Correlation between spirituality, religiosity and quality of life of adolescents

This study consists in an integrative review of the literature, conducted through electronic search in Lilacs, PubMed, Scopus and Web of Science databases. Articles published in the last five years (2012-2017), were selected, primary, available in full, in English, Portuguese or Spanish. The following descriptors were used: Spirituality, religion, quality of life and adolescence, which have been combined with their respective synonyms. A total of 10 articles were included, from which three thematic categories emerged: 1) Favoring and strengthening spirituality and/or religiosity in adolescents; 2) Repercussions of spirituality and/or religiosity referring to the situational confrontation; and 3) Influence of spirituality and/or religiosity in the quality of life of adolescents. There was consensus among the authors studied that there is a strong correlation between religiosity and / or spirituality in the quality of life of adolescents.

Quality of life can be defined as the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns 1 . It is directly related to physical health, psychological state, social relations, personal beliefs and the interaction of the individual with the environment, being therefore in this context, an indicator of health 2 . It is also directly linked to spiritual well-being. In this way, the daily involvement of the person in this sphere tends to improve their well-being and health 3 .
Spirituality refers to the awareness that there is something sacred, based on particular values and concepts of each individual. Religion is a collectively developed activity, encompassing a system of defined or preestablished beliefs, dogmas, and practices 4 . The benefits of developing these spheres of human life, as already pointed out by various publications, include increased sense of well-being, optimism, better situational coping, depression and stress reduction. In addition, they bring more meaning to the individual's life, making it more peaceful and comfortable [5][6][7][8][9][10] .
Adolescence is defined as a phase of growth and development, characterized by intense physical, mental and especially psychosocial transformations 11 . Adolescents usually have difficulties or limitations regarding the interaction and development of issues related to religiosity and spirituality 12 . At the confluence of these concepts and perspectives, the following question arises: do more spiritualized adolescents or more religionlinked adolescents have a better perception of their quality of life?
Using the integrative review method, the objective of this research was to identify and analyze the evidence in the literature regarding the correlation between these two factors and the perception of well-being of adolescents.

Methods
The integrative literature review allows us to approach several types of studies, admitting a broad analysis of the subject matter and the synthesis of the knowledge produced 13 . In order to elaborate this review, the following steps were considered: development of the guiding question "is there a correlation between spirituality and religiosity with adolescents' quality of life?"; search for primary studies in databases; extraction of study data; evaluation of selected research; analysis and synthesis of the results and presentation of the review 14 .
Primary papers, available in full, in English, Spanish or Portuguese, published in the last five years (2012-2017), were included. Non-primary studies were excluded, considering those of opinion and revisions, and those that, after full reading, did not respond to the guiding question. The Literatura Latino-Americana e do Caribe em Ciência da Saúde -LILACS (Latin American and Caribbean Literature in Health Sciences), the US National Library of Medicine (PubMed), Scopus and the Web of Science databases were queried with the descriptors "spirituality"; "Religion", "quality of life" and "adolescent", in English and Portuguese. Both these terms and their synonyms were combined.
The process of identification, selection and inclusion of the studies took place in three stages. In the first one, the search was made through the descriptors and their synonyms in the databases. Articles were initially selected by careful reading of titles and abstracts, including those that met the inclusion criteria. For the final choice, articles were read in their entirety. The following variables were used to collect, systematize and analyze the data: article title, authors, year of publication, method, country of origin, level of evidence, degree of recommendation and database. After these steps, the content of the articles was classified in thematic categories.
The method used to evaluate the quality of the evidence was Oxford, being classified in 1a, 1b, 1c, 2a, 2b, 2c, 3a, 3b, 4 and 5. This methodology allows to classify the studies in degree of recommendation, including " A "," B "," C "and" D ", where: "A" corresponds to good evidence to support the recommendation; "B": there is reasonable evidence to support the recommendation; "C" insufficient evidence, against or in favor; and "D" means that there are indications to discard it 15 . The search for articles was conducted in May 2017, by two independent evaluators, concurrently. In cases in which there was no consensus, a third evaluator was consulted.

Results
Initially, 39 studies were selected from the database query. After the titles and abstracts were read, 14 articles were selected. Of these, three were excluded because they were found in more than one database. Thus, 11 articles were chosen for reading in full. Of these, 10 composed the final sample ( Figure 1).  Of the articles that were part of the final sample, the oldest had been published in 2012 and the most recent in 2016. All were in English and available in international databases. Regarding the origin, those developed in the United States (USA) prevailed, accounting for 60% of the total. Regarding the design of the studies, the transversal ones with evidence level 2c (60%) and degree of recommendation B (60%) prevailed. (Table 1).  Based on the analysis of the studies selected, three thematic areas were established: 1) favoring and strengthening spirituality and religiosity among adolescents; 2) repercussions of spirituality and religiosity regarding situational confrontation; and 3) influence of spirituality and religiosity on the quality of life of adolescents ( Figure 2).

