Religiosity, spirituality, and self-esteem in adolescents with cleft lip and palate: a correlational study^*

ABSTRACT

Objective

To evaluate the correlation between religiosity, spirituality, and self-esteem in adolescents with uni- and bilateral cleft lip and palate.

Method

Correlational and cross-sectional study developed in a public and tertiary hospital in Brazil between July 2018 and February 2019. The sample comprised 100 adolescents divided into two groups: G1 (unilateral cleft, 50 participants) and G2 (bilateral cleft, 50 participants). For data collection, three instruments were used: Sociodemographic Questionnaire, DUREL Religion index, Rosenberg self-esteem scale. Statistical analysis was performed with the tests Chi-squared, Mann-Whitney, Pearson Correlation, and analysis of linear correlation strength, with a 5% significance level (p ≥ 0.05).

Results

Only organizational religiosity was higher in G1 when compared with G2 (p = 0.03). The overall self-esteem was satisfactory for both groups; however, there was no significant difference between them (p = 0.34). No correlation between religiosity and spirituality with self-esteem were identified for G1 and G2.

Conclusion

The adolescents with uni- or bilateral cleft lip and palate presented high levels of religiosity, spirituality, and self-esteem. However, no correlation between these variables was identified.

Religion; Spirituality; Self Concept; Adolescent; Cleft Lip; Cleft Palate

RESUMO

Objetivo

Avaliar a correlação entre religiosidade, espiritualidade e autoestima em adolescentes com fissura de lábio e palato, uni e bilateral.

Método

Estudo correlacional e transversal, desenvolvido em um hospital público e terciário brasileiro, entre julho de 2018 e fevereiro de 2019. A amostra constou de 100 adolescentes divididos em dois grupos, G1 (fissura unilateral, 50 participantes) e G2 (fissura bilateral, 50 participantes). Para a coleta de dados, foram utilizados três instrumentos: Questionário Sociodemográfico, a Escala de Religiosidade de Durel e a Escala de Autoestima de Rosenberg. Utilizaram-se para a análise estatística os Testes Qui-Quadrado, Mann-Whitney, Correlação de Pearson e a análise das forças de correlação linear, com nível de significância de 5% (p ≥ 0,05).

Resultados

Apenas a religiosidade organizacional foi maior no G1 em comparação com o G2 (p = 0,03). A autoestima geral foi satisfatória em ambos os grupos; contudo, não houve diferença significante entre eles (p = 0,34). Não foram evidenciadas correlações de religiosidade e espiritualidade com a autoestima nos G1 e G2.

Conclusão

Adolescentes com fissura de lábio e palato, uni ou bilateral, apresentaram elevados níveis de religiosidade, espiritualidade e autoestima. Porém, não se evidenciou correlação entre essas variáveis.

Religião; Espiritualidade; Autoimagem; Adolescente; Fenda Labial; Fissura Palatina

RESUMEN

Objetivo

Evaluar la correlación entre religiosidad, espiritualidad y autoestima en adolescentes con labio y paladar hendido unilateral y bilateral.

Método

Estudio correlacional y transversal desarrollado en un hospital público y terciario de Brasil entre julio de 2018 y febrero de 2019. La muestra consistió en 100 adolescentes divididos en dos grupos, G1 (fisura unilateral, 50 participantes) y G2 (fisura bilateral, 50 participantes). Para la recogida de datos se utilizaron tres instrumentos: Cuestionario sociodemográfico, Escala de Religiosidad DUREL y Escala de Autoestima de Rosenberg. Para el análisis estadístico se utilizaron los testes de Chi-cuadrado, Mann-Whitney, correlación de Pearson y el análisis de la fuerza de correlación lineal, con un nivel de significación del 5% (p ≥ 0,05).

Resultados

Sólo la religiosidad organizacional fue mayor en el G1 en comparación con el G2 (p = 0,03). La autoestima general fue satisfactoria en ambos grupos, pero no hubo diferencias significativas entre ellos (p = 0,34). No se evidenciaron correlaciones de religiosidad y espiritualidad con la autoestima en G1 y G2.

Conclusión

Los adolescentes con labio y paladar hendido unilateral o bilateral presentan elevados niveles de religiosidad, espiritualidad y autoestima. Sin embargo, no se evidenció una correlación entre estas variables.

Religión; Espiritualidad; Autoimagen; Adolescente; Labio Leporino; Fissura del Paladar

INTRODUCTION

Cleft lip and palate are predominant craniofacial malformations which may isolatedly or jointly affect lips, alveolar ridge, and palate. It has a multifactorial etiology and includes genetic and environmental factors. In Brazil, an incidence of one case for every 650 live births is assumed¹-².

Patients affected by cleft lip and/or palate may present functional problems (difficulty in the process chewing-deglutition-respiration, dental disorders, hearing, phonation, frequent otological disorders), aesthetic and psychosocial (distinct physical appearance, problems with communication and socialization) which may lead to social exclusion¹.

