Impact of Religious Participation and Spirituality on the Health of Nigerian Older People: an online survey

ABSTRACT Africa, especially Nigeria, is reported to have high religious participation among her growing proportion of older people, yet few works are found in the literature on the impact of religiosity, or spirituality, on the health of the older people in Africa. Thus, this study explored the impact of religious participation and spirituality on the health or well-being of older Christians in Nigerian. A total of 103 Nigerian older people aged 65 years and above participated in this cross-sectional survey by responding to a researcher-administered questionnaire on the topics of religiosity, spirituality, and health status. The findings of this study demonstrated a significant correlation between the level of religious participation, the level of spirituality and psychological health, and the general well-being of older people, especially those aged 60–70 years. We conclude that religious participation and the level of spirituality of older people have an impact on their psychological health domain.


Background
The World Health Organization (WHO) defines health or well-being as "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity" (World Health Organization, 2006, p. 1). This definition portrays a biopsychosocial approach to health, which supports Lara et al. (2013, p. 189) description of health into five domains including; "physiological and metabolic health; physical capability; cognitive function; social well-being; and psychological well-being." These definitions are a progressive shift in approach to health from earlier biomedical perspectives to a more comprehensive biopsychosocial approach where religion and spirituality represents a valuable niche. Religiosity (religious participation) and spirituality are close in meaning but differ in concepts. Religiosity is described based on concrete concepts with structural and institutionalized elements and established rituals and practices. Spirituality is described and represented in abstract terms with an abstract element of sacred soul interaction to a higher being (Wulff, 1997). Africans' involvement in religious and spiritual activities has been shown in the literature to have profound recognition and wide practice, especially in older people (Lipka & Hackett, 2017;Sampson, 2014;Zimmer et al., 2016).
The subject of spirituality and religious impact on the health of older people is of sociological interest because spirituality positions as a positive resource to successful ageing (McFadden, 1995), and a key tool for end-of-life care (Daaleman et al., 2004;Daaleman & VandeCreek, 2000;Porte et al., 2017). Reasoning from an activity theory perspective of ageing as argued by Cavan et al. (1949), it has been shown that religious participation is the most familiar form of unpaid social engagement in old age as it readily provides alternatives for older people to subscribe to after retirement (Neill & Kahn, 1999). Previous studies have also shown that older people are more religiously involved compared to their younger counterparts (Bengtson & Putney, 2009;McFadden, 1995;Van Ness & Larson, 2002). And, it serves as social support in addition to the family. Secondly, from the arguments of Fields et al. (2018) on the social constructionist perspective of ageing, a religious group can provide a positive and beneficial social construct of age and health by its faith-based approaches to life situations (McFadden, 1995).
Although many biological and quantitative studies (Harold, 2012;Zimmer et al., 2016) have found it challenging to verify various benefits of religious participation on the health of the older people cited across literature, including healthier physical and mental function, social context of health practices, facilitation of healthier lifestyle, and lesser demand on caregivers. On the contrary, many gerontologists and sociological theories show convincing explanations for the possible role of religion on the well-being of older people. For instance, Tornstam's (1996) description of gero-transcendence perspective of ageing, the older age is a stage of adjustment in pursuit and expectations from acquisitive to religious goals. However, religion also poses challenges to health care in older people, especially in cases of noncompliance with medical advice and appointments due to reliance on faith (Kretchy et al., 2013). Also, the level of religious participation is an important factor in understanding the associated influence of spirituality on older people's health. Reasoning from the life course perspective, it is arguable that the life stage in which the individual began religious activity could have a profound effect on their state of health in later life (Wen & Gu, 2011). Therefore, it is pertinent that the impacts of religious participation in the various domains of health and wellbeing are verified from a sociological perspective and evidence.
The literature discussing the effect of religion on the health of the older people (Kirby et al., 2004;De La Porte, 2016;Levin & Chatters, 1998;Malone & Dadswell, 2018;Manning, 2013) most often only relates to a specific aspect of man's health needs, such as mental health in McFadden and Lunsman (2009), rather than on the comprehensive domain of health in ageing. Mostly they relied on a subjective measure of health status only and are often limited to a particular culture and time, making it difficult to adapt it to older persons in other nations. The only study that attempted a comprehensive perspective was a review of published articles by McFadden (1995), but this gives poor quality evidence as there is no detail on methodology. Ainlay et al. (1992) used both subjective and objective measures of health, but their study objectives focused on the effects of declining health on the level of religious participation. As well, the findings of Daaleman et al. (2004) could be limited by its use of selfreported health for the assessment of health status. Also, De La Porte (2016) conducted a review on spirituality and healthcare in South Africa that suggested that spirituality plays a valuable role towards comprehensive individual-centered care. However, this review did not include any original research done on religion and religiosity in Africa.
No literature was found on religion and health of the older people in Nigeria; the cross-cultural validity of the studies in literature and their adaptability to the African context is in doubt. In the case of the impact of religious participation on the health or well-being of older Christians in Nigeria, this is a particularly important omission given that the health of an individual is influenced by social and behavioral factors other than biomedical factors (Lara et al., 2013), and the reported high religious participation in Africa especially in Nigeria, which has the highest proportion of older people in Africa (Lipka & Hackett, 2017;Sampson, 2014;Zimmer et al., 2016). These crucial gaps in literature defined the objectives of this study: to explore the effect of religious participation and spirituality on the health or well-being of older Christians in Nigeria.