Strengthening of spirituality and religiosity
Spirituality and religiosity are among the most important cultural factors, since they give meaning to life and are an especially useful mechanism for coping with chronic diseases 20 .
Research carried out with 45 HIVpositive adolescents demonstrated that talking about spirituality and religiosity was a way of strengthening in the fight against the disease. HIV negative participants also believed that, if infected, they would consider it important for their fight against the disease to talk about these issues 17 .
Most patients said they would like physicians to ask about their spiritual beliefs in the following situations: when they were diagnosed with a serious illness; when they were suffering from long-term illness, when they were recovering from serious illness and when they were possibly dying. The reasons why they wished to discuss spiritual matters related to their desire for physicians to understand them better, favoring treatment 17 .
The desire to talk and expose ideas stems from physical maturation, intellectual development, and identity-building. Adolescence is a period of growth and change in which young people are establishing their own belief systems, while still being influenced by their parents, either accepting or challenging their opinions 17 . Therefore, spiritual development is part of the maturation of children in the transition to adolescence and adult life. Becker, Maestri and Bobato 21 also point out the responsibility of the family in the evolution of the spiritual health of the young. After some time, the adolescent can progressively commit to this issue, although needing guidance to progress spiritually and participate in religious activities.
It follows that the family has great influence on the religious and spiritual formation of the adolescent. Research shows that parental beliefs and participation in religious ceremonies with the family contribute significantly to this topic, with consequent improvements in quality of life 9,22 . A longitudinal study on palliative care in this age group evidenced the fundamental role of the family in strengthening the coping ability of adolescents 16 .
A study with groups of students revealed that spiritual well-being is directly related to the sense of spirituality and participation in religious activities. The participation of adolescents in these activities stems from the influence of the parents, as well as from a positive view of the community, which motivates the student to take part and interact with the others 12 .
Several studies show that spirituality and religiosity are linked to the mental health of adolescents and young people. Some show that in this age group many seek help and counseling with psychologists, whether because of anxieties and concerns about the subject, or due to confusion of values, problematic relationships with peers, sexual concerns and thoughts of being punished for their own sins 23,24 .
In general, the studies considered that, in order to help adolescents to manage stress, reduce depressive symptoms and stimulate health promotion behaviors, educators and family members should be prepared to address their spiritual health 7 .

Spirituality and religiosity in situational coping
Several studies warn that these two points can help the situational coping when it refers to the health of the individual. The increase in spirituality and religiosity has been associated with favorable health outcomes 2,3,6 .
Research conducted with American adolescents pointed out that there is a strong belief in God among them and that faith is important in making decisions and making choices 6 . However, another study showed that regardless of religious affiliation, people with spiritual values have more resources to manage challenges, find meaning and purpose in their lives, which promotes their physical and psychological well-being 7 .
A research conducted with children and adolescents aged 5 to 18 and undergoing oncological treatment in two large pediatric medical centers in Los Angeles (USA) identified that spiritual and religious aspects, independently and combined, are associated with the best preparation of survivors for self-care, as well as helping them to maintain hope in this transition process and the connection with others. The research also associated quality of life with self-efficacy as a result of self-care activities 18 .
A survey that included HIV-positive adolescents and their families identified that the former had more difficulty than the latter to forgive the damage caused by the disease 6. This finding may reflect the spiritual struggle waged by adolescents to forgive or not the "other" who was the source of transmission. This inability to forgive is associated with depression and revolt, and may have implications even for the adherence to antiretroviral treatment. The researchers also recognized the importance of religious communities to address the HIV epidemic, as they can help adolescents individually and collectively to reduce behaviors linked to HIV transmission 6 .
Religiosity and spirituality can have different meanings, influencing attitudes, decisions and behaviors of adolescents, besides involving physical, mental, emotional and social aspects. With this, the adolescent can develop health-related behaviors because of these two elements that will function as factors of protection and health promotion 9 .
Another study with adolescents with HIV identified that, although religiosity plays an important role, reducing risk behaviors, giving support and being a coping mechanism, as well as generating hope and comfort, it can also increase spiritual distress. That is, the individual can think of the disease as punishment, which will lead to poor adherence to medication and worse results 17 .
However, other studies have demonstrated the positive relationship between spirituality and religiosity to face certain situations, demonstrating an important relationship with the decision not to consume alcohol and marijuana, for example, which, therefore, favors health in general 25,26 . Spiritual well-being and religious activity, including meditation, prayer, spiritual reading, as well as the participation of church meetings, are related to positive evaluations of the individual's health 12 . Thus, more spiritual or religious people suffer fewer physical problems recover faster and feel less stress during serious illness 26,27 .

Spirituality and religiosity in the quality of life
The studies analyzed indicate that these factors have a great influence on the issue addressed here. A study carried out with Chinese university students identified that their spiritual values and religious affiliation act on the perception about quality of life. On the other hand, it was found that, for them, more earthly matters, such as money and material goods, did not promote daily well-being. The work showed that, in their view, these values were more linked to influence in society, to gaining and preserving social status, to experiencing material pleasures than to ensuring one's overall well-being 7 .
Spiritual intelligence plays an important role in people's lives and health. Iranian university students questioned about this point and quality of life indicated that there is a positive and relevant relationship between both, that is, the more spiritualized the better the perception of wellbeing 8 . Another study confirmed that there is a positive relationship between quality of life and spiritual well-being in Iranian teenagers 2 .
A study among HIV-positive adolescents and their families found that well-being in daily life was also linked to higher spirituality 6 . Another study that explored religiosity and spirituality among young people in the same condition identified that quality of life was strongly linked to these two factors. In addition, it showed that participation in religious services provided social support and could be attributed to improved health and general well-being 19 .

Final considerations
Considering the individual aspects of the articles and the fact that they analyze different contexts, a consensus was observed that religiosity and spirituality directly influence the perception of quality of life in adolescents. By establishing meaning for existence and stimulating the shared experience of world beliefs and visions, strengthening social bonds and the sense of belonging, they become effective allies in the protection, promotion and recovery of health in situations of insecurity and anguish, as is commonly the case in adolescence and especially when one is living with severe illness in this age group.