EXPLORING THE CONNECTION BETWEEN SPIRITUAL WELL-BEING AND QUALITY OF LIFE AMONG OLDER ADULTS IN MARAWI CITY

Ashley A. Bangcola1, 2*, Hamdoni K. Pangandaman1

1College of Health Sciences, Mindanao State University, Marawi City,Philippines.

2College of Nursing, Cebu Normal University, Cebu City,Philippines

*Corresponding Author’s Email: ashley.bangcola@msumain.edu.ph

ABSTRACT

This study aims to explore the relationship between spiritual well-being and the quality of life of older adults. Thus, a descriptive correlational study was conducted with 97 older adults from Marawi City who were residing in temporary evacuation centers. The older adults were recruited by census from 5 evacuation centers located in Iligan City and the Municipalities of Pantar, Saguiaran, and Balo-i. Data were collected through the Spirituality Assessment Scale, and the Older People’s Quality of Life Questionnaire. Most of the older adults attained a fair or mixed spiritual well-being (overall mean=3.80) and a fairly positive overall quality of life (overall mean=3.50). According to Spearman Rho Correlation, there was a positive correlation between spiritual wellbeing and quality of life (p=0.048). Therefore, as spiritual well-being increases, so does the quality of life.

INTRODUCTION

In recent years, spiritual well-being has particular importance on health-related fields as researchers investigate its influence on health (Hill, 1999; Ridnour, 2008). Spiritual well-being seems to be related to different aspects of mental and physical health (Ridnour, 2008). While the acceptance of spirituality as a firm component of good mental and physical health is becoming more standardized (Moberg & Bruseck, 1978). the fact remains that there is still much debate on a unified definition of spiritual wellbeing. This leaves a gap in the literature related to the link between spiritual wellbeing and other aspects of health.

Quality of life, as used in this study, is defined as theoretical concept encompassing the individual’s physical health, psycho-social well-being and functioning, independence, control over life, material circumstances, and external environment. It is a concept that is dependent on the perceptions of individuals, and is likely to be mediated by cognitive factors (Bowling, 2009).

Researchers have proposed that spirituality improves coping and an individual’s response to stress (Koenig & Cohen, 2002) by serving as a buffer between stress and immune function and improving a person’s quality of life (QOL) (Rabin, 1999). Mueller et al., (2001) in a comprehensive review of the literature, found that most studies showed an association between spirituality and better health outcomes, including, less depression and greater coping skills and health-related quality of life (HRQOL).

Spirituality in the present thoughtful exploration of the reemergence appear as an important factor in nursing practice (Barnum, 2006). Nurses who have explored and reconciled their own spiritual beliefs can learn to address their patients' unique needs within the broad context of family and environment (Monareng 2012; Friedemann, Mouch, & Racey, 2002). Research has been done to examine the quality of life of persons with HIV and other chronic illnesses as it relates to spiritual (Grimsley 2006; Sowell et al., 2001; Tate & Forchheimer 2002; Tuck et al., 2000), psychological (Nannis et al., 1997; Sarna et al., 1999), or physiological health (Weinfurt et al., 2000). Research on the QOL of geriatrics remains limited till date. Very little research has also been done to examine the relationships between spiritual well-being and quality of life among older people and even less among geriatrics living in Marawi City. Hence, a need exists for more information about the role that spiritual well- being plays in the quality of life among older people.

The study is an attempt to determine if older adults’ spiritual well-being will influence other facets of well-being, which in this study shall be determined by exploring the relationships, if any, between spiritual well-being, and quality of life. In this study, a survey will be set up to assess the spiritual well-being of older people in Marawi City vis-à-vis their quality of life to determine whether or not there is a significant relationship between an older person’s spiritual well-being and their quality of life.

METHODOLOGY

This research study employed a descriptive correlation design to assess the influence of spirituality on the spiritual well-being and quality of life of older adults living or having lived in Marawi City. Specifically, descriptive design was utilized with the use of a structured questionnaire to capture information on the variables that are assumed to have an influence on the reliance of the respondents of their spiritual beliefs as support to their spiritual well-being, and their quality of life. On the other hand, the correlation design was used to test the hypotheses concerning the existence of significant relationships between the variables.

