SciELO - Scientific Electronic Library Online

vol.38 issue1Portuguese (Brazil) translation, cross-cultural adaptation and content validity of Body Checking Cognitions Scale - BCCSTranscultural adaptation: translation and content validation of the Commitment Exercise Scale to the Brazilian language author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand




Related links


Archives of Clinical Psychiatry (São Paulo)

Print version ISSN 0101-6083

Rev. psiquiatr. clín. vol.38 no.1 São Paulo  2011 



Evaluation of quality of life and importance given to spirituality/religiousness/ personal beliefs (SRPB) in adults with and without chronic health conditions



Neusa Sica da Rocha; Marcelo Pio da Almeida Fleck

Associate professor of Psychiatry, Post-Graduate Program in Medical Science: Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Hospital de Clínicas de Porto Alegre, Brazil

Mail address




BACKGROUND: There is a lack of studies seeking to elucidate the association of religiousness with quality of life, comparing sick and healthy people, regardless the type of disease and age group.
OBJECTIVE: To examine the association between: (1) presence of a chronic health condition and the importance given to spirituality/ religiousness/personal beliefs (SRPB); (2) presence of a chronic health condition and quality of life (QOL) adjusted for age, socioeconomic level and depressive symptoms; (3) QOL and importance given to SRPB, also adjusted for the same factors.
DESIGN: cross-sectional study. Participants: n = 241 consisted of 122 inand outpatients from a university hospital and 119 religious healthy subjects from community. Measurements: a) WHOQOL-100 (QOL); b) BDI (depressive symptoms); c) WHOQOL-SRPBi – scale of importance assigned to the facets of the Spirituality/Religiousness/Personal Beliefs Module of WHOQOL-100 to measure importance given to religiousness.
RESULTS: Patients in comparison to healthy subjects showed worse scores in most WHOQOL-100 domains. The patients' mean score of the WHOQOL-SRPBi was 97.2 compared to the healthy subjects' mean score = 92.9 (P = 0.03). After using a multiple regression model, the WHOQOL-SRPBi appears positively associated with the psychological, the social relationships, the environment, the SRPB domains and general QOL (beta = 0.17; beta = 0.12; beta = 0.11; beta = 0.72; beta = 0.10, respectively), when adjusted for age, SEL, BDI and the presence of a chronic health condition.
DISCUSSION: The more important is the SRPB for these people, the better is their QOL in most of their domains, independently of other factors involved. This finding may be taken into account when planning interventions to improve QOL of chronic health patients.

Keywords: Quality of life, religiousness, chronic health conditions, WHOQOL.




There is growing evidence that religiousness is associated with mental health. In a systematic review of approximately 200 articles, a positive association was shown in 50% of the cases and a negative one in 25%. In this review, religiousness was considered a protective factor against suicide, drug abuse and alcohol, delinquent behavior, marital satisfaction, psychological suffering and psychoses1. Some researchers have observed increased religiousness during negative life events, which include falling ill1-4. On the other hand, the connection with religion may be both a source of relief and discomfort depending on how the person relates to it3,5.

Although there are many studies related to the evaluation of religiousness, they present a number of methodological limitations. Reviewing the subject, Sloan et al.6 have pointed out that genetic, behavioral and variable differences such as age, gender, education, ethnic group, socioeconomic level and the presence of a physical illness may be important confounding biases in these studies. In a latest review7, the authors ascertained that the majority of well-conducted studies found that higher levels of religious involvement are positively associated with indicators of psychological well-being (life satisfaction, happiness, positive affect, and higher morale) and with less depression, suicidal thoughts and behavior, drug/alcohol use/abuse. Usually the positive impact of religious involvement on mental health is more robust among people under stressful circumstances (the elderly, and those with disability and medical illness).

Another difficulty is how to measure religiousness. The evaluation of religiousness is done in different ways in the different studies8,9. Generally, the religiousness variable is evaluated as to affiliation (for instance, Catholic, Buddhist and etc.), or religious practice (practicing/non-practicing), or frequency of attendance to religious services (weekly, monthly, etc.). These strategies are known to be limited to the study of just one variable of complex aspect such as religiousness in patient's life8,10.

Independently of its effect on the evolution of diseases, this dimension has been identified as very relevant and an important domain to be taken into account when evaluating quality of life11-16. As an example of acknowledging the importance of the spiritual dimension, the World Health Organization, included a domain on spirituality/religiousness/personal beliefs17 in its instrument for the evaluation of quality of life (WHOQOL)14.