Initially, the problems are functional, including nutrition. Subsequently, mainly during adolescence, aesthetic and psychosocial problems are emphasized³-⁴. Adolescence comprises age 10 to 19, a phase in which individuals learn to manage feelings and extrafamilial relationships⁵.

Adolescents with cleft lip and/or palate and may be subject to prejudice and discrimination, which may result in low self-esteem, little social acceptance, and isolation. However, these behaviors depend on their life history, family relations, development of their rehabilitation process, and social and cultural standards⁶.

Adolescence is guided by many physiological and psychological transformations, which are influenced by self-esteem. Adolescents search for constant approval, both in the family context and in their social groups. In this phase, reflecting on self-esteem levels is utterly important, as is analyzing their thoughts and attitudes, since these influence directly their school performance and social circle⁷.

The concepts of self-image and self-esteem are commonly misunderstood. Self-image refers to the others’ image of an individual, whereas self-esteem denotes how individuals see themselves. Therefore, self-image leads to self-esteem, i.e., individuals with low self-image will consequently have a low self-esteem⁸.

Self-esteem in adolescents with malformation may be compromised, since social relations are filled with negative feelings, such as anxiety, fear, and shame. In this context, fighting or coping strategies are necessary. Among them, spirituality and/or religiosity are emphasized⁹.

Despite being commonly used as synonyms, the terms religiosity and spirituality have different definitions. Religiosity is related to the practice of a specific religion or doctrine, with their beliefs and adorations. On the other hand, spirituality refers to a broader human proportion, considering that which gives meaning to life and existence, and is not always related to religion¹⁰.

Studies suggest that individuals, including adolescents, with high levels of religiosity present lower indexes of drug consumption, safer sexual life, sensation of well-being, better confrontation of crises, lower likelihood of depression and anxiety, lower suicide rates, and lower risk of developing cardiovascular diseases¹¹-¹⁴.

Therefore, religion influences how individuals face situations of stress, suffering, and other problems in life, possibly providing them with beer acceptance, stability, and adaptation to hardships, generating peace, self-confidence, and a positive self-image, whereas spirituality, mainly in cases of people with some physical alteration, may lead to better confrontation in the rehabilitation process¹¹-¹⁴.

In this sense, a study which assessed the correlation of spirituality and religiosity with quality of life in adolescents with cleft lip and/or palate has shown that adolescents with more spirituality show a better perception of quality of life when compared with those with no cleft¹⁵.

As far as we know, up to this moment, there are no studies correlating religiosity and/or spirituality to self-esteem in adolescents, particularly in those with cleft lip and palate, reinforcing the importance of this study, whose approach is unprecedented.

Given this, the following questions have emerged: do adolescents with uni- or bilateral cleft lip and palate are more adept to religious practices or more spiritualized? How does self-esteem behave in adolescents with cleft lip and palate? Does the adolescent’s self-esteem differ according to their cleft classification (unilateral or bilateral lip and palate)? Is there a correlation between religiosity and/or spirituality in adolescents with uni- and bilateral cleft lip and palate?

The hypothesis was that adolescents with unilateral cleft lip and palate, less anatomically complex when compared to bilateral, would present higher levels of religiosity and spirituality, with a positive influence on self-esteem.

Considering the psychosocial vulnerability of adolescents with cleft lip and palate, as well as the benefits of spirituality and/or religiosity as a coping modality, determining its correlation may strengthen the use of these variables as health and well-being indicators.

Thus, the objective of this study was to assess the correlation between religiosity, spirituality, and self-esteem in adolescents with uni- and bilateral cleft lip and palate.

METHOD

DESIGN OF STUDY

Descriptive, correlational, cross-sectional, quantitative study developed in a public tertiary hospital specializing in care to patients with craniofacial anomalies and related syndromes. The institution has 91 beds, is maintained with resources of the Unified Health System, and is related to Universidade de São Paulo. It is nationally and internationally recognized for its interdisciplinary and humanized service in care, teaching, and research.

POPULATION

The population was composed of adolescents with cleft lip and palate. For comparison, two groups were formed based on cleft classification, with G1 comprising adolescents with unilateral cleft lip and palate and G2 by adolescents with bilateral cleft lip and palate.

SELECTION CRITERIA

The adolescents who were invited to participate were under outpatient care at the hospital. The inclusion criteria were being aged 10 to 19 and having been previously submitted to primary surgeries of cheiloplasty (lip correction) and palatoplasty (palate correction). Adolescents using psychiatric medications were excluded, as these alter perception.

SAMPLE DEFINITION

For sample calculation, a moderate correlation coefficient (0.4), 5% error, and 80% test power were used. Estimations suggested thus 47 participants in each group. Finally, 50 participants were assigned to each group, with a total sample of 100 adolescents.

DATA COLLECTION

Data collection was performed in a private environment, individually, from July 2018 to February 2019. Initially, the participants were informed of research objectives; those under 18 were provided with the Consent Form and their legal guardians were provided the Informed Consent Form. The Informed Consent Form was also provided to patients who were 18 or older. In addition, the data collection instruments were applied.

