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ORIGINAL ARTICLE

An exploratory study of religious involvement as a moderator between anxiety, depressive symptoms and quality of life outcomes of older adults
Chiung-Yu Huang, Mei-Chi Hsu and Tai-Jui Chen

Aims. The aims of this study were to examine the relationships among religion, religious involvement, anxiety, depressive symptoms and quality of life in older adults with psychological problems and whether religious involvement moderated anxiety and depressive symptoms on the outcome of quality of life. Evidence for the mechanism through which religious involvement exerts its moderated effect on anxiety and depressive symptoms was provided. Background. Older adults suffering from stress may consequently have anxiety or depressive symptoms and their quality of life is also inuenced. The meanings of religious involvement are well documented but less is known about moderating characteristics that determine which older adults with psychological problems are most likely to benet. Design. A correlational, cross-sectional study. Methods. The study was conducted in 20072008 with a purposive sample of 115 older adults who were 60 years of age or older at a psychiatric centre in Taiwan. Three reliable and valid questionnaires and a demographic sheet were administered. Results. Approximately 75% of older adults had mild to severe anxiety; 765% had depressive symptoms; and 678% of participants who had depressive symptoms also had comorbid anxiety. Findings indicated that there was a signicant moderating effect for religious involvement on the quality of life outcome. Religious involvement signicantly moderated anxiety and depressive symptoms on quality of life. Moreover, religious participants had a better quality of life and had lower anxiety and depressive symptoms than non-religious participants. Conclusion. Testing for moderating effects provides important information regarding the benets of religious involvement. The current study reveals that religious participants have lower levels of depressive symptoms and anxiety and better quality of life than non-religious ones. Religious involvement plays a role in buffering the relationship between psychological problems and quality of life. Relevance to clinical practice. Nurses can encourage individuals with health problems to participate in religious involvement, which may help individuals to experience a feeling of support and enhance their quality of life. Key words: anxiety, depressive symptoms, moderating effect, nursing, quality of life, religious involvement
Accepted for publication: 21 June 2010

Introduction
Depression will become the second leading cause of disability worldwide by the year 2020 (Judd et al. 2000). Approximately 3% of older adults who live in the community had
Authors: Chiung-Yu Huang, PhD, RN, Associate Professor, Department of Nursing, I-Shou University; Mei-Chi Hsu, PhD, RN, Associate Professor, Department of Nursing, I-Shou University; Tai-Jui Chen, MD, Psychiatrist, E-DA Hospital, Department of Psychiatry, Kaohsiung County, Taiwan

serious depression and 10% of older people were institutionalised in long-term care systems with serious depression (Regier et al. 1993). In Taiwan, the prevalence of community-dwelling older adults with depressive symptoms is 3157% (Lyu & Lin 2000, Wang 2001).
Correspondence: Mei-Chi Hsu, Associate Professor, Department of Nursing, I-Shou University, No. 8, Yida Rd., Jiaosu Village Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C. Telephone: +886 7 6151100 ext. 7720. E-mail: hsu88@isu.edu.tw

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Quality of life has been emphasised as an important outcome of psychological problems (Michalak et al. 2004, Swan et al. 2009). The psychological problem has a specic and persisting detrimental effect on the health and quality of life (Michalak et al. 2004, Swan et al. 2009) and that disability strongly results from the impingement on quality of life. Further, patients with anxiety or depressive symptoms may have diminished quality of life (Michalak et al. 2004, Swan et al. 2009). Religion has been an essential component of health and well-being. Aranda (2008) dened religious involvement as encompassing formal, public and collective involvement at worship-related services as well as more informal activities such as private prayer. Religious involvement may play a role to positively affect physical and psychological well-being (Schnittker 2001, Townsend et al. 2002), especially for older adults (Lauder et al. 2006). Adherence to religious practices and beliefs may be of great importance to patients with health problems (Halligan 2006). However, an understanding of religious involvement on health outcomes is still incomplete. Reports regarding the moderation of religious involvement on quality of life among older adults with psychological problems are also spare. The key features of the methodology selected for the study are to test moderator effects using regression techniques and provide a general framework for moderation analysis, suggestions for further reading and relevance to clinical practice.