The participants of the study consisted of 97 older adults aged 60 years and over, living in Marawi City and were displaced in evacuation centers in Iligan City and nearby municipalities because of the Marawi Crisis. As a selection criterion, the participants have been selected on the basis of their age (that they were at least sixty years age and above), regardless of their gender and has lived in Marawi City. Additionally, participants of both genders, apparently healthy, independent, mobile, and were able to communicate verbally, were defined as inclusion criteria. Exclusion criteria included individuals with Alzheimer disease and other cognitive disorders without the ability to answer the questions and take part in the interview.

For the purpose of selecting the setting of the study, all evacuation centers in the nearby areas (Municipalities of Saguiaran, Pantar, Balo-i, and Iligan City) where the Internally Displaced Persons ((IDP’s) from Marawi City can be found were selected as the locale and focus area of the study. There were five evacuation centers where the samples were purposively recruited.

The study was carried out through a survey method using questionnaires as the main instrument. Data collection tools included a modified three-part questionnaire developed from research and through literature review related to spiritual wellbeing and quality of life. Except for the demographic questionnaire, the questionnaires used in this study have been published and have undergone stringent and rigorous validation. The researcher decided to use previously published and validated questionnaires to save time and resources and also to be able to compare the findings with those from other studies.

Part I dealt with the profile of the respondents and includes measures of demographic characteristics. All information gained in this section had been used only for the preparation of a general profile for individuals participating in this research.

Meanwhile, Part II of the research instrument assessed the spiritual well-being of the respondents utilizing the Spirituality Assessment Scale (SAS) (Howden, 1992), a 28-item questionnaire which is based on the Spiritual Well-Being Scale developed by Ellison (1983) which measured both religious well-being and existential well-being. The response scale also follows the Likert scale. Religious well-being is described as dealing with an individual's sense of well-being in relation to God. Existential well-being is described as an individual's perception of their purpose and satisfaction in life apart from any specific religious reference (Ellison, 1983). Spiritual well-being as used in this study combines both of these concepts. After two test instrument revisions, internal consistency for the final 28-item instrument was evaluated with a Cronbach alpha correlation coefficient and yielded a score of 92. Factor analysis in Howden’s research supported construct validity for the four-factor model of spirituality presented in the Spirituality Assessment Scale, as demonstrated in item-total correlations of 0.30 to 0.70, item-subscale correlations of 0.50 to 0.70, and subscale-subscale correlations of 0.55 to 0.70.

The Spirituality Assessment Scale is composed of four subscales: 1) Unifying Interconnectedness (Items 1, 2, 4, 6, 7, 9, 19, 25, and 26) which is defined as a sense of relationship to all life; 2) Meaning or Purpose in Life (Items 18, 20, 22, and 28) which is defined as a sense of having a reason for living; 3) Inner Resources (Items 8, 10, 12, 14, 16, 17, 23, 24, 27) which is defined as the process of striving for inner strength or a sense of empowerment. 4) Transcendence (items 3, 5, 11, 13, 15, and 21) which is defined as the ability to go beyond the limits of one’s experience or the capacity to achieve wellness or self-healing (Howden, 1992). With response options scored from 1 to 6 (Strongly Disagree to Strongly Agree) possible total SAS scores range from 28 to 168. It was determined that score ranges would represent spiritual wellbeing as follows: 1) 122-168 represent strong, positive spiritual well-being, 2) 75-121 would represent fair, or mixed positive and negative spiritual well-being, and 3) 28 - 74 would represent weak or negative spiritual well-being - possibly "spiritual distress".

Finally, Part III of the research instrument measured the quality of life of the respondents using the Older People’s Quality of Life Questionnaire (OPQLQ) (Bowling, 2009), which has 5-point Likert scales from Strongly Agree to Strongly Disagree, with 35 items, representing: life overall (4 items), health (4 items), social relationships and participation (8 items), independence, control over life, freedom (5 items), area: home and neighborhood (4 items), psychological and emotional well-being (4 items), financial circumstances (4 items), religion/culture (2 items).

