & Hallal,
a significant effect upon QOL. Negative SRC × POR did 2012). Ironically NHRs physical QOL ratings were sig-
not (F = 1.204, df = 10, p = .288). Positive SRC had nificantly higher among NHRs. These higher ratings
significantly greater associations with six aspects of may be due to the continuous provision of care by health
NHRs’ QOL (see Table 2). Covariate-adjusted mean care professionals (HCPs). Surrendering the overseeing
scores for the WHOQOL-BREF and WHOQOL-OLD of day-to-day care to long-term care professionals can
are reported in Table 3. bring a sense of relief to older people in physically frail
circumstances (Golant, 2014). Positive SRC further
enhanced NHRs higher ratings. Positive SRC is most
Discussion beneficial to people in physically fragile (or in our case
The aim of this Brazilian study was to compare the wholly dependent) circumstances (Pargament et al.,,
effects of Positive and Negative SRC upon the QOL of 2011; Pargament et al., 2000). Spiritual beliefs per se
CDRs and NHRs. Our study is the first study to focus on have also moderated the effects of physical, mental,
the role of POR. We investigated whether SRC would nutritional, and sensory frailty upon the psychological
significantly affect the same or different aspects of QOL well-being of older adults in partial-assistance housing
among CDRs and NHRs. Moreover, when the same estates (Kirby, Coleman, & Daley, 2004).
QOL aspects are affected, are the observed SRC effect Positive SRC was significantly associated in psy-
sizes the same or significantly different? Positive SRC chological QOL across both study samples. Older age
4 Gerontology & Geriatric Medicine

Table 1. Participant Characteristics (N = 403).

Total sample Community Nursing home

Variables n (%) n (%) n (%)

Age (M ± SD) 69.01 ± 7.03 67.22 ± 4.84 76.56 ± 9.46
Gender
Male 142 (35.2) 104 (31.9) 38 (49.4)
Female 261 (64.8) 222 (68.1) 39 (50.6)
Education
No education 117(29.04) 77 (23.6) 40 (51.9)
Has education 286 (70.96) 249 (76.4) 37 (48.1)
Marital status
Never/divorced 232 (57.56) 158 (48.5) 74 (96.1)
Married 171 (42.44) 168 (51.5) 3 (3.9)
Has adult children
Yes 337 (83.6) 298 (73.9) 39 (50.6)
No 143 (16.4) 105 (26.1) 38 (49.4)
Religion
Yes 294 (73.10) 222 (68.1) 73 (94.8)
No 109 (26.90) 104 (31.9) 4 (5.2)
Leisure practices
Yes 210 (52.10) 173 (53.1) 37 (48.1)
No 193 (47.90) 153 (46.9) 40 (51.9)
Physical activity
Yes 187 (46.40) 167 (51.2) 20 (26.0)
No 216 (53.60) 159 (48.8) 57 (74.0)
Chronically ill
Yes 261 (64.80) 204 (62.6) 57 (74.0)
No 142 (35.20) 122 (37.4) 20 (26.0)
Perceived health
Very good 108 (26.8) 74 (22.7) 34 (44.2)
Good 262 (65.0) 236 (72.4) 26 (33.8)
Poor 33 (8.2) 16 (4.9) 17 (22.1)

Table 2. Effect of Positive SRC × Place of Residencea Upon Quality of Life (N = 403).

Quality of life F β (SE), p value

WHOQOL-BREF
Physical health 31.078 1.86 (.334), <.001
Psychological 17.655 1.58 (.376), <.001
Social relationships 0.907 −0.549 (.576), .343
Environment 24.752 1.695 (.341), <.001
WHOQOL-OLD
Sensory abilities 19.944 0.441 (.099), <.001
Autonomy 9.714 1.341 (.430), <.01
Past, present, future 1.497 0.499 (.408), .224
Social participation 2.967 0.802 (.465), .086
Death and dying 3.669 0.957 (.500), .057
Intimacy 8.204 1.283 (.448), <.01

Note. Covariates: age, gender, education, marital status, perceived health, and having adult children and a religion, being physically active.
SRC = Spiritual and Religious Coping.
a
Community-dwelling resident = 0; nursing home resident = 1.

is considered a period of life that evokes negativity, owing to ill health, institutionalization, and economic
loneliness, anxiety, and depression (Lucchetti et al., hardships (Prince et al., 2015; World Health
2012; World Health Organization, 2013). There can be Organization, 2013). The association between Positive
losses in their independence and autonomy largely SRC and psychological QOL was more pronounced
Vitorino et al. 5

Table 3. Mean Scores for the WHOQOL-BREF and WHOQOL-OLDa (N = 403).

