Journal of Religion and Health

https://doi.org/10.1007/s10943-019-00906-7

ORIGINAL PAPER

The Relationship Between Spiritual Health and Religious

Coping with Death Anxiety in the Elderly

Farzaneh Solaimanizadeh1 · Neda Mohammadinia2 · Laleh Solaimanizadeh2

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
The elderly is a period of life when a person reaches the age of 65 years. This study
aimed to determine the relationship between spiritual health and religious cop-
ing with the death anxiety in the elderly people. The study is a descriptive cross-
sectional study: 180 Elderly according to similar studies. Data gathering tools are
Paloutzain and Ellison SH questionnaire, religious coping questionnaire and death
anxiety questionnaire. SPSS16 and descriptive and analytical tests were used; there
was a relationship between religious health and religious coping with the anxiety
(p < 0.05).The M(SD) religious health is 39.25 (11.67), existential health is 40.50
(11.29), total spiritual health is 79.75 (22.03), and also the M(SD) religious cop-
ing is 23.84 (5.02). Considering the relationship between RC and SH with DA in
the elderly, it is necessary to make the necessary spiritual–religious arrangements to
reduce DA.

Keywords  Spiritual health · Religious coping · Death anxiety · Elderly

Background

The elderly is a period of life when a person reaches the age of 65 years (Abdi
et  al. 2018). Aging is associated with problems such as osteoporosis (Hatefi
et al. 2019b), heart disease (Catalan-Serra et al. 2019), low back pain (Ito et al.
2019) and hemodialysis (Nasrabadi 2018). Chronic diseases (CD) are one of the

* Laleh Solaimanizadeh
l.solaimani@mubam.ac.ir; lalehsolaimanizadeh@yahoo.com
Farzaneh Solaimanizadeh
fsolaimanizadeh@yahoo.com
Neda Mohammadinia
nedamohammadinia@yahoo.com
1
Ministry of Health and Medical Education, Tehran, Iran
2
Department of Nursing, Faculty of Nursing and Midwifery, Bam University of Medical Science,
Bam, Iran

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 Journal of Religion and Health

major challenges of the recent century (Ghadiri and Motaghi 2016; Hatefi et al.
2019a). By increasing the age, the probability of suffering CD in the elderly
people increases (Akhoondzadeh et al. 2014; Woo et al. 2007). Iran is one of the
aging countries that needs the widespread about this age group (Akhoondzadeh
et al. 2014; Hatefi et al. 2019c). These diseases can cause cognitive status prob-
lem in the patient (Akhoondzadeh et al. 2014).
One of the important components of quality of life in individuals is mental
health (MH) (Pouy et  al. 2018). Anxiety is one of the most important compo-
nents of MH. Anxiety of death means constant, abnormal and morbid fear of
dying or dying (Bahrami et al. 2013; Bala and Maheshwari 2019; Kim and Kim
2019). Anxiety of death is a difficult concept and is often defined as fear of
death (Bahrami and Behbahani 2019; Gire 2002). This type of anxiety is a kind
of death experienced by a living person and can affect his or her health (Curcio
et al. 2019; Hoelterhoff 2010). The death anxiety (DA) is natural. But if the DA
is too severe, it becomes problematic. Such feelings can lead to helplessness,
loneliness and a decline in quality of life (Majidi and Moradi 2018; Shafaii et al.
2017).
In the aging period, especially in the elderly people with CD, it is necessary to
consider the spiritual health (SH) and religious dimensions of patients (Akhoondza-
deh et  al. 2014; Hatefi et  al. 2019c). SH is a unique power that coordinated the
physical, mental and social dimensions of people, and it is necessary to adapt with
disease (Rezaei et al. 2008; Vazifeh doust et al. 2019). The lack or reduction in SH
in patients, especially CD, can lead to worsening the health of patients (Hojjati et al.
2017). Increased spirituality can reduce pain (Vasigh et  al. 2018). The concept of
spiritual health consists of two dimensions of religious and existential health that
interact and overlap (Jones 1999; Soleimani et  al. 2019). In fact, most models of
health include SH, and the concept of spirituality is relevant to all areas of health
and to all ages (Smith and McSherry 2004).
Religion intends to encourage the daily routine that thanksgiving is one of
them (Ahmadpoori 2019). One of the other religious categories is religious cop-
ing. Religious coping (RC) acts as a support for patient and reduces the prob-
lems of patients (Hatefi et  al. 2019d; Okhli et  al. 2019). RC includes positive
(an individual believes in positive changes with the help of God and negative the
unreliable relationship of individual with God) (Taheri-Kharameh et  al. 2013).
Positive RC feels that God will not leave him alone in painful situations, but
negative RC feels that God will leave him alone in difficult conditions (Parga-
ment et al. 2000; Taheri-Kharameh et al. 2013). SH affects MH. That’s why it is
important to pay attention (Hojjati et al. 2017).