In the original questionnaire, the items are scored with reverse coding of positive responses, so that higher scores represent higher Quality of Life (QoL). However, the researcher opted not to use reverse-coding for the OPQLQ with the rationale that it might be confusing for the respondents, since part I and part II of the research instruments were all positively-coded and positively-scored. Instead, the researcher decided to modify the questionnaire such that scoring would be continuous and positively-coded, as well as positively-scored. All reverse-coded items would be reverse- scored, such that a higher score on the questionnaire represents a higher quality of life. The scale ranges from 35, which is the lowest possible score (QoL is so bad it could not be worse) to 175, which is the highest possible score (QoL is so good that it could not be better). Using Cronbach Alpha, reliability for the Older People’s Quality of Life Questionnaire was 0.90. The questionnaire was further assessed for interpretation, face and content validity with four focus groups of older people, three of which reflected ethnic diversity .

The nature of this study is descriptive-correlational, and designed to investigate whether the spiritual well-being of older adults can influence the quality of their life. The older adults voluntarily decided to take part in the study. A written informed consent was taken from the eligible participants after the researcher has explained the whole protocol of the study.

The data was analyzed using the Statistical Software for Social Sciences. Descriptive statistics such as percentages, mean, and standard deviation have been used to describe the demographic data, the older adults’ level of spirituality, spiritual well-being, and their quality of life. To find out possible correlation and significant relationship between respondents’ spirituality, spiritual well-being, and their quality of life the Spearman Rho Correlation was deemed appropriate due to the nature of the variables’ scale which is ordinal. The parameters for assessing the magnitude of the correlation coefficients were: 0 ≤|rs|< 0.3=low correlation; 0.3≤ |rs| <0.7= moderate correlation; 0.7≤|rs|≤ 1= strong correlation.

RESULTS AND DISCUSSION

Socio-Demographic Characteristics

All the participants (n=97) were Meranao Muslims from five evacuation centers: Iligan City (14.4%), Municipalities of Saguiaran (23.71%), Pantar (21.64%), Baloi (31.95%), and Maria Christina (8.24%), where most of the families were displaced due to the Marawi City siege. The statistics on the older persons in these evacuation centers were based on the records available in the designated social work office. Of the 97 older adults who participated in the research, 62 (64%) were women, and all were between 60 and 99 years old, with a mean of 68.1 years (sd=6.98). Older adults between 60 to 69 years old predominated (53.9%), along with older adults who were married (60.1%). In terms of education, more than half were high school graduates (51.5%). The majority (66.0%) had a monthly income of less than 10,000 pesos. Most of them consider themselves as moderately religious - attending religious events at least once a week, a believer who believes in the power of Supreme Being, and had recently experienced situational crisis such as financial difficulty, death of spouse, and being displaced in other place, that fairly affects their health.

Spiritual Well-being

Table 1 illustrates that the older adults who have lived in Marawi City generally ‘somewhat agree’ with an overall mean of 3.80 on the subscales of spirituality assessment or spiritual well-being in the context of unifying interconnectedness (mean=4.07, sd=1.113), meaning or purpose in life (mean=3.50, sd=1.144), inner resources (mean=3.74, sd=1.172), and transcendence (mean=3.89, sd=1.104).

The score on the Spirituality Assessment Scale representing the older adults’ spiritual well-being ranges from 28 to 168. Over-all, the subscales generally describe the spiritual well-being of the older adults from Marawi City based on the average scores of 106.26. The data in Table 2 showed that the older adults in this study have a fair or mixed positive and negative spiritual well- being which imply that, although their spiritual well-being is not strong, it is at least slightly above average, or their positive spiritual well-being outweighs their negative spiritual well-being.