Since most of the studies refer to populations of aged patients, with chronic or terminal diseases, there is a lack of studies seeking to elucidate the association of religiousness with quality of life, comparing sick and healthy people, regardless the type of disease and the age group, using a more defined concept of the attitudes and beliefs to non-material dimension. Brazilian Center of WHOQOL Group found interesting results using focus group technique. Most patients and religious groups highlighted the importance of studying spiritual/ religious issues in health care. On the other hand, health professionals and atheistic groups disagreed with the former. Brazilian people have strong faith in God and Spiritual dimension; this becomes evident through the diverse range of religious commitment they have18. Many people in Brazil credit their health improvement to spiritual forces rather than medical treatment. It would be of great interest to verify if this kind of behavior can improve their quality of life.

The objectives of the present study are to examine the association between (1) presence of a chronic health condition and the importance given to religiousness; (2) presence of a chronic health condition and quality of life; (3) QOL and importance given to religiousness, adjusted for age, socioeconomic level and depressive symptoms.



Data collection was performed in the wards and outpatient clinic in a tertiary hospital in Brazil, and in the community, based on the religious centers, during a three month-period. After obtaining informed consent, the interviewers performed a brief interview with the participants, collecting the demographic and health-related variables. The other variables were obtained through self-report instruments under the supervision of the interviewers.

The design was a cross-sectional study.

The sample was selected according to convenience, both for the patients and for the healthy group. For the patients group, the research team contacted the senior nurse of the unit (clinical, ambulatory or surgery) who provided a list of eligible subjects who were selected if they had clinical conditions to answer the questionnaires. For the group of healthy individuals, the "snow-ball" technique was used (each individual selected indicated one more participant19 who attended temples and places of prayer close to the geographical area of the hospital). Afterwards, each healthy individual was paired (age, gender and religion) with a patient for ensuring pairing.

The choice of religions was performed based on the prevalence of the religious groups in the Brazilian population. The percentages of religions in Brazil are: 72% Catholics, 15% Protestants (evangelical), 5% Spiritist, 3% African-Brazilian religions and 5% atheists20.

Inclusion criteria for individuals in the group of patientswith chronic health conditions: Adult patients (18 or older) chosen among those seen at Hospital de Clínicas de Porto Alegre, in the inpatient unit and outpatient clinic in the various clinical (e.g. Internal Medicine, Cardiology, Nephrology, Neurology, Psyquiatry etc.) and surgical specialties who presented clinical conditions and agreed to participate in the study.

Inclusion criteria for the group of healthy individuals withoutchronic health conditions: Adult individuals from the community (18 or older), from the geographical area close to the hospital, who did not have any clinically detectable disease. The individuals who answered affirmatively to any of the questions below were excluded from the sample:

– Do you have any chronic disease?

– Do you currently use any medication regularly?

– Have you consulted any physician or health professional during the last month (except for preventive care, such as gynecological check-up)?

Religious belief and commitment were defined by self-evaluation, independently if the subject came from healthy or patient groups. In the case of atheists, they should consider themselves as such.



WHOQOL-SRPBi: Is a measure of importance given to the facets of the WHOQOL-SRPB, this is calculated by the total sum of scores given to the questions relating to the degree of importance assigned to its facets. It was used here to evaluate the importance of this dimension. The WHOQOL-SRPB is a cross-cultural self-report instrument developed by the World Health Organization (WHO), involving over 15 centers throughout the world, to evaluate religiousness, spirituality and personal beliefs related to QOL using eight facets: connection with a spiritual being or force, inner peace/serenity/harmony, meaning of life, admiration, totality/integration, spiritual strength, faith and hope/optimism. The pilot study with a preliminary psychometric analysis showed correlations between the facet between 0.51 to 0.91 and total alpha = 0.9117. The WHOQOL-SRPB measures SRPB related to QOL and WHOQOL-SRPBi measures the importance given by the person to the aspects evaluated by the WHOQOL-SRPB.

WHOQOL-100: Cross-cultural self-report instrument organized by the WHO to evaluate QOL through six domains: physical, psychological, environment, social relationships, level of independence and spirituality/religiousness/personal beliefs17,21,22.

Beck Depression Inventory (BDI) and Beck Hopelessness Scale (BHS): Self-report instruments, validated and translated into Portuguese, which evaluate depressive symptoms (BDI) and hopelessness (BHS) in the weeks preceding their use23,24.