Nursing home (n = 77); Own home (n = 326); Mean difference (SD);

Quality of life M ± SD M ± SD p value
WHOQOL-BREF
Physical health 16.97 ± 0.933 13.33 ± 0.17 3.64 (0.96), <.001
Psychological 17.34 ± 0.938 13.26 ± 0.18 4.08 (0.96), <.001
Social relationships 17.46 ± 1.354 15.36 ± 0.26 2.1 (1.39), .132
Environment 17.41 ± 0.833 13.54 ± 0.16 3.87 (0.85), <.001
WHOQOL-OLD
Sensory abilities 15.82 ± 0.36 14.16 ± 0.15 1.66 (0.42), <.001
Autonomy 12.88 ± 0.37 14.58 ± 0.15 −1.70 (0.43), <.001
PPFA 13.61 ± 0.34 14.62 ± 0.14 −1.01 (0.40), <.05
Social participation 13.34 ± 0.39 14.55 ± 1.5 −1.21 (0.45), <.01
Death and dying 15.27 ± 0.41 14.58 ± 0.17 0.69 (0.49), .152
Intimacy 13.31 ± 0.38 14.69 ± 0.15 −1.37 (0.44), <.01

Note. PPFA = past, present, and future activities.

a
Adjusted for participants’ age, gender, education, marital status, perceived health, having adult children and a religion, and being physically
active.

among NHRs. This domain of life refers to accepting and being with familiar people. Upon admission,
bodily appearance, self-satisfaction, life enjoyment, there are acute changes in daily life marked by new
memory and concentration, negative feelings such as routines, rules, and schedules that are less flexible
anxiety and depression, and meaning in life. One third and quite different; this can enhance environmental
of older Brazilian CDRs (Del Duca et al., 2012) and dissatisfaction and difficulty adapting (R. J. Taylor,
49% of NHRs experience depression (Silva, Sousa, Chatters, & Jackson, 2007; Vitorino & Vianna, 2012).
Ferreira, & Peixoto, 2012). Positive SRC can protect Older people tend to experience significant decre-
against social isolation, depression, and anxiety ments as opposed to increments in QOL when they
(Pargament, 2011; Pargament et al., 2004). Positive move into a nursing home (Kostka & Jachimowicz,
SRC enhances older adults’ understanding of the mean- 2010). The average length of residency of NHRs was
ing and significance of limitations and losses, and find 9.3 years (Vitorino & Vianna, 2012). Presumably,
meaning and purpose in life (Koenig, 2012; Pargament, NHRs had time to adjust and adapt. NHRs’ environ-
2011). Religious practices can improve mental health mental QOL scores were, on average, higher than
in older age (Koenig, 2012; Lucchetti et al., 2012). CDRs’ scores. Nonetheless, the very wide (6 months
Religiosity and spirituality is an effective treatment for to 42 years) range for duration of residence makes the
depression and anxiety in older age (Koenig et al., markedly larger effect size of POR × Positive SRC
2012; Lucchetti et al., 2012). Nonetheless, NHRs did more provocative. Positive SRC enhances psycholog-
have far higher psychological QOL scores to begin ically adjusting to living in an institution in older age
with. The majority of older Brazilians move into nurs- (Scandrett & Mitchell, 2009). Religious coping has
ing homes because family members become physically helped older Americans (Scandrett & Mitchell, 2009)
and mentally exhausted, and they cannot afford not to and Brazilians (Vitorino et al., 2015) accept living in
work, and the level and complexity of care becomes an institution.
unmanageable (Del Duca et al., 2012; Silva et al., Golant (2014) also argues that what is most beneficial
2012). Less than 1% of older Brazilians live in nursing to QOL are physical, functional, and participatory fea-
homes ( Institute for Applied Economic Research tures or structures residents have everyday access to.
–IPEA, 2011). Surrendering decisions around day-to- Everyday access evokes a shared culture of trust and
day care to family can be a source of emotional relief sense of community, and opportunities for meaningful
for NHRs (Golant, 2014). action. NHRs had access to a chapel and 95% had a reli-
Positive SRC was associated with environmental gion (vs. only 68.1% of CDRs). Spiritual environments
QOL across both study samples; however, its effect allow NHRs access to continue to engage with their faith
size was far larger among NHRs. Environmental QOL community and empowerment in a more restrictive living
pertains to money to meet one’s needs, access to environment (Anabere & DeLilly, 2013; Tschida, 2012).
information and transport, personal safety, healthful- Other resources for NHRs included around-the-clock
ness and quality of a dwelling, and health care ser- HCPs, security doors for physical safety, hosted leisure
vices. Radical and permanent changes in living activities, and meal preparation. Ready-driven cars for
environments in older age evokes feelings of what professional appointments are also available for NHRs.
Atchley (1989) refers to as discontinuity in being and Horelli (2006) describes these features or structures as a
doing in familiar places, practicing familiar skills, means to provide collective fit for locally dependent
6 Gerontology & Geriatric Medicine