Objectives

This study aimed to determine the relationship between SH and RC with the DA
in the elderly people.

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Journal of Religion and Health

Methods

Study Type and Settings

The study is a descriptive cross-sectional study.

Sample Size and Sampling

180 elderly according to similar studies.

Inclusion Criteria

Elderly than 5 years of age, informed consent to participate in study, Elderly liv-
ing in Bam.

Data Gathering Tools

Spiritual Health Questionnaire

Paloutzain and Ellison SH questionnaire with 20 questions is one of the valid

questionnaires that its validity and reliability have determined and measured the
spiritual–religious health of patient in the range of 20–120 scores (Ellison 2006;
Scott et al. 1998). The scoring and analysis of this questionnaire conform to the
previous studies in this field (Seyedfatemi et al. 2006).

Religious Coping Questionnaire

Religious coping questionnaire is a 14-question questionnaire that has seven ques-

tions for positive strategies and seven questions for negative strategies. Its scoring
is never (0) to very high (3). The validity of reliability of this questionnaire was
determined in Iran in Ahmadi et  al. study (Pargament et  al. 2000; Sharak et  al.
2017).

Death Anxiety Questionnaire

The DA questionnaire consists of 15 questions that are scored in the form of

5-point Likert responses ranging from very disagree (score 1) to very strongly
agree (score 5). The rating range of this questionnaire is between 15 (lowest
score) to 75 (highest score). The validity and reliability of this tool have been
confirmed in various studies (Aghajani et  al. 2011; Ghorbanalipour et  al. 2010;
Masoudzadeh et al. 2008; Shafaii et al. 2017).

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Data Collection

A total number of 180 elderly entered the study. For this purpose, the mem-
bers of research team referred to public places like parks, hospitals, mosques,
etc. They gave questionnaires to them to fill out. Researchers studied the medi-
cal documents of the patients to ensure that they are qualified to participate in
the study, and if patients were illiterate and could not understand the question-
naire, they completed it with interview. If patients were tired, the completing of
questionnaire stopped and after rest, they recompleted the questionnaire. It was
said to patients that their participation or non-participation has no effect in their
treatment, and their participation is optional. They were told that it is not neces-
sary to write their name and surname, and the obtained information will be kept
confidential.

Statistical Analyses

SPSS16 and descriptive and analytical tests were used.

Results

The findings of Table  1 show the status of demographic characteristics as well as

the level of SH, RC and DA according to the demographic characteristics. M(SD)
age is 74.00 (9.41) and not relation between age and SH (R = 0.12, R Square = 0.01,
p = 0.09) and RC (R = 0.033, R Square = 0.001, p = 0.66).
According to Table  2, there was a relationship between SH and RC with the
anxiety (p < 0.05).The M(SD) religious health is 39.25 (11.67), existential health is
40.50 (11.29), total SH is 79.75 (22.03), and also the M(SD) RC is 23.84 (5.02).