Three instruments were used: the Sociodemographic Questionnaire, the DUREL Religion Index, and the Rosenberg Self-esteem Scale – RSS¹⁶-¹⁷.

The Sociodemographic Questionnaire was used to characterize participants regarding the variables age, sex, education, civil/affective status, socioeconomic classification, religion, children, and employment bond.

The DUREL scale was used assess religiosity and spirituality. This instrument encompasses three dimensions of religiosity: organizational religiosity (OR), non-organizational religiosity (NOR), and intrinsic religiosity, or spirituality¹⁶. Thus, in this study, intrinsic religiosity was referred to as spirituality, in conformity with the literature¹⁵-¹⁶,¹⁸-¹⁹. The DUREL is emphasized to approach the main precepts of religiosity, which includes spirituality¹⁶,¹⁸,²⁰. Indeed, although religiosity and spirituality have distinct concepts, both are correlated and represent, thus, a construction²¹.

The OR refers to frequency at churches and/or temples with social interaction, with a score ranging from one to six. The NOR is independent of other people. It corresponds to an individual religious activity (worship, mediation, prayer) which has a one to six score. Spirituality assesses the behavior and influence that religion has in an individual’s life and its score ranges from three to fifteen. For calculating the instrument’s score, the three domains are recommended to be analyzed separately and not summed to a final score¹⁶.

The DUREL was translated and validated for the Brazilian population²⁰. In an investigation that used it for the adolescent population, Alpha Cronbach was 0.82, suggesting an appropriate internal consistency¹⁵.

The RSS was used to assess self-esteem, constituting a unidimensional, Likert type measure, whose score ranged from one to four. It comprises ten questions targeted at globally assessing the positive and negative attitudes of individuals towards themselves, six of which refer to a positive view, whereas four refer to a negative view. The score ranges from one (completely agree) to four (completely disagree), with a total score between 10 and 40. The higher the score, the higher the self-esteem level will be. A satisfactory self-esteem level has a score equal to or higher than 30¹⁷.

The data referring to sociodemographic characterization were obtained by consultation of a secondary data source, i.e., consultation to the medical records. Both the DUREL scale and RSS are self-applicable. The mean time for data collection was 30 minutes.

DATA ANALYSIS AND TREATMENT

To compare the groups for sociodemographic characteristics (sex, education, marital status, socioeconomic classification, religion, and employment bond), the Chi-squared test was used. In the comparison between the levels of religiosity and spirituality and self-esteem of the groups, the Mann-Whitney test was used. To correlate the measures of interest – religiosity, spirituality, and self-esteem – in both groups, Pearson Correlation test was applied. Also, the analysis of strength for linear correlation between the measures was used, which determines which correlation values under 0.30 indicate weak correlation, i.e., even if statistically significant, pose no clinical relevance; values from 0.30 to 0.50 show a moderate correlation and over 0.50 show a strong correlation²². A 5% significance level (p ≤ 0.05) was adopted for all tests.

ETHICAL ASPECTS

Data collection was started after approval by the Hospital’s Human Research Committee in Consolidated Opinion n. 2,739,764, dated 2018, and CAAE 87138618.3.0000.5441. Participants under 18 formalized their participation by signing the Consent Form, whereas their legal guardians signed the Informed Consent Form simultaneously. Participants 18 or older signed the Informed Consent Form, in agreement with Resolution No. 466/2012 by the National Health Council.

RESULTS

Study participants were 100 adolescents divided into two groups, G1 and G2, being G1 composed of 50 adolescents with unilateral cleft lip and palate and G2 by 50 adolescents with bilateral cleft lip and palate. In G1 the mean age was 15.5 years (SD = 2.7), whereas in G2 the mean was 14.6 years (SD = 2.5).

In G1, participants were predominantly male (n = 36; 72%), with incomplete secondary education (n = 20; 40%), single (n = 43; 86%), with high-low socioeconomic status (n = 33; 66%), protestant (n = 21; 42%), and with no employment bond (n = 39; 78%). In G2, participants were predominantly male (n = 34; 72%), with complete primary education (n = 28; 56%), single (n = 42; 84%), with high-low socioeconomic status (n = 35; 70%), catholic (n = 22; 44%) and with no employment bond (n = 42; 84%). No statistically significant differences were observed regarding sociodemographic characterization among groups, according to Table 1.

Table 1
– Distribution of participants according to the sociodemographic characteristics sex, education, marital status, socioeconomic status, religion, and employment bond – Bauru, SP, Brazil, 2019.