Economic Classification Criterion – Brazil: This classification evaluates the economic level of the subject considering consumer goods and educational level. In this classification, each consumer good (e.g. refrigerator, television, telephone, etc.) receives a certain value, and the final score is this sum of these values plus the value related to the educational level. This final score can be also classified in classes which can vary among A, B, C, D, E. Through this criterion, 71% of city population where this study was carried out belongs to poor economic classes25. This instrument was applied by the interviewers.

All the individuals invited to participate in the study completed a written consent presenting the objectives of the study. The Ethics Research Committee at Hospital de Clínicas de Porto Alegre (HCPA) approved the project.



The following tests were used: Student T test to compare means; Pearson's Chi-square, with Yates correction when necessary, to compare the proportions of the categorical variables; Multiple Linear Regression to control confounding biases and co-variables. The level of significance used was 5% for most tests except for Multiple Regression, in which the 10% level was used. The statistical program used was SPSS 10.0.



The main characteristics of the sample are presented in table 1. The health problems most frequently presented by the patients were: hypertension 18%, heart diseases 15.6%, neoplasm 13.1%, diabetes 13.1%, emphysema/asthma/bronchitis 11.5%, autoimmune diseases 8.2%, and chronic kidney diseases 8.2%.



Patients had mean scores significantly lower in most domains of QOL, including QOL in general, except for the domain of SRPB, where patients had a slight higher mean, but this difference was not statistically significant as shown in table 2.



Comparing patients and healthy individuals as to the measure of importance given to spirituality/religiousness/personal beliefs (WHOQOL-SRPBi), patients had significantly higher scores than healthy individuals.

Since, despite pairing, there were significant differences between patients and healthy individuals in the main variables of interest (age, socioeconomic level, marital status and BDI scores) and these may be correlated to religiousness (r2 age = 0.19; r2SEL = -0.14; r2BDI = -0.08; P < 0.05), we control statistically the differences found in religiousness through a multiple linear regression model.

Only the socioeconomic level variable was included in the model. Years of study and level of education were excluded for colinearity reasons. The same rationale was used to include the variable BDI and exclude BHS (Beck Inventory of Hopelessness).

The importance given to SRPB is positively associated with the majority of the quality of life domains of WHOQOL-100, including quality of life in general, even when other factors such as age, SEL, depressive symptoms and the presence of a chronic health condition are taken into account. The highest correlations are found with the SRPB domain (beta = 0.72; P < 0.0001) and the psychological domain (beta = 0.17; P < 0.0001), followed by the domains of social relationships (beta= 0.12; P < 0.05), environment (beta = 0.11; P < 0.10) and quality of life in general (beta= 0.10; P < 0.10).

The presence of a chronic health condition is negatively correlated to the physical domain, level of independence and quality of life in general (beta = -0.32; beta = -0.48; beta = -0.22, respectively).

Another important finding is the participation of depressive symptoms with negative correlations in all quality of life domains26.

The socioeconomic level appears to be negatively correlated only to the domains of social relationships and environment.



The present study showed differences in the importance given to SRPB between groups of patients and healthy individuals. This difference may be underestimated in the present study, since the healthy individuals were practicing members of their religion and therefore would tend to have higher religiousness scores than the population at large. Therefore, the difference can be accounted for: 1) the increased need of support presented by the patients in order to face the demands associated with falling ill3,27-30, 2) the possibility that sick individuals seek a meaning or explanation for the fact that they had fallen ill31, or, 3) an attempt at healing through faith32. Since all patients are in treatment in a hospital, all possible explanations are not mutually excluding.

As to QOL, it can be seen that the presence of a chronic health condition may be associated with worsening in most domains, except the SRPB domain. In this domain, the scores are higher in sick people. This finding suggests that the SRPB domain may not be appropriate to demonstrate the differences between healthy and sick individuals17,33.

It is interesting to note that when one analyzes the impact of religiousness on the different domains of quality of life, it is observed that this may be positively associated with most of its domains. Spirituality/religiousness/personal beliefs importance (measured by WHOQOL-SRPBi) is positively correlated to the psychological domain, social relationships, environment, and QOL and, obviously, with SRPB even after the adjustment for socioeconomic level, depressive symptoms, age and the presence of a chronic health condition. This finding is in agreement with the current literature that shows the relationship between religiousness and better social relationships1,34. Also, as regards the psychological domain, it is well known how much religiousness can be associated with lower levels of depression35,36, higher indices of hope and well-being37, which could also account for the positive correlation with quality of life in general.



The role of the socioeconomic level in the findings makes us seek for explanations. In Brazil, the people with a lower socioeconomic level often find it much easier to achieve access to the religious centers than to the health services38. Furthermore, people with a lower socioeconomic level may have less explanatory models that compete with religion due to an issue of associated cultural level.