Discussion

According to the findings, the mean (SD) score of SH of the elderly is 79.75 (22.03).
In the study of Khalili et al. (2013), M(SD) SH score is 95.2 (13.98); in the study
of Sadrollahi and Khalili (2015), M(SD) SH score is 72.07 (9.03); in the study of
Jadidi et al. (2011), M(SD) SH score is 93.17 (26.96); in the study of Abedi et al.
(2016), M(SD) SH score is 96.72 (65.21); in the study of Ilali et al. (2016), M(SD)
SH score is 101.28 (18.89); and in the study of Vasigh et al. (2019), M(SD) SH in
patients with chronic pain is 65.16 (9.88). According to the findings, the M(SD) SH
score of spiritual health in this study was lower than other studies, which may be due
to differences in study year and demographic characteristics of the elderly.
According to the findings, there was a relationship between SH and RC with
the DA score. In the study of Hedayati et  al. (2016), anxiety scores decreased
with an increase in SH score of the elderly. In a study by Khademvatani et  al.

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Table 1  Relation between demographic characteristics and variables studied

Demographic characteristics SH M(SD) RC M(SD) DA M(SD)

Gender
 Female
100 (55.6) 81.98 ± 23.72 23.70 ± 5.30 35.72 ± 14.61
 Male
80 (44.4) 76.96 ± 19.52 24.02 ± 4.68 41.72 ± 16.59
 p value p = 0.12 p = 0.66 p = 0.01
Marital status
 Single
105 (58.3) 84.15 ± 19.43 24.21 ± 4.93 33.86 ± 13.54
 Married
75 (41.7) 73.58 ± 24.03 23.32 ± 5.13 44.72 ± 16.55
 p value p = 0.23 p = 0.16 p = 0.90
Job
 Yes
44 (24.4) 86.31 ± 22.66 25.22 ± 5.15 43.00 ± 19.03
 No
136 (75.6) 77.62 ± 21.48 23.39 ± 4.91 36.89 ± 14.32
 p value p = 0.023 p = 0.035 p = 0.025
Education
 Illiterate
92 (51.1) 77.95 ± 23.22 23.23 ± 5.05 37.03 ± 14.88
 Reading and writing
85 (47.2) 81.14 ± 20.87 24.45 ± 4.94 40.23 ± 16.69
 Academic
3 (1.7) 95.33 ± 6.42 25.00 ± 6.24 27.66 ± 8.02
 p value p = 0.29 p = 0.19 p = 0.25
Place of living
 With wife
85 (47.2) 86.08 ± 18.76 24.35 ± 4.97 31.88 ± 11.58
 With your spouse or children
50 (27.8) 72.26 ± 22.92 24.32 ± 4.50 48.22 ± 17.08
 Single
45 (25) 76.11 ± 23.74 22.35 ± 5.47 39.75 ± 15.38
 p value p = 0.001 p = 0.07 p = 0.000

2015, an increase in SH reduced anxiety in cardiac patients. In the Rahimi et al.

(2017) study, increasing the SH score reduced the anxiety of the students. The
M(SD) RC is 23.84 (5.02). In the study of Hatefi et  al. (2019c), M(SD) RC in
the elderly with chronic back pain is 20.67 (2.59). In the study of Hatefi et  al.
2019d, increasing the religious beliefs score decreased the anxiety of patients.
The results of these studies are in line with the results of this study.

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Table 2  Relationship between Items DA

treatments with RC and spiritual
health
Spiritual health
 Religious health R = − 0.69, p = 0.000
 Existential health R = − 0.69, p = 0.000
 Total spiritual health R = − 0.72, p = 0.000
Religious coping
 Positive RC R = − 0.41, p = 0.000
 Negative RC R = − 0.16, p = 0.04
 Total RC R = − 0.26, p = 0.001

Conclusion

Considering the relationship between RC and SH with DA in the elderly, it is neces-

sary to make the necessary spiritual–religious arrangements to reduce DA.