Variable		G1		G2		p-value
		N	%	N	%
Sex*	Male	36	72	34	68	0.82
	Female	14	28	16	32
Education*	Incomplete Higher Education	5	10	1	2	0.09
	Complete Secondary Education	6	12	2	4
	Incomplete Secondary Education	20	40	19	38
	Incomplete Primary Education	19	38	28	56
Marital/affective status*	Single	43	86	42	84	0.60
	Dating	7	14	7	14
	Married	-	-	1	2
Socioeconomic status*	Lower-low	9	18	8	16	0.77
	Higher-low	33	66	35	70
	Middle-low	7	14	7	14
	Middle	1	2	-	-
Religion*	Protestant	21	42	21	42	0.35
	Catholic	20	40	22	44
	Atheist/Agnostic/Irreligious	9	18	5	10
	Spiritist	-	-	2	4
Employment bond*	No	39	78	42	84	0.61
	Yes	11	22	8	16

• Note: (n = 100)
• * Chi-squared Test; 5% significance level (p ≤ 0.05)

Regarding OR, NOR, and spirituality, only OR was higher in G1 than G2 (p = 0.03) (Table 2). However, the median values were high in both groups for all studied variables, as shown in Table 2.

Table 2
– Participant distribution per levels of Organizational Religiosity (OR), Non-organizational Religiosity (NOR), and spirituality– Bauru, SP, Brazil, 2019.

Variable		N	Median	Q1§	Q3||	Mean	Standard deviation	p-value
Organizational Religiosity†	G1	50	2.0	1.0	4.0	2.5	1.8	0.03‡
	G2	50	3.0	2.0	4.0	3.0	1.6
Non-Organizational Religiosity†	G1	50	2.0	2.0	5.0	3.0	1.7	0.11
	G2	50	3.0	2.0	5.0	3.5	1.8
Spirituality†	G1	50	5.0	4.0	8.0	6.1	3.0	0.64
	G2	50	5.0	4.0	8.0	5.7	2.4

• Note: (n = 100)
• † Mann-Whitney Test; ‡5% significance level (p ≤ 0.05); §1st Quartile; || 3rd Quartile

Overall self-esteem was satisfactory in both groups (score of 32 in G1 and 30 in G2). However, there was no significant statistical difference, as shown in Table 3.

Table 3
– Distribution of participants per levels of Positive, Negative and Overall Self-esteem in G1 and G2– Bauru, SP, Brazil, 2019.

Variable		N	Median	Q1§	Q3||	Mean	Standard deviation	p-value
Positive self-esteem†	G1	50	17.0	15.0	18.0	16.3	2.3	0.18
	G2	50	15.5	13.8	18.0	15.5	2.8
Negative self-esteem†	G1	50	16.0	11.8	18.0	14.6	3.9	0.92
	G2	50	14.5	11.0	18.0	14.3	4.4
Overall self-esteem†	G1	50	32.0	27.0	35.0	31.1	5.3	0.34
	G2	50	30.0	24.8	35.0	29.7	6.5

• Note: (n = 100)
• † Mann-Whitney Test; 5% significance level (p ≤ 0.05); §1st Quartile; || 3rd Quartile

No correlations were shown between OR, NOR, and spirituality with self-esteem in G1 (Table 4).

Table 4
– Correlation between Organizational Religiosity, Non-Organizational Religiosity, Spirituality, and Self-esteem in patients with unilateral cleft lip and palate (G1) – Bauru, SP, Brazil, 2019.

Correlation variable	r	Correlation	p-value
Organizational Religiosity¶
Positive self-esteem	-0.12	Weak	0.39
Negative self-esteem	-0.10	Weak	0.48
Overall self-esteem	-0.12	Weak	0.39
Non-Organizational Religiosity¶
Positive self-esteem	-0.23	Weak	0.10
Negative self-esteem	-0.20	Weak	0.17
Overall self-esteem	-0.23	Weak	0.24
Spirituality¶
Positive self-esteem	-0.23	Weak	0.10
Negative self-esteem	-0.03	Weak	0.82
Overall self-esteem	-0.11	Weak	0.44

• Note: (n = 100)
• ¶ Pearson Correlation Test; 5% significance level (p ≤ 0.05)

No correlations were shown between OR, NOR, and spirituality with self-esteem in G2 (Table 5).

Table 5
– Correlation between Organizational Religiosity, Non-Organizational Religiosity and Spirituality and Self-esteem in patients with bilateral cleft lip and palate (G2) – Bauru, SP, Brazil, 2019.

Correlation variable	r	Correlation	p-value
Organizational Religiosity¶
Positive self-esteem	-0.14	Weak	0.32
Negative self-esteem	-0.10	Weak	0.48
Overall self-esteem	-0.15	Weak	0.29
Non-Organizational Religiosity¶
Positive self-esteem	-0.31	Weak	0.06
Negative self-esteem	-0.10	Weak	0.47
Overall self-esteem	-0.21	Weak	0.14
Spirituality¶
Positive self-esteem	-0.24	Weak	0.09
Negative self-esteem	-0.21	Weak	0.15
Overall self-esteem	-0.26	Weak	0.07

• Note: (n = 100)
• ¶ Pearson Correlation Test; 5% significance level (p ≤ 0.05)

DISCUSSION

For a long time, the questions which approach religiosity were depreciated in the scientific community due to being considered opposed areas which are difficult to control. However, currently, experiences related to religiosity are being observed to be important elements in the lives of individuals, drawing interest from researchers and being incorporated into health systems¹¹.