The data in the present study indicate that between religiousness and the presence of a chronic health condition, there are variables that interrelate and, therefore, a linear model of cause and effect, as well a cross-sectional approach does not apply to the complexity of the phenomenon.

Based on our data and those found in literature, the study of attitudes and beliefs related to non-material dimension of life is clearly complex. Even having adjusted statistically our results by a multiple regression model, it is necessary to have a longitudinal approach to assess all confounding and reverse causation that could account for correlations found.

The data presented suggested that beliefs and attitudes related to non-material dimension should be considered as an important factor in the process of falling ill. Our findings points to the importance of religiousness for patients' life during this process, these may be taken into account when planning intervention aiming to improve their QOL. It is evident that religiousness is a relevant aspect to be evaluated when assessing QOL. In this respect, is recommended that other generic QOL instruments, which don't include this facet in their conceptual model, could be revised to incorporate the assessment of the attitudes to this unique dimension.



This study was partly funded by the Research Development Fund (Fundo de Incentivo à Pesquisa) at Hospital de Clínicas de Porto Alegre (HCPA), Brazil, and by the Fetzer Foundation.



1. Levin JS, Chatters LM. Research on religion and mental health: an overview of empirical findings and theoretical issues. In: Koenig HG, editor. Handbook of religion and mental health. London: Academic Press; 1998, p. 33-50.         [ Links ]

2. Ferraro KF, Kelley-Moore JA. Religious consolation among men and women: do health problems spur seeking? J Sci Stu Relig. 2000;39:220-34.         [ Links ]

3. Pargament KI, Smith BW, Koenig HG, Perez L. Patterns of positive and negative religious coping with major life stressors. J Sci Stu Relig. 1998;37:710-24.         [ Links ]

4. Guimarães HP, Avezum A. O impacto da espiritualidade na saúde física. Rev Psiquiatr Clín. 2007;34(Supl 1):88-94.         [ Links ]

5. Kendler KS, Gardner CO, Prescott CA. Clarifying the relationship between religiosity and psychiatric illness: the impact of covariates and the specificity of buffering effects. Twin Res. 1999;2(2):137-44.         [ Links ]

6. Sloan RP, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet. 1999;353(9153):664-7.         [ Links ]

7. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental health: a review. Rev Bras Psiquiatr. 2006;28(3):242-50.         [ Links ]

8. King M, Speck P, Thomas A. Spiritual and religious beliefs in acute illness: is this a feasible area for study? Soc Sci Med. 1994;38(4):631-6.         [ Links ]

9. King M, Speck P, Thomas A. The effect of spiritual beliefs on outcome from illness. Soc Sci Med. 1999;48(9):1291-9.         [ Links ]

10. Larson DB, Pattison EM, Blazer DG, Omran AR, Kaplan BH. Systematic analysis of research on religious variables in four major psychiatric journals, 1978-1982. Am J Psychiatr. 1986;143(3):329-34.         [ Links ]

11. Brady MJ, Peterman AH, Fitchett G, Mo M, Cella D. A case for including spirituality in quality of life measurement in oncology. Psycho-oncology. 1999;8(5):417-28.         [ Links ]

12. Gioiella ME, Berkman B, Robinson M. Spirituality and quality of life in gynecologic oncology patients. Cancer Pract. 1998;6(6):333-8.         [ Links ]

13. Holland JC, Kash KM, Passik S, Gronert MK, Sison A, Lederberg M, et al. A brief spiritual beliefs inventory for use in quality of life research in life-threatening illness. Psycho-oncology. 1998;7(6):460-9.         [ Links ]

14. Moreira-Almeida A, Koenig HG. Retaining the meaning of the words religiousness and spirituality: a commentary on the WHOQOL SRPB group's "a cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life" (62: 6, 2005, 1486-1497). Soc Sci Med. 2006;63(4):843-5.         [ Links ]

15. Panzini RG, Rocha NS, Bandeira DR, Fleck MPA. Qualidade de vida e espiritualidade. Rev Psiquiatr Clín. 2007;34:105-15.         [ Links ]

16. Rocha NS, Fleck MP. Religiosidade, saúde e qualidade de vida: uma revisão da literatura. In: Teixeira EFB, Müller MC, Silva JDT, eds. Espiritualidade e Qualidade de Vida. Porto Alegre: EDIPUCRS; 2004, p. 165-80.         [ Links ]

17. The WHOQOL group. A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life. Soc Sci Med. 2006;62(6):1486-97.         [ Links ]