groups. The fit between the person and their environ- relative or have a television in their living quarters.
ment means considering QOL in terms of residential sat- Main meals, that is, lunch, also occur at set times. This
isfaction; the environmental conditions should not lends credence to our finding that autonomy scores
impede what the resident considers essential or needs were significantly lower among NHRs. Presumably
for their well-being (Moser et al., 2009). This would be CDRs do not face the same constraints on their day-to-
particularly important when families cannot manage day freedom. Positive SRC behaviors are not a panacea
elder care, physically or financially, as is the case for for not being free to do what one likes at one’s own
NHRs in Brazil (Del Duca et al., 2012; Instituto Pesquisa convenience. Positive SRC behaviors may have helped
Economica Aplicada, 2011). NHRs accept that choosing to engage in activities of
Despite sensory abilities being deemed a key aspect interest also meant asking others’ permission to do so.
for QOL in older age across 20 countries (Power et al., Positive SRC engaged the NHRs to participate in their
2005), our study is the first study to link Positive SRC choices. Religious and spiritual practices bring a
with sensory abilities in older age. Positive SRC had a heightened sense of effectiveness, credibility, and dig-
stronger positive association with NHR’s sensory abili- nity in older age (Pargament et al., 2000). Religiosity
ties. NHRs also more favorably appraised how sensory has improved older people’s decisiveness around seek-
losses affected participation in activities, social inter- ing out meaningful and satisfying activities (Low &
actions, and general sensory functioning (hearing, Molzahn, 2007; Sturz & Zografos, 2014). Perhaps this
touch, taste, smell, sight). These higher scores may be is why Positive SRC was most strongly associated with
explained by having continuous access to HCPs that NHRs’ autonomy.
offer compensatory supports through sensory aides, Positive SRC enhanced the QOL of both groups with
group activities, and palatable food. There is some evi- respect to opportunities for intimacy. As people age,
dence indicating that religious practices improve peo- they tend to invest more energy into close and meaning-
ple’s compliance with health-promoting treatments and ful relationships (Carstensen, Fung, & Charles, 2009).
activities (United Nations, Department of Economic Engaging in positive SRC with significant others rein-
and Social Affairs, Population Division, 2013). Positive forces older people’s sense of fellowship and belonging
SRC could have done the same for NHRs. Spirituality (Pargament et al., 2011). Spirituality and religiousness
can reduce the negative effects of frailty, including are an especially significant and meaningful source of
sensory problems, upon psychological well-being support for older people (Atchley, 1989). Religious prac-
(Sturz & Zografos, 2014). tices such as going to a place of worship can provide sig-
Autonomy has been defined by others as an enhancer nificant opportunities for meaningful social interaction
of dignity and of perceptions of still being able to exer- in older age (Agli et al., 2015). For NHRs, opportunities
cise one’s mental capacities in older age (Kirby et al., for socialization are limited; thus, close and meaningful
2004). Religious and spiritual practices have enhanced connections become especially important (Anabere &
the sense of effectiveness, credibility, and dignity DeLilly, 2013; Andresen & Puggaard, 2008). In this
among older people (Lucchetti et al., 2012; Pargament study, NHRs had significantly lower intimacy (opportu-
et al., 2011; Scandrett & Mitchell, 2009). Religious nities to show love and to feel loved) scores than did
and faith practices improve feelings of control in CDRs. The vast majority of NHRs had either never been
everyday life (Heydari-Fard et al., 2014; Lucchetti married or were divorced, and only half had adult chil-
et al., 2012). Positive SRC has been associated with dren. However, neither marital status nor having adult
hope and optimism, and the ability to plan one’s life in children significantly affected NHRs intimacy scores.
older age (Pargament et al., 2004). Autonomy enhances There is still some degree of stigma for family when they
older people’s dignity and perceptions of still being institutionalize a parent as NHs are associated with lone-
able to exercise their mental capacities (Andresen & liness, contempt, and abandonment in Brazilian society
Puggaard, 2008). (Freitas & Noronha, 2010). Fortunately, positive SRC
Positive SRC per se also had a stronger positive was most strongly associated with NHRs scores and they
association with NHRs’ autonomy. Autonomy as it per- had an accessible place of worship (churches and cha-
tained to QOL had to do being able to do what one pels) where they could practice positive SRC. Lawton
likes, making decisions on one’s own part, and having (1991) deems the tendency among frail to find ways to
people around who respect one’s freedom. Living in a enhance relational aspects of their QOL in the immediate
nursing home can limit one’s autonomy and perceived surrounding environment. Having a relationship with
control (Scandrett & Mitchell, 2009). For example, in God and nurturing this relationship through Positive
the NHs where we recruited participants, there were SRC was a more important way to experience intimacy
ready-driven cars for professional appointments but for NHRs. Positive SRC partly pertained to having a
NHRs needed permission from managers to leave their partnership with, trusting and turning over one’s trou-
POR at any time. NHRs also had to ask NH staff if they bles to God. There was a significant relationship between
were able to go for a walk outside of their POR with a a higher power and NHRs.
Vitorino et al. 7