Study participants
A convenient sample of 103 older Christians aged 65 years and above participated in this cross-sectional survey, which was conducted between January and March 2021. A preliminary power analysis showed that a sample size of 100 participants will be needed for Fisher's transformation of the correlation coefficient to achieve 95% (0.95) power with a moderate to a large effect size of 0.50 at an alpha level of 0.05 (Cohen, 1998). Only older Christians living in any of the 36 states of Nigeria and who were available and willing to give their informed consent were considered eligible for inclusion. Those who have cognitive impairment and other physical challenges that could have reduced their functional ability to participate in religious activities were excluded from this study. The University of Nigeria Teaching Hospital Research Ethics Committee approved the study protocol (with the approval number: NHREC/ 05/01/200B-FWA00002458-1RB00002323) and all participants gave written and verbal informed consents before participation in the study.

Study instrument
A researcher-administered questionnaire designed to assess the effect of religious participation and spirituality on the health or well-being of older Christians was used for this study. The questionnaire, comprised of four sections, was developed in English. The first sections investigated older Christians' sociodemographic variables. In the three subsequent sections, levels of religious participation, spirituality, and the various domains of the older Christians' health status were assessed. Levels of religion were assessed with five questions, drafted in keeping with the context of religious practices and values in Nigeria and Krause's (1993) distinction of individual's religious involvement and group religious activities. The five questions were centered on religion status and membership, duration of membership, as well as frequency of participation in group religious activities and personal devotions. For the levels of spirituality, 12 questions previously validated by Daaleman et al. (2004) were adopted for this study. The questions centered on reliance on a third supreme being or on an individual's personal ability. Additionally, the fourth section was subdivided into the four domains of health as proposed by Lara et al. (2013). The physical functioning index of the medical outcomes study was adopted to assess the physiological health status (Stewart & Ware, 1992;Ware & Sherbourne, 1992). The Mini-Mental State Examination (MMSE) was adopted to assess cognitive function (Sugiyama et al., 2015). The Australian Community Participation Questionnaire (ACPQ) was adopted to assess their social well-being (Berry et al., 2007), and Geriatric Depression Scale was adopted to assess psychological health status (Yesavage et al., 1982). Also, a self-adapted proforma for documenting the participants' socio1demographics was used.