Table 1: Summary of Spirituality Assessment Scale (Spiritual Well-being)

The subscale that garnered the highest score of 36.59 is the unifying interconnectedness which is defined as the older adults’ sense of belongingness, ability to forgive, stability of the environment, feeling of kinship and connection with others in life, service to others, and of feeling responsibility in preserving the planet. This is consistent with the research of Jafari et al., (2010) where it was found that individuals having active spiritual life are healthy people mentally, self-confident, and can find a deeper connection with other people and the environment. These people are inclined to see themselves lively, skillful and competent and can find a God to guide them in their lives, make them happy and support them when they need. The results of the research confirmed that patients having spiritual well-being and great hope turned to related behaviors to health such as prayer to improve chance of being alive and the quality of their life (Jafari et al., 2010).

In the context of the Marawi crisis, one explanation for the reason of the first subscale, unifying interconnectedness, has the highest score may due to the harsh circumstances, that the respondents had faced. Tragedy has a way of bringing people together, through shared understanding and pain. There is also the matter of the respondents’ spirituality factoring into it. Ordinarily, in the face of such overwhelming violence, some people would lose hope, be focused only on their own survival, feel as if there was no longer any meaning to life, lose their self-confidence, or be unable to overcome their own experience. However, it is notable that despite the occurrence of crisis the levels of the respondents’ spiritual well-being are still relatively positive, which corresponds with the high levels of spirituality the respondents have as shown by the data.

Older People’s Quality of Life

There are nine (9) indicators which the quality of life of older adults are expected to have an impact on are covered in this inquiry. These are: life’s overall; health and functioning; social relationships; independence, control over life, and freedom; home and neighborhood, psychological and emotional well-being; financial circumstances, leisure and social activities; and religion or culture.

Table 3 below shows the indicators of older adults’ quality of life with corresponding scores, mean, standard deviation, and descriptive rating. As depicted in the results, older adults generally ‘agree’ (overall mean=3.50) in the context of life’s overall (mean=3.42, sd=0.910), social relationships (mean=3.83, sd=0.866), psychological and emotional well-being (mean=3.66, sd=0.847), leisure and social activities (mean=3.85, sd=0.883), and religion or culture (mean=3.78, sd=0.881).

Specifically, the results reflect that the older adults somewhat enjoy the gift of life, are happy most of the time, and positively looking forward to things. They neutrally expressed that sometimes life gets them down. The positive responses in the context of social relationships indicates that most, if not all, of the respondents have dependable support systems like their family, friends, neighbours, and other companions where giving and sharing of love and affection is possible.

Table 2: Older People Quality of Life

Scaling:4.21-5.00=Strongly Agree; 3.40-4.20=Agree; 2.61-3.40=Neither Agree nor Disagree;1.81-2.60= Disagree;1.00-1.80=Strongly Disagree

Moreover, the older adults perceive life positively and that they considered themselves lucky compared to most people. In terms of leisure and social activities, they have identified outlets, activities that define their role, and getting involved with things.

They have also acknowledged and described religion and culture as important facets of their quality of life. In the research by Manning–Walsh (2005) which studied spiritual effort and its effect on satisfaction and quality on 100 women suffering from breast cancer, it was specified that spirituality as a coping source had significant influence on promoting life satisfaction and quality of life.

Older adults however seemed uncertain about their health and functioning; independence, control over life and freedom; home and neighborhood; and, financial circumstances. These findings reflect the current situation of Meranaos in general, not only older adults, in light of the Marawi crisis. They feel uncertain about the future especially when it comes to material wealth and possessions as most of these are now lost because of the conflict. It also makes sense that the respondents would be uncertain about their health, as besides death, occurrences of illness also run rampant during crisis situations. It also follows that they would feel uncertain about their home as they have been displaced due to the internal fighting in Marawi city. They also feel as if they no longer have any control or independence about the larger events surrounding them, and the awful event which they feel they can do nothing about.

However, what is notable and should be taken into consideration is that despite this tragedy, or because of it, the respondents still maintain a strong level of spirituality and a fairly positive spiritual wellbeing. It is expected that they would consider themselves unlucky economically, however their spirituality and spiritual well-being, as shown by the data, still have enough of an impact to raise the quality of life of these evacuee respondents, which is fairly positive despite their surrounding circumstances.