Acknowledgments  We appreciate the elders of this study. Funding was provided by 344224 (Grant No.
24533).

Compliance with Ethical Standards 

Conflict of interest  The authors declare that they have no competing interests.

Research Involving Human Participants and/or Animals  Research involving human.

Informed Consent  Compliance with the ethical codes of 24 in the research, the non-imposing of the cost
on the patient, explaining the goals of the research to patients.

References
Abdi, A., Tarjoman, A., & Borji, M. (2018). Prevalence of elder abuse in Iran: A systematic review and
meta-analysis. Asian Journal of Psychiatry, 39, 120–127.
Abedi, S., Foroughan, M., Khanjani, M. S., Bakhshi, E. A., & Farhadi, A. (2016). Relationship between
meaning of life and spiritual well-being in the older people residing in nursing homes Shemiranat,
2014. [Research]. Salmand: Iranian Journal of Ageing, 11(3), 456–465.
Aghajani, M., Valiee, S., & Tol, A. (2011). Death anxiety amongst nurses in critical care and general
wards. Iranian Journal of Nursing, 23(67), 59–68.
Ahmadpoori, F. (2019). The effect of positive thinking skills (optimism) based on thanksgiving notebook
on the spiritual health of adolescent girls. [Community health nursing]. Iranian Journal of Nursing
Research, 14(1), 50–57.
Akhoondzadeh, G., Jalalmanesh, S., & Hojjati, H. (2014). Effect of reminiscence on cognitive status and
memory of the elderly people. Iranian Journal of Psychiatry and Behavioral Sciences, 8(3), 75.
Bahrami, M., & Behbahani, M. A. (2019). The effect of a health literacy promotion program on the level
of health literacy and death anxiety in women with breast cancer. Iranian Journal of Nursing and
Midwifery Research, 24(4), 286.
Bahrami, N., Moradi, M., Soleimani, M., Kalantari, Z., & Hosseini, F. (2013). Death anxiety and its rela-
tionship with quality of life in women with cancer. Iran Journal of Nursing, 26(82), 51–61.