Procedure for data collection
Ethical approval was sought from the ethical and research committee, University of Nigeria Teaching Hospital before the commencement of this study. The researchers first used online social media platforms to recruit younger adults who live with an older person (age 65 and above) in their immediate household. The younger people willing to take part in the study were trained over the social media platform (WhatsApp group) on how to engage their closest older people using the structured researcher-administered questionnaire. The training included how to administer oral informed consent, in which they were given a participant's information document to read out to their older people and ask the older people to rehearse it back to them. The older people that were able to rehearse it satisfactorily proceeded to respond to the questionnaire. The oral informed consent was audio recorded and sent back to the researchers, which was used as an outcome to check the ability of the younger people to administer the questionnaire. The training also included a description of the questionnaire items, and criteria for inclusion of the older people. Because the research questions were targeted at the older people, to help afford a collaborative approach and increase the reach and representation of the older Christians across different locations in Nigeria, thus making it a national survey, the younger people who are more reachable online, and could follow the self-administered questionnaire were used to helped reduce the barriers to responses from the seldom-heard older populations (Community Care, 2008).
Thus, the younger people were then requested to help administer the online questionnaire on the older people in their family, or immediate household as an avenue towards discussing with their seniors matters about their health, and level of religious activity and spirituality after the older people had given their informed consent.
The researchers also administered the questionnaire in an in-depth interview with 15 older Christians to allow comparison and verify the effectiveness of using insider relatives. These were used for test-retest analysis with those collected online; the reliability value obtained was 0.78, which showed that the online data were reliable. Moreover, this afforded the benefit of the insider effect (Adamson & Donovan, 2002;Gunaratnam, 2003;Lee, 2008;Sedlakova & Souralova, 2019) and a form of collaboration with the close caregivers of the older people (Bindels et al., 2014;Marjanovic et al., 2019;Waite et al., 2019).

Statistical analysis
The data collected was analyzed using descriptive statistics tables of frequency counts and proportions for responses on sociodemographics, levels of religious participation and spirituality among the older people, and responses on general well-being. Each item of the questionnaire was scored, and the sections were categorized as high, moderate, and poor as appropriate; with items scored from the reverse direction. The inferential statistics of the Spearman Correlation were used to verify the relationships between the predictor variables; levels of religious participation, spirituality, and sociodemographic factors and the dependent variables; the various domains of the older Christians' health status. All analysis was carried out using Statistical Package for Social Science (SPSS) version 23 with a level of significance set at p < .05.

Results
A total of 103 responses were achieved at the end of this study. The demographic pattern of older Christians in Nigeria is presented in Table 1. It showed that the majority of the older Christians (52.5%) are within the age range of 60-70, and were married (52.4%), although most of them had no formal education (48.4%).
In Table 2, the levels of religious participation across the sociodemography and health status of Nigerian older Christians were shown. It showed that majority (30.1%) of older Christians aged 60-70 had high levels of religious activity, yet those above the age of 70 had the lowest levels of religious participation. However, religious activities did not have any statistical significance with the age of the older Christians. Similarly, levels of religious participation of the older Christians showed no statistical significance with the gender, education, marital status, household income, residential areas, and the social well-being, psychological and cognitive functions of the older Christians. On the other hand, there was a statistically significant positive correlation between levels of religious participation and the older Christians' occupation (r = 0.207; p = .037) with the self-employed showing the highest levels of religious participation (19.6%). The levels of spirituality across the sociodemography and health status of Nigerian older Christians are presented in Table 3. The result showed that the majority (42.7%) of the older Christians aged 60-70 had high levels of spirituality, yet those above the age of 70 had the lowest levels of spirituality. However, there was only a statistically significant positive correlation between levels of spirituality and the older Christians' education (r = 0.234; p = .017) with those having no formal education showing the highest levels of spirituality (36.0%). As well, residential areas showed a statistically significant positive correlation to levels of spirituality (r = 0.328; p = .001) with most urban settlers (51.5%) showing high levels of spirituality. Table 4 summarizes the inferential relationship of the older Christians' health status across the sociodemography, levels of religious participations and spirituality of the older Nigerian Christians. It showed there were statistically significant positive correlations between their psychological health and their religiosity (r = 0.243; p = .013) and their spirituality (r = 0.501; p = .000).