The scores on the Older People’s Quality of Life scale representing the older adults’ quality of life (QoL) ranging from 35, which is the lowest possible score (QoL is so bad it could not be worse) to 175, which is the highest possible score (QoL is so good that it could not be better). The older adults’ total quality of life as based on the computed scores result in an average score of 125.96 which is only 29% short of the highest possible score of 175 points of quality of life. This implies that the older adults have a fairly positive level of quality of life, despite their circumstances.

Correlation of Variables

Furthermore, another important presentation in this part of the discussion on possible relationships or correlations between sets of variables is the relationship between spiritual well-being and quality of life. The results are depicted in Table 3.

The results of the present research indicated that there is a significant relationship between spiritual well- being and quality of life among older adults in Marawi City. As revealed in the findings, spiritual well- being has low correlation with quality of life, however this is still significant, (rho=0.324) (p value=0.048).

Table 3: Correlation of Variables

*Correlation is significant at the 0.05 level (2-tailed).

The relationship of the variables is positively correlated, which means that as spiritual well-being increases, quality of life also increases. These findings are consistent with the results of previous researches (Rippentrop et al., 2006; Manning-Walsh, 2005; Yoon, 2006; Snyder et al., 2002; Mascaro et al., 2004; Lark, 2007). Therefore, spiritual well-being is an element which influences quality of life.

The findings of this research show that older adults in Meranao have mixed positive and negative spiritual well-being, and the findings reflect a state of average level of quality of life. These two variables have a proportional or unidirectional relationship, in which an increase of spiritual well-being leads to an increase in quality of life.

The findings would imply that the Marawi siege crisis did affect the spiritual well-being of the Meranao people. This in turn affects their quality of life, as independence, control over life, freedom, home and neighborhood, psychological and emotional well-being, and financial circumstances are all indicators of quality of life. Aside from their spiritual well-being, other factors may contribute to their perception of quality of life, however those variables are not the subject of this study.

CONCLUSION

The older adult respondents in the study have a fair or mixed spiritual well-being, and a fairly positive overall quality of life. Additionally, there is a significant relationship between spiritual well-being and quality of life. Therefore, as spiritual well-being increases, so does quality of life. In conclusion, the significant relationships found between spiritual well-being and quality of life would show that there is a need to provide more comprehensive and appropriate care services for elderly patients and to dedicate programs and approaches in enhancing their spiritual health, as spiritual well-being is an important component affecting overall health in general.

Conflict of Interests

The authors declare that they have no conflict of interests.

ACKNOWLEDGEMENT

The authors express genuine and heartfelt gratitude to all participants for their time and cooperation in participating in this study.

REFERENCES

Barnum, B. S. (2006). Spirituality in nursing: From traditional to new age. Springer Publishing Company.

Bowling, A. (2009). The psychometric properties of the older people's quality of life questionnaire, compared with the CASP-19 and the WHOQOL-OLD. Current Gerontology and Geriatrics Research, 2009.https://doi.org/10.1155/2009/298950.

Ellison, C. W. (1983). Spiritual well-being: Conceptualization and measurement. Journal of Psychology and Theology, 11(4), 330-338.https://doi.org/10.1177%2F009164718301100406

Friedemann, M. L., Mouch, J., & Racey, T. (2002). Nursing the spirit: The framework of systemic organization. Journal of Advanced Nursing, 39(4), 325-332.https://doi.org/10.1046/j.1365-2648.2002.02293.x

Grimsley, L. P. (2006). Spirituality and quality of life in HIV-positive persons. Journal of Cultural Diversity, 13(2), 113.

Hill, P. C., & Pargament, K. I. (2003). Advances in the conceptualization and measurement of religion and spirituality: Implications for physical and mental health research. American Psychologist, 58(1), 64.https://psycnet.apa.org/doi/10.1037/0003-066X.58.1.64

Howden, J. W. (1992). Development and psychometric characteristics of the Spirituality Assessment Scale (Doctoral dissertation, Texas Women’s University, 1992). Dissertation Abstracts International, 54(01B), 0166.