In the present study, within the religious and spiritual level, a predominance of OR in adolescents with cleft lip and palate is observed, in comparison with adolescents with bilateral malformation. These results show that adolescents with unilateral clefts went more often to religious meetings, such as temples, masses, cults, ceremonies, religious study groups, prayer groups, and others¹⁶.

The OR is directly related to the interaction and social support, which is extremely necessary to adolescents with cleft, considering the social implications they experience. Adolescents with unilateral clefts, by the fact of presenting lesser anatomical, functional, and aesthetic impairment, present more easiness of social interaction.

Given the segmented social reality, which precludes equanimous access to public health services, the importance of social interactions and of the inclusion in communities, support groups and networks are emphasized both for situational and financial coping, regardless of whether these are composed of relatives, friends, neighbors, religious institutions, or others²³.

Thus, improving access to care is fundamental to effectively achieve the goals of care and rehabilitation of patients with cleft lip and/or palate, including their families. The importance of follow-up of patients with cleft from adolescence to adulthood to explore psychosocial development is also emphasized²⁴.

As shown in this study, adolescents with cleft, in general, belong to the less favored social class. In other words, being in this social condition indicates that these individuals are provided with unfavorable living infrastructure, education, and income⁶. Thus, these adolescents are inferred to search for psychosocial support in the OR for this reason. Adolescents with cleft do indeed present higher levels of OR in comparison to those without this malformation¹⁵.

Being inserted in social groups and having friends reinforces feelings of acceptance and social interaction, in addition to minimizing negative sensations and worries related to physical appearance. Encouragement of these practices is thus recommended as part of therapeutic interventions²⁵.

Concerning NOR, although there is no statistical difference between adolescents with uni- or bilateral clefts, the scores were high for both, indicating the habit of practicing religiosity in a more intimate manner through prayer, meditation, watching or listening to religious shows, reading religious books and/or texts, and others¹⁶.

In fact, one study including adolescents with cancer diagnosis has shown that most considered prayers to bring them a sensation of calmness, tranquility, and increased trust, positively influencing health treatment and recovery²³.

High levels of NOR are associated to OR, i.e., the individual has the opportunity of putting their belief into practice in an individualized manner¹⁶. In this sense, a study conducted with adolescents with cleft lip and/or palate has shown a correlation between OR levels and NOR levels, showing them to be linked¹⁵.

Concerning spirituality, although no statistically significant difference was observed between adolescents with unilateral cleft in comparison with the ones with bilateral cleft, both presented high scores, indicating that these adolescents sought for a sense or meaning for human experience, either related to a religion or not¹⁶.

A study conducted with adolescents with no cleft, with the objective of verifying the influence of spirituality in interpersonal relationships, has pointed that spirituality had a strong influence on interaction with family and friends, on love relations and on life. Still, the increase in proximity, respect, and strengthened family bonds stood out. An increase in number of friends and care in avoiding discussions were observed. Finally, concerning love relations, a search for partners with the same beliefs or religion was observed²⁶.

An investigation which included adolescents with cleft lip and/or palate has shown a correlation between spirituality and a better perception of quality of life¹⁵. Another study which included Iranian adolescents has shown that they used beliefs, education, and spiritual experiences to control stress, manage crises and deal with general problems²⁷.

The levels of overall self-esteem were satisfactory both in the groups of adolescents with unilateral and bilateral cleft lip and palate. A person with high self-esteem is considered to maintain a continuous image of their capabilities, with more opportunities of performing active behavior in social groups, in addition to usually being directly and actively oriented to pursuing their personal goals⁷.

The high levels of self-esteem shown in the adolescents participating in this study are inferred to be related to their rehabilitation in an excellence center, which has certainly influenced aesthetic and functional results. The patient’s satisfaction with treatment result is of extreme importance and influences the perception of oneself and of their living environment. However, facial appearance, including nasal and labial in patients with operated cleft, is not the only factor to influence self-esteem: psychosocial factors present the same relevance²⁸.

On the other hand, diverse studies show that adolescents with clefts present low self-esteem²⁹-³⁰. A research has concluded that adolescents with cleft lip and/or palate, when operated, presented low self-esteem associated to supposed flaws, spots, scars, and nasal and dental aesthetic problems when compared to adolescents with no cleft²⁹.

A study has shown that adolescents with cleft lip and/or palate present low self-esteem when compared to adolescents with no cleft, related to dissatisfaction with their voices, which led to communication problems, and facial aesthetics dissatisfaction, including lip, nose and/or teeth, causing psychoemotional frailty³⁰.

In fact, aesthetic perceptions, including those related to the orthodontic context, influence the psychological self-concept of the patient, social confidence, and the need for treatment. These aspects present a higher relevance as the patient ages, i.e., in adolescence and adulthood³¹.

An Australian study evaluating self-esteem and its related factors in adolescents with and without cleft lip and/or palate has shown that having more anatomically complex clefts, being overweight, and giving high importance to facial appearance were determinant for low self-esteem, whereas maintaining a normal body weight and attributing less importance to facial appearance has contributed to improve it³².