18. Fleck MP, Borges ZN, Bolognesi G, Rocha NS. [Development of WHOQOL spirituality, religiousness and personal beliefs module]. Rev Saude Publica. 2003;37(4):446-55.         [ Links ]

19. Victora CG, Knauth DR, Hassen MNA. Metodologias qualitativas e quantitativas. Pesquisa qualitativa em saúde: uma introdução ao tema. Porto Alegre: Tomo Editorial; 2000, p. 33-44.         [ Links ]

20. Pierucci AF, Prandi R. Religiões e voto: a eleição presidencial de 1994. In: Pierucci AF, ed. A realidade social das religiões no Brasil. São Paulo: Hucitec; 1996, p. 211-38.         [ Links ]

21. Fleck MP, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. [Application of the Portuguese version of the instrument for the assessment of quality of life of the World Health Organization (WHOQOL-100)]. Rev Saude Publica. 1999;33(2):198-205.         [ Links ]

22. Power M, Bullinger M, Harper A. The World Health Organization WHOQOL-100: tests of the universality of quality of life in 15 different cultural groups worldwide. Health Psychol. 1999;18(5):495-505.         [ Links ]

23. Beck AT. Beck Depression Inventory. Handbook of Psychiatric Measures. Washington: American Psychiatric Association; 2000, p. 519-23.         [ Links ]

24. Gorestein C. Inventário de Depressão de Beck. Propriedades psicométricas da versão em português. Escalas de Avaliação Clínica em Psiquitria e Psicofarmacologia. São Paulo: Lemos Editorial; 2000, p. 89-93.         [ Links ]

25. Association of Brazilian Market. Economic Classification Criterion. 2006.         [ Links ]

26. Rocha NS, Fleck M. Evaluation of quality of life in adults with and without chronic health conditions: the role of depressive symptoms. Rev Bras Psiquiatr. 2010. 2010;32(2):119-24.         [ Links ]

27. Koenig HG, Larson DB, Larson SS. Religion and coping with serious medical illness. Ann Pharmacother. 2001;35(3):352-9.         [ Links ]

28. O'Neill DP, Kenny EK. Spirituality and chronic illness. J Nurs Scholarship. 1998;30(3):275-80.         [ Links ]

29. Thune-Boyle IC, Stygall JA, Keshtgar MR, Newman SP. Do religious/spiritual coping strategies affect illness adjustment in patients with cancer? A systematic review of the literature. Soc Sci Med. 2006;63(1):151-64.         [ Links ]

30. Landis BJ. Uncertainty, spiritual well-being, and psychosocial adjustment to chronic illness. Issues Ment Health Nurs. 1996;17(3):217-31.         [ Links ]

31. Ross L. The spiritual dimension: its importance to patients' health, well-being and quality of life and its implications for nursing practice. Soc Indic Res. 1996;38:193-211.         [ Links ]

32. Rabelo MC. Religião e cura: algumas reflexões sobre a experiência religiosa das classes populares urbanas. Cad Saude Publica. 1993;9:316-25.         [ Links ]

33. Skevington SM, O'Connell KA. Can we identify the poorest quality of life? Assessing the importance of quality of life using the WHOQOL-100. Qual Life Res. 2004;13(1):23-34.         [ Links ]

34. Levin JS, Vanderpool HY. Is frequent religious attendance really conducive to better health? Toward an epidemiology of religion. Soc Sci Med. 1987;24(7):589-600.         [ Links ]

35. Braam AW, Beekman AT, Deeg DJ, Smit JH, Van Tilburg W. Religiosity as a protective or prognostic factor of depression in later life; results from a community survey in The Netherlands. Acta Psychiat Scand. 1997;96(3):199-205.         [ Links ]

36. Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. Am J Psychiatr. 1998;155(4):536-42.         [ Links ]

37. Elerhorst-Ryan JM. Instruments to measure spiritual status. In: Spilker B, ed. Quality of life and pharmacoeconomics in clinical trials. Philadelphia: Lippincott-Raven Publishers; 1996, p. 145-53.         [ Links ]

38. Dalgalarrondo P. Religiões cristãs evangélicas e diagnóstico psiquiátrico: dados de uma pesquisa transcultural. Rev ABP-APAL. 1996;18:125-35.         [ Links ]



Mail address:
Neusa Sica da Rocha
Av. Iguaçu, 119/201
Petrópolis – 90470-030 – Porto Alegre, RS, Brazil
Telephone: (+55 51) 3338-0496. Fax: (+55 51) 2101-8413

Received: 20/10/2009
Accepted: 15/4/2010

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License