The present study has some weaknesses. Our find- Human and Animal Rights and Informed
ings are findings of association based on cross-sectional Consent
data. There were also significantly fewer NHRs than All procedures followed were in accordance with the ethical
CDRs in our study. Less than 1% of older people reside standards of the responsible committee on human experimen-
in NHs in Brazil ( Institute for Applied Economic tation (institutional and national) with the Helsinki Declaration
Research – IPEA, 2011). This tiny proportion also meant of 1975, as revised in 2000. Informed consent was obtained
recruiting NHRs by convenience. Our use of secondary from all participants for being included in the study. Ethical
data did not permit us to explain why only 68% CDRs approval was given by Federal University of São Paulo
reported having a religion despite 96% of Brazilians Committee for Ethics in Research (#16176513.6.0000.5505).
reporting that religion is an important aspect of life.
Positive SRC was not significantly associated with par- Declaration of Conflicting Interests
ticipants’ social relationships and social participation. In The authors declared no potential conflicts of interest with respect
non-Brazilian studies, older adult’s religious behaviors to the research, authorship, and/or publication of this article.
(attendance, temple meetings, group meditation/prayer)
have enhanced their social participation with peer Funding
groups (Charlemagne-Badal & Lee, 2016; Koenig et al., The authors disclosed receipt of the following financial sup-
2014; Krause, Shaw, & Liang, 2011; Pargament et al., port for the research, authorship, and/or publication of this
2000). The positive link between Positive religious cop- article: The study was funded by Brazilian Federal Agency for
ing and older Muslim’s social functioning was attributed Support and Evaluation of Graduate Education; National
to the valuing of communicating and engaging in activi- Counsel of Technological and Scientific Development; São
ties with social ties in Islamic culture and religion Paulo Research Foundation, Process Number:231370/2013-0.
(Heydari-Fard et al., 2014). Our study focuses on spiri-
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