Having high self-esteem levels is however emphasized not to necessarily indicate that the adolescents will not face other psychosocial problems. In this context, an investigation which included Norwegian teenagers has concluded that, although having cleft lip and/or palate had low impact on depressive symptoms and low self-esteem, the prevalence of romantic relationships was significantly lower among adolescents with cleft lip and/or palate in comparison with those without the malformation²⁵.

In addition, another research evaluating, among other objectives, the self-esteem of Polish adolescents and adults, with and without cleft lip and/or palate, has shown no significant difference between them³³. These findings indicate thus the complexity of self-concept and the factors that influence self-esteem.

Contradicting the initial hypothesis of this investigation, there was no correlation between religiosity, spirituality, and self-esteem. Spirituality and/or religiosity are broad and dynamic concepts which may influence meanings or perceptions, which is believed to have influenced the results. In addition to that, adolescents may reproduce values absorbed by influence of their parents’ spiritual and religious contexts, without necessarily incorporating them or living them as they should. They may therefore partially benefit from these¹⁵.

Self-esteem levels are related to intrinsic and extrinsic factors. Consequently, family support and the rehabilitation process are of extreme importance, not only focused on aesthetic aspects, but also on psychological, physical, social, functional aspects of these adolescents. After surgical correction of the malformation, benefits are shown regarding the improvement of levels of self-esteem and self-confidence, which contribute to an improved perception of quality of life.

Finally, the monocentric characteristic and the cross-sectional design of this study are posed as limitations, since they do not enable an assessment of cause-and-effect relations. Multicenter and prospective studies are therefore encouraged.

Nonetheless, this study’s benefits are observable and include an investigation on the details of religiosity, spirituality, and self-esteem in adolescents with uni- or bilateral cleft lip and palate. Although the correlation between the studied variables has not been demonstrated, this study enabled identifying that its adolescents had high levels of religiosity, spirituality, and self-esteem.

CONCLUSION

Adolescents with uni- or bilateral cleft lip and palate presented high levels of religiosity, spirituality, and self-esteem. However, contradicting the hypothesis, no correlation was observed between the studied variables.