13
Journal of Religion and Health

Bala, R., & Maheshwari, S. (2019). Death anxiety and death depression among elderly. International
Journal of Psychiatric Nursing, 5(1), 55–59.
Catalan-Serra, P., Campos-Rodriguez, F., Reyes-Nuñez, N., Selma-Ferrer, M. J., Navarro-Soriano, C.,
Ballester-Canelles, M., et al. (2019). Increased incidence of stroke, but not coronary heart disease,
in elderly patients with sleep apnea: Role of continuous positive airway pressure treatment. Stroke,
50(2), 491–494.
Curcio, C. S. S., & Moreira-Almeida, A. (2019). Who does believe in life after death? Brazilian data from
clinical and non-clinical samples. Journal of Religion and Health, 58(4), 1217–1234.
Ellison, L. (2006). A review of The Spiritual Well-Being Scale. NewsNotes, 44(1).
Ghadiri, M., & Motaghi, M. (2016). Homeopathy impact on physical health aspects of quality of life of
patients with chronic headache in Isfahan in 2015. Biomedical and Pharmacology Journal, 9(1),
269–274.
Ghorbanalipour, M., Falsafinejad, M., Sohrabi, F., & Borjali, A. (2010). The effect of death anxiety and
age on health promoting behaviors. The Journal of Urmia University of Medical Sciences, 21(2),
286–292.
Gire, J. T. (2002). How death imitates life: Cultural influences on conceptions of death and dying. Online
Readings in Psychology and Culture, 3(2), 2.
Hatefi, M., Abdi, A., Tarjoman, A., & Borji, M. (2019a). Prevalence of depression and pain among
patients with spinal cord injury in Iran: A systematic review and meta-analysis. Trauma Monthly,
24(4), e87503–e87503.
Hatefi, M., Parvizi, R., Borji, M., & Tarjoman, A. (2019b). Effect of self-management program on pain
and disability index in elderly men with osteoarthritis. Anesthesiology and Pain Medicine, 4(4),
e92672.
Hatefi, M., Tarjoman, A., & Borji, M. (2019c). Do religious coping and attachment to god affect per-
ceived pain? Study of the elderly with chronic back pain in Iran. Journal of Religion and Health,
58(2), 465–475.
Hatefi, M., Vaisi-Raygani, A., Borji, M., & Tarjoman, A. (2019d). Investigating the relationship between
religious beliefs with care burden, stress, anxiety, and depression in caregivers of patients with spi-
nal cord injuries. Journal of Religion and Health. https​://doi.org/10.1007/s1094​3-019-00853​-3.
Hedayati, E., Hazrati, M., Momen Nasab, M., Shokoohi, H., & Afkari, F. (2016). The relationship
between spiritual well-being and anxiety of aged people admitted in coronary care units. Salmand
Iranian Journal of Ageing, 11(3), 432–439.
Hoelterhoff, M. (2010). Resilience against death anxiety in relationship to post-traumatic stress disorder
and psychiatric co-morbidity. Plymouth: University of Plymouth.
Hojjati, H., Sarbani, A., & Alimmohammadzadeh, K. (2017). The Relationship between daily spiritual
experiences and perceived stress in the spouses of war veterans with post-traumatic stress. Journal
of Military Medicine, 19(2), 135–142.
Ilali, E., Taraghi, Z., Yazdani, J., Golmohammadi, M., Savasari, R., & Mosavi Jarrahi, A. (2016). The
relationship between praying and spiritual health among iranian older people with cerebrovascular
accidents. Salmand: Iranian Journal of Ageing, 11(3), 424–431.
Ito, H., Tominari, S., Tabara, Y., Nakayama, T., Furu, M., Kawata, T., et al. (2019). Low back pain pre-
cedes the development of new knee pain in the elderly population; a novel predictive score from a
longitudinal cohort study. Arthritis Research and Therapy, 21(1), 98.
Jadidi, A., Farahaninia, M., Janmohammadi, S., & Haghani, H. (2011). The relationship between spiritual
well-being and quality of life among elderly people residing in Kahrizak senior house. Iran Journal
of Nursing, 24(72), 48–56.
Jones, G. L. (1999). The relationships among spirituality, religion, and mental health for African Ameri-
cans. Ann Arbor: ProQuest Information & Learning.
Khademvatani, K., Aghakhani, N., Esm-Hoseini, G., Hazrati, A., Alinezhad, V., Nazari, H., et al. (2015).
Study of relationship between spritual health, anxiety and depression in acute myocardial infarc-
tionpatients hospitalized in Seyyedoshohada Hospital in Urmia. Urmia Medical Journal, 25(12),
1092–1101.
Khalili, F., Sum, S., & Asayesh, H. (2013). Spiritual health among Isfehanian elderly people. Salmand:
Iranian Journal of Ageing, 8(1), 16–23.
Kim, Y., & Kim, M. (2019). Factors influencing death anxiety in community-dwelling elderly: Based on
the ecology theory. The Korean Journal of Hospice and Palliative Care, 22(1), 30.
Majidi, A., & Moradi, O. (2018). Effect of teaching the components of spiritual intelligence on death
anxiety in the elderly. Iranian Journal of Ageing, 13(1), 110–123.