Jafari, E., Najafi, M., Sohrabi, F., Dehshiri, G. R., Soleymani, E., & Heshmati, R. (2010). Life satisfaction, spirituality well-being and hope in cancer patients. Procedia-Social and Behavioral Sciences, 5, 1362-1366.https://doi.org/10.1016/j.sbspro.2010.07.288

Koenig, H. G., & Cohen, H. J. (Eds.). (2002). The link between religion and health: Psychoneuroimmunology and the faith factor. Oxford University Press.

Manning-Walsh, J. (2005). Spiritual struggle: Effect on quality of life and life satisfaction in women with breast cancer. Journal of Holistic Nursing, 23(2), 120-140.https://doi.org/10.1177%2F0898010104272019

Mascaro, N., Rosen, D. H., & Morey, L. C. (2004). The development, construct validity, and clinical utility of the spiritual meaning scale. Personality and Individual Differences, 37(4), 845- 860.https://doi.org/10.1016/j.paid.2003.12.011

Moberg, D. O., & Brusek, P. M. (1978). Spiritual well-being: A neglected subject in quality of life research. Social Indicators Research, 5(1), 303-323.https://doi.org/10.1007/BF00352936

Monareng, L. V. (2012). Spiritual nursing care: A concept analysis. Curationis, 35(1), 1-9.

Mueller, P. S., Plevak, D. J., & Rummans, T. A. (2001, December). Religious involvement, spirituality, and medicine: implications for clinical practice. In Mayo Clinic Proceedings (Vol. 76, No. 12, pp. 1225-1235). Elsevier.https://doi.org/10.4065/76.12.1225

Nannis, E. D., Patterson, T. L., & Semple, S. J. (1997). Coping with HIV disease among seropositive women: Psychosocial correlates. Women & Health, 25(1), 1-22.https://doi.org/10.1300/J013v25n01_01

Rabin, B. S., & Rabin, B. C. (1999). Stress, Immune Function, and Health: The Connection. Wiley-Liss.

Ridnour, H., & Hammermeister, J. (2008). Spiritual well-being and its influence on athletic coping profiles. Journal of Sport Behavior, 31(1), 81.

Rippentrop, A. E., Altmaier, E. M., & Burns, C. P. (2006). The relationship of religiosity and spirituality to quality of life among cancer patients. Journal of Clinical Psychology in Medical Settings, 13(1), 29. https://doi.org/10.1007/s10880-005-9000-9

Sarna, L., van Servellen, G., Padilla, G., & Brecht, M. L. (1999). Quality of life in women with symptomatic HIV/AIDS. Journal of Advanced Nursing, 30(3), 597-605.https://doi.org/10.1046/j.1365-2648.1999.01129.x

Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., Yoshinobu, L., Gibb, J., Langelle, C., & Harney, P. (1991). The will and the ways: development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60(4), 570. https://psycnet.apa.org/doi/10.1037/0022-3514.60.4.570

Sowell, R., Moneyham, L., Hennessy, M., Guillory, J., Demi, A., & Seals, B. (2000). Spiritual activities as a resistance resource for women with human immunodeficiency virus. Nursing Research, 49(2), 73-82.

Tate, D. G., & Forchheimer, M. (2002). Quality of life, life satisfaction, and spirituality: Comparing outcomes between rehabilitation and cancer patients. American Journal of Physical Medicine & Rehabilitation, 81(6), 400-410.

Tuck, I., McCain, N. L., & Elswick Jr, R. K. (2001). Spirituality and psychosocial factors in persons living with HIV. Journal of Advanced Nursing, 33(6), 776-783.https://doi.org/10.1046/j.1365-2648.2001.01711.x

Weinfurt, K. P., Willke, R. J., Glick, H. A., Freimuth, W. W., & Schulman, K. A. (2000). Relationship between CD4 count, viral burden, and quality of life over time in HIV-1-infected patients. Medical Care, 404-410.

Yoon, D. P. (2006). Factors affecting subjective well-being for rural elderly individuals: the importance of spirituality, religiousness, and social support. Journal of Religion & Spirituality in Social Work: Social Thought, 25(2),59-75.https://doi.org/10.1300/J377v25n02_04