REFERÊNCIAS

• ¹
  Freitas JA, Neves LT, Almeida AL, Garib DG, Trindade-Suedam IK, Yaedú RY, et al. Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP)—Part 1: overall aspects. J Appl Oral Sci. 2012;20(1):9-15. https://doi.org/10.1590/S1678-77572012000100003
  » https://doi.org/10.1590/S1678-77572012000100003
• ²
  Xiao Y, Taub MA, Ruczinski I, Begum F, Hetmanski JB, Schwender H, et al. Evidence for SNP-SNP interaction identified through targeted sequencing of cleft case-parent trios. Genet Epidemiol. 2017;41(3):244-50. https://doi.org/10.1002/gepi.22023
  » https://doi.org/10.1002/gepi.22023
• ³
  Cunha GF, Mondini CC, Almeida RJ, Bom GC. Prenatal discovery of baby’s cleft lip and palate: pregnant women’s main doubts. Rev Enferm UERJ. 2019;27:e34127. https://doi.org/10.12957/reuerj.2019.34127
  » https://doi.org/10.12957/reuerj.2019.34127
• ⁴
  Hlongwa P, Rispel LC. “People look and ask lots of questions”: caregivers’ perceptions of healthcare provision and support for children born with cleft lip and palate. BMC Public Health. 2018;18(1):506. https://doi.org/10.1186/s12889-018-5421-x
  » https://doi.org/10.1186/s12889-018-5421-x
• ⁵
  World Health Organization. Adolescent development [Internet]. Geneva: World Health Organization; 2018 [cited 2019 Jan 3]. Available from: http://www.who.int/maternal_child_adolescent/topics/adolescence/dev/en/#
  » http://www.who.int/maternal_child_adolescent/topics/adolescence/dev/en/#
• ⁶
  Graciano MI, Souza EG, Rosa JA, Blattner SH. [Content validation of an instrument of socio-economic assessment whitin the social servisse]. RIPE - Rev Inst Pesq Estud Constr Serv Soc [Internet]. 2015 [cited 2020 Jun 9];19(36):29-57. Portuguese. Available from: http://ojs.ite.edu.br/index.php/css/article/viewFile/214/253
  » http://ojs.ite.edu.br/index.php/css/article/viewFile/214/253
• ⁷
  Deffendi LT, Schelini PW. [Self-esteem, overall intellectual level and metacognitive knowledge in teenagers]. Psicol Esc Educ. 2014;18(2):313-20. Portuguese. https://doi.org/10.1590/2175-3539/2014/0182752
  » https://doi.org/10.1590/2175-3539/2014/0182752
• ⁸
  Jesus PB, Santos I, Brandão ES. Self-image and self-esteemin persons with skin disorders:an integrative literature review based Callista Roy’s model. Aquichan. 2015;15(1):75-89. Portuguese. https://doi.org/10.5294/aqui.2015.15.1.8
  » https://doi.org/10.5294/aqui.2015.15.1.8
• ⁹
  Taheri Kharame Z, Zamanian H, Foroozanfar S, Afsahi S. Religious wellbeing as a predictor for quality of life in Iranian hemodialysis patients. Glob J Health Sci. 2014;6(4):261-9. https://doi.org/10.5539/gjhs.v6n4p261
  » https://doi.org/10.5539/gjhs.v6n4p261
• ¹⁰
  Machado FR, Zangari W, Maraldi EO, Martins LB, Shimabucuro AH. Contribuições da psicologia para a compreensão das relações entre a espiritualidade, a religiosidade e as experiências anômalas. Clareira Rev Filosof Reg Amazônica [Internet]. 2015 [cited 2020 Jun 9];3(2):1-21. Available from: http://www.revistaclareira.com.br/index.php/clareira/article/view/114
  » http://www.revistaclareira.com.br/index.php/clareira/article/view/114
• ¹¹
  Santero M, Daray FM, Prado C, Hernández-Vásquez A, Irazola V. Association between religiosity and depression varies with age and sex among adults in South America: evidence from the CESCAS I study. PLoS One. 2019;14(12):e0226622. https://doi.org/10.1371/journal.pone.0226622
  » https://doi.org/10.1371/journal.pone.0226622
• ¹²
  Kent BV, Stroope S, Kanaya AM, Zhang Y, Kandula NR, Shields AE. Private religion/spirituality, self-rated health, and mental health among US South Asians. Qual Life Res. 2020;29(2):495-504. https://doi.org/10.1007/s11136-019-02321-7
  » https://doi.org/10.1007/s11136-019-02321-7
• ¹³
  Michaelson V, King N, Inchley J, Currie D, Brooks F, Pickett W. Domains of spirituality and their associations with positive mental health: a study of adolescents in Canada, England and Scotland. Prev Med. 2019;125:12-8. https://doi.org/10.1016/j.ypmed.2019.04.018
  » https://doi.org/10.1016/j.ypmed.2019.04.018
• ¹⁴
  Ozdemir A, Saritas S. Effect of yoga nidra on the self-esteem and body image of burn patients. Complement Ther Clin Pract. 2019;35:86-91. https://doi.org/10.1016/j.ctcp.2019.02.002
  » https://doi.org/10.1016/j.ctcp.2019.02.002
• ¹⁵
  Farinha FT, Banhara FL, Bom GC, Kostrisch LM, Prado PC, Trettene AS. Correlation between reliogiosity, spirituality and quality of life in adolescents with and without cleft lip and palate. Rev Latino-Am Enfermagem. 2018;26:e3059. https://doi.org/10.1590/1518-8345.2498-3059
  » https://doi.org/10.1590/1518-8345.2498-3059
• ¹⁶
  Moreira-Almeida A, Peres MF, Aloe F, Lotufo Neto F, Koenig H. Portuguese version of Duke Religious Index – DUREL. Rev Psi Clin. 2008 [cited 2020 Jun 9];35(1):31-2. Available from: https://www.scielo.br/pdf/rpc/v35n1/v35n1a06.pdf
  » https://www.scielo.br/pdf/rpc/v35n1/v35n1a06.pdf
• ¹⁷
  Sbicigo JB, Bandeira DR, Dell’Aglio DD. [Rosenberg Self-Esteem Scale (RSS): factorial validity and internal consistency]. Psico-USF. 2010;15(3):395-403. Portuguese. https://doi.org/10.1590/S1413-82712010000300012
  » https://doi.org/10.1590/S1413-82712010000300012
• ¹⁸