Discussion
The study of religion and spirituality is important in the field of gerontology as religion could match with health, financial security, and social support in defining the quality of life of the older person (McFadden, 1995). Thus, this study explored the impact of religious participation and spirituality on the health of older Nigerian Christians to determine the associated influence on successful ageing and shine a light on major ageing theories, such as: the activity and disengagement theory; the replacement of social role with religious roles, life course perspective; effect of spiritual practice in earlier age and the later life health status, psychological perspectives; aspect of resilience, as well as the social context of health promotion; positive social constructions of faith, and social support from religious bodies. The findings of this study demonstrated an increased engagement of the older Christians in religious and spiritual activities. According to the social constructionist explanation of ageing, which is confirmed by this study finding; as people age, they tend to participate more in religious activities, which indirectly improves their health and their perceived quality of life (Philipson et al., 2010). In the sequel, Zimmer et al. (2016) demonstrate this positive relationship between religious participation and health as helping to minimize the burden of carers of people as they age, as older Christians are constantly engaged in religious activities, which they delight in, and it fosters their sense of belonging in later life.
Although increased religious participation was common, this is most evident among those aged 60-70 years, as a decline in religious participation is shown to be higher among older Christians aged 70 years plus. This is in line with the disengagement theory by Bengtson and Putney (2009), which argues that people tend to dissociate from their environment and from participating in social activities as they age. However, our study distribution could hold a potential bias to age-effect as the participants were mostly within the age group of 60-70 years. More so, this decline in religious participation demonstrated by the participants who are 70 plus years old is not significant relative to the overall increase in religious and spiritual activities in older age. Therefore, it could be argued that religious participation practiced by people as they age influenced the state of their health in the Nigerian context. Also, the finding of this study demonstrates a significant correlation between the level of religious participation, the level of spirituality and psychological health, and the general well-being of older Christians, especially those aged 60-70 years. The relationship between religiosity, spirituality in old age, the psychological and the general well-being of older Christians is in tandem with the psychological perspective of active spirituality in the older people, which posit that older people trust in a supreme being to draw hope, explanations, and reliance of life circumstances from, therefore causing older people to report a better health outcome-especially psychological health status (Segal et al., 2018). This also supports the argument against the medicalization of the unmet health needs of older people as it confirms that the health of an older person is influenced by social and behavioral factors other than biomedical factors (Lara et al., 2013). Although the findings of the study by Kretchy et al. (2013) demonstrate that religion poses challenges to health care in older people, as it fosters noncompliance with medical advice and appointments due to reliance on faith. This dissimilarity in findings may be because of the different study populations, different participant characteristics, and research setting. Rather, the findings of this study demonstrate a positive relationship between the overall health outcome and religious participation and spirituality, suggesting that improving the level of religious participation and spirituality in later life may be employed as a measure to engage people as they age which could, in turn, improve older people's health outcome in Nigeria.
Furthermore, the significant relationship between older peoples' religiosity, spirituality, and their self-reported psychological health status highlights an emphatic role of religious participation and spirituality on the psychological domain of an older person's health status compared to the other health domains. This relationship has been implied in previous studies (Fields et al., 2018) and in the gero-transcendence perspective of ageing, which posits that though religiosity and spirituality may not stop the incidence of frailty, nor stop low social support, and influence of low financial capacity in the older age, it helps the older Christians to adjust in their pursuit and expectations from acquisitive goals to drawing their hope from a supreme being to foster their sense of belonging and succor in later life. This adjustment is shown to take place in the psychological domain of older people (Fields et al., 2018;Tornstam, 1996). Also, in the biopsychosocial approach to health, spirituality positions as a positive resource to successful ageing (McFadden, 1995) and is a key tool for end-of-life care (Daaleman et al., 2004;Daaleman & VandeCreek, 2000). This finding holds relevance for social service organizations, long-term care facilities, educational institutions, healthcare services, churches, and gerontologists.
This study's strength is found in its attempt to provide novel data on the impact of religious participation on the health of older Christians from the Nigerian context. Empirical data is provided on the level of participation in religious and spiritual activities, duration of initiation in religious and spiritual activity across the life cycles, and aspects of well-being that are associated with religion and spirituality. These could inform clinicians, gerontologists, institutional care and home services, and other agencies involved in the care of the older people on the appropriate application of religion and spirituality as a coping resource in critical or terminal health and sociological concerns in older people. However, this study finding is to be reviewed with its limitations in view. The major limitation of this study includes the use of online social media platforms for data collection, which could have impaired the accessible population of the older people. For instance, the older adults interviewed all had younger family members with whom they were in contact, which further defines the characteristics of the sample and may impact the results. We recommend that further studies on the topic of the impact of religion and spirituality be carried out with the effort to comprehensively and proportionately compare the different categories of older people's religious status in Nigeria.

Conclusion
Religious participation and the level of spirituality of older Christians have an impact on the psychological domain of their health status. This supports the argument that the health of an older person is influenced by social and behavioral factors other than biomedical factors. Thus, religiosity and spirituality could help to ameliorate the deleterious impact of the incidence of frailty, low social support, and influence of low financial capacity in the older age, by helping the older people to adjust in their pursuit and drawing their hope from a supreme being to foster their sense of belonging and succor in later life.