13
 Journal of Religion and Health

Masoudzadeh, A., Setareh, J., & Mohammadpour, R. A. (2008). A survey of death anxiety among per-
sonnel of a hospital in Sari. Journal of Mazandaran University of Medical Sciences, 18(67), 84–90.
Nasrabadi, T. (2018). Investigating the impression of diet training on patients under hemodialysis. Annals
of Tropical Medicine and Public Health, 1, 11–19.
Okhli, A., Hojjati, H., Sadeghloo, A., Molaei, A., & Shahrabady, S. (2019). The relationship between
observing religious beliefs and suffering in hemodialysis patients. Journal of Religion and Health.
https​://doi.org/10.1007/s1094​3-019-00887​-7.
Pargament, K. I., Koenig, H. G., & Perez, L. M. (2000). The many methods of religious coping: Develop-
ment and initial validation of the RCOPE. Journal of Clinical Psychology, 56(4), 519–543.
Pouy, S., Peikani, F. A., Nourmohammadi, H., Sanei, P., Tarjoman, A., & Borji, M. (2018). Investigating
the effect of mindfulness-based training on psychological status and quality of life in patients with
breast cancer. Asian Pacific Journal of Cancer Prevention: APJCP, 19(7), 1993.
Rahimi, N., Asadolahi, Z., & Afsharipour, A. (2017). A study on the relationship between spiritual health
and level of anxiety in the students of nursing and midwifery faculty. Religion and Health, 4(2),
56–64.
Rezaei, M., Seyedfatemi, N., & Hosseini, F. (2009). Spiritual well-being in cancer patients who undergo
chemotherapy. Hayat, 14(4 and 3), 33–39. http://hayat​.tums.ac.ir/artic​le-1-135-en.html.
Sadrollahi, A., & Khalili, Z. (2015). Spiritual well-being and associated factors among the elderly popu-
lation in Kashan. Journal of Geriatric Nursing, 1(2), 94–104.
Scott, E. L., Agresti, A. A., & Fitchett, G. (1998). Factor analysis of the ‘Spiritual well-being scale’
and its clinical utility with psychiatric inpatients. Journal for the Scientific Study of Religion, 37,
314–321.
Seyedfatemi, N., Rezaie, M., & Givari, A. (2006). HosseiniF. Prayer and spiritual well-being in cancer
patients. Journal of the Iranian Institute for Health Sciences Research, 4(5), 295–303.
Shafaii, M., Payami, M., Amini, K., & Pahlevan, S. (2017). The relationship between death anxiety and
quality of life in hemodialysis patients. Hayat, 22(4), 325–338.
Sharak, F. M., Bonab, B. G., & Jahed, M. (2017). Relationship between stress and religious coping and
mental health in mothers with normal and intellectually disabled children. International Journal of
Educational and Psychological Researches, 3(3), 198.
Smith, J., & McSherry, W. (2004). Spirituality and child development: A concept analysis. Journal of
Advanced Nursing, 45(3), 307–315.
Soleimani, M. A., Sharif, S. P., Yaghoobzadeh, A., Sheikhi, M. R., Panarello, B., & Win, M. T. M. (2019).
Spiritual well-being and moral distress among Iranian nurses. Nursing Ethics, 26(4), 1101–1113.
Taheri-Kharameh, Z., Saeid, Y., & Ebadi, A. (2013). The relationship between religious coping styles and
quality of life in patients with coronary artery disease. Iranian Journal of Cardiovascular Nursing,
2(1), 24–32.
Vasigh, A., Tarjoman, A., & Borji, M. (2018). The effect of spiritual-religious interventions on patients’
pain status: systematic review. Anaesthesia, Pain & Intensive Care, 22(4), 499–505.
Vasigh, A., Tarjoman, A., & Borji, M. (2019). Relationship between spiritual health and pain self-effi-
cacy in patients with chronic pain: a cross-sectional study in west of Iran. Journal of Religion and
Health. https​://doi.org/10.1007/s1094​3-019-00833​-7.
Vazifeh doust, M., Hojjati, H., & Farhangi, H. (2019). Effect of spiritual care based on ghalbe salim on
anxiety in adolescent with cancer. Journal of Religion and Health. https​://doi.org/10.1007/s1094​
3-019-00869​-9.
Woo, E.-K., Han, C., Jo, S. A., Park, M. K., Kim, S., Kim, E., et al. (2007). Morbidity and related factors
among elderly people in South Korea: Results from the ansan geriatric (AGE) cohort study. BMC
Public Health, 7(1), 10.

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