  Lucchetti G, Lucchetti ALG, Peres MF, Leão FC, Moreira-Almeida A, Koenig HG. Validation of the Duke Religion Index: DUREL (Portuguese version). J Relig Health. 2012;51(2):579-86. https://doi.org/10.1007/s10943-010-9429-5
  » https://doi.org/10.1007/s10943-010-9429-5
• ¹⁹
  Bravin AM, Trettene AS, Cavalcante RS, Banin VB, Padula NA, Saranholi TL, et al. Influence of spirituality on renal function of kidney transplant patients. Acta Paul Enferm. 2017;30(5):504-11. https://doi.org/10.1590/1982-0194201700073
  » https://doi.org/10.1590/1982-0194201700073
• ²⁰
  Cruz JP, Colet PC, Qubeilat H, Al-Otaibi J, Coronel EI, Suminta RC. Religiosity and health-related quality of life: a cross-sectional study on filipino christian hemodialysis patients. J Relig Health. 2016;55(3):895-908. https://doi.org/10.1007/s10943-015-0103-9
  » https://doi.org/10.1007/s10943-015-0103-9
• ²¹
  Taunay TC, Gondim FA, Macêdo DS, Moreira-Almeida A, Gurgel LA, Andrade LM, et al. Validação da versão brasileira da escala de religiosidade de Duke (DUREL). Rev Psiq Clín. 2012;39(4):130-5. https://doi.org/10.1590/S0101-60832012000400003
  » https://doi.org/10.1590/S0101-60832012000400003
• ²²
  Mukaka MM. Statistics corner: a guide to appropriate use of correlation coefficient in medical research. Malawi Med J [Internet]. 2012 [cited 2020 Jun 9];24(3):69-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576830/
  » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576830/
• ²³
  Souza VM, Frizzo HC, Paiva MH, Bousso RS, Santos AS. Spirituality, religion and personal beliefs of adolescents with câncer. Rev Bras Enferm. 2015;68(5):509-14. https://doi.org/10.1590/0034-7167.2015680504i
  » https://doi.org/10.1590/0034-7167.2015680504i
• ²⁴
  Bennett KG, Ranganathan K, Patterson AK, Baker MK, Vercler CJ, Kasten SJ, et al. Caregiver-reported outcomes and barriers to care among patients with cleft lip and palate. Plast Reconstr Surg. 2018;142(6):884e-91e. https://doi.org/10.1097/PRS.0000000000004987
  » https://doi.org/10.1097/PRS.0000000000004987
• ²⁵
  Feragen KB, Stock NM, Sharratt ND, Kvalem IL. Self-perceptions of romantic appeal in adolescents with a cleft lip and/or palate. Body Image. 2016;18:143-52. https://doi.org/10.1016/j.bodyim.2016.06.009
  » https://doi.org/10.1016/j.bodyim.2016.06.009
• ²⁶
  Drosdek LP, Geronasso MC. [The influence of spirituality in interpersonal relationships of teenagers who are engaged in the young apprentice program]. Rev. Psicol Foco [Internet]. 2015 [cited 2020 Jun 9];7(10):35-53. Portuguese. Available from: http://revistas.fw.uri.br/index.php/psicologiaemfoco/article/view/2027
  » http://revistas.fw.uri.br/index.php/psicologiaemfoco/article/view/2027
• ²⁷
  Hekmati Pour N, Mahmoodi-Shan GR, Ebadi A, Behnampour N. Spiritual self-care in adolescents: a qualitative study. Int J Adolesc Med Health. 2020 Oct 16 Ahead of print. https://doi.org/10.1515/ijamh-2019-0248
  » https://doi.org/10.1515/ijamh-2019-0248
• ²⁸
  Patjanasoontornm N, Wongniyom K, Pradubwong S, Piyavhakul N, Chowchuen B. A Relationship between nasolabial appearance and self-esteem in adolescent with repaired cleft lip and cleft palate at Khon Kaen University Cleft Center. J Med Assoc Thai [Internet]. 2014 [cited 2020 Jun 9];97(10 Suppl 10):S49-52. Available from: https://kkucleft.kku.ac.th/research/JMAT_FINAL/JMAT%20Final%202014/JMAT%202014%20Vol%2097,%20No%2010-7.pdf
  » https://kkucleft.kku.ac.th/research/JMAT_FINAL/JMAT%20Final%202014/JMAT%202014%20Vol%2097,%20No%2010-7.pdf
• ²⁹
  Andrade D, Angerami EL. [The self-esteem of adolescents with and without a cleft lip and/or palate]. Rev Latino-Am Enfermagem. 2001;9(6):37-41. Portuguese. https://doi.org/10.1590/S0104-11692001000600007
  » https://doi.org/10.1590/S0104-11692001000600007
• ³⁰
  Glaeser A, Costa SS, Collares MV. Cleft lip and palate: evaluation of the psycological impact using the Rosenberg self-esteem scale. Rev Bras Cir Plást. 2018;33(2):187-95. https://doi.org/10.5935/2177-1235.2018RBCP0094
  » https://doi.org/10.5935/2177-1235.2018RBCP0094
• ³¹
  Raghavan S, Philip K, Batra P, Marcusson A. Aesthetic perceptions and psychosocial impact of malocclusion: comparison between cleft and non-cleft patients and their parents. Eur J Orthod. 2019;41(1):38-45. https://doi.org/10.1093/ejo/cjy022
  » https://doi.org/10.1093/ejo/cjy022
• ³²
  Nicholls W, Harper C, Selvey LA, Robinson S, Hartig G, Persson M. Body esteem in a western Australian cleft lip and/or palate cohort across 3 age groups. Cleft Palate Craniofac J. 2018;55(4):487-98. https://doi.org/10.1177/1055665617730362
  » https://doi.org/10.1177/1055665617730362
• ³³
  Pisula E, Lukowska E, Fudalej PS. Self-esteem, coping styles, and quality of life in polish adolescents and young adults with unilateral cleft lip and palate. Cleft Palate Craniofac J. 2014;51(3):290-9. https://doi.org/10.1597/13-002
  » https://doi.org/10.1597/13-002

• *
  Extracted from the dissertation: “Religiosidade, espiritualidade e autoestima em adolescentes com fissura de lábio e palato uni e bilateral: estudo correlacional, Programa de Pós-Graduação em Ciências da Reabilitação, Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, 2020.

Publication Dates

• Publication in this collection
  28 June 2021
• Date of issue
  2021

History

• Received
  01 July 2020
• Accepted
  24 Feb 2021