Background
Religious beliefs are central to peoples lives and are powerful inuences on cognition, behaviours and affect (Strawbridge et al. 2001, Rammohan et al. 2002, Halligan 2006). Researchers have identied the effects of religion on health outcomes and psychological well-being in chronic illness in older adults (Chen et al. 2007, Hebert et al. 2007, Shih et al. 2009). Religious involvement has particular importance in coping with illness or long-term illness (Kabat-Zinn et al. 1997, Shih et al. 2009) and may acts as a buffer between stress and mental health (Williams et al. 1991). Research has suggested that religious beliefs and practices made a difference in anxiety and depression rates (Russinova et al. 2002, Hahn et al. 2004, Hill et al. 2005) and treatment (Koenig et al. 1998). Adults with more religious involvement may have less depression (Braam et al. 1997, Koenig 1998). Kabat-Zinn et al. (1997) examined the effect of Buddhisms mindfulness of 1200 older adults with mental or physical illness in a medical centre in the USA. The researchers used the skill of breathing in and out and a mindfulness skill that helps to prevent negative consequent emotions. Kabat-Zinn

(1997) reported some patients with decreased depressive symptoms, anxiety or anger after this mindfulness practice. Furthermore, recent studies had also used mindfulness meditation in clinical practice and displayed a signicant effect of mindfulness religious practices in minimising health problems (Speca et al. 2000, Teasdale et al. 2000, Marlatt 2002, Russinova et al. 2002). Depressive patients may recover from their illness by religiousness (Wang 2000a). Increased religious attendance is directly related to less depressive symptoms, increased perceived health and higher life satisfaction (Aranda 2008). Religion had also been used for depression therapy (Raab 2007). In Chinese culture, religion has its own historical and cultural traditions and has had a profound inuence on the values and the way of life of the Chinese people. Religious or spiritual activities may be sought in Chinese culture to help people who are suffering from mental illness. A large study investigated the association between religious attendance and the prevalence of depressive symptoms among communitydwelling older persons in Taiwan (Hahn et al. 2004). The study found that those who had not attended religious activities during the past six months were at higher risk of being depressed than those who had. The attending of religious activities is a protective factor for geriatric depression. Moreover, Lee et al. (2004) compared the illness and help-seeking behaviours of outpatients with major depressive disorders and non-depressive minor mental disorders in Taiwan. They found that both groups used psychiatrists and folk therapy together for treating depression. Nearly 60% of Taiwanese patients used religion quite often as a mechanism for coping with their illness (Koenig et al. 1997). Two studies also reported that depressive patients recovered from their illness by religiousness or after a three-week Buddhist mindfulness meditation (Chuang 1997, Wang 2000b). Taken together, the studies reviewed suggest that religious involvement exhibits both preventive and therapeutic benets on mental health outcomes. Some aspects of religious involvement are associated with less depression. In addition, with regard to clinical care, it is clear that the assessment of religious issues become an important part of patient evaluation in mental health care. Importantly, efforts to expand the understanding of the role of religion in health care of Taiwanese people should be made.

The conceptual framework to guide the moderation model


The counterbalancing model (Krause & Tran 1989) was used to explain the role of religious involvement as a moderator
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that enhances quality of life. The moderator variable selected for this study based on the counterbalancing model and empirical research ndings to explain the relationship between predictors, moderating characteristics and specic outcomes. This conceptual framework contributes to our understanding of the possible ways religion serves to buffer the impact of anxiety or depressive symptoms on the quality of life of older adults and the mechanisms underlying these links. The study is focused with the following sequential hypothesis testing. Hypotheses of this study included: 1 There were signicant relationships among independent variables (age, gender, life arrangement, duration of symptoms, religion and religious involvement) and outcomes variables (anxiety, depressive symptoms and quality of life). 2 Religious involvement played a role to moderate anxiety/ depressive symptoms on quality of life.

size was sufcient to conduct multiple regression and obtain statistically stable results. Participants were eligible for the study if they were (1) 60 years of age or above, (2) were able to communicate in Chinese or Taiwanese. Exclusion criteria consisted of drug abuse or dependence, clinically diagnosed neurological illness, such as dementia, medical illness or physical impairments, severely inuencing individuals cognitive dysfunction.

Instruments
Several instruments were used to collect data. The demographic information sheet was used to measure sample characteristics. Data were collected on age in years, gender, education years (non, 26, 9, 12, >12), living arrangements as being independent or supervised and duration in months of symptoms. In addition, one question measured the subjects frequency of attendance ranging from never or almost never, once or twice a year, every few months, once or twice a month, once a week or more than once a week. The range of scores was coded from 212, higher scores indicating a greater frequency (Koenig et al. 1997, Bosworth et al. 2003, Hill et al. 2005). Beck Anxiety Inventory (BAI) Beck Anxiety Inventory (BAI) was developed by Beck et al. (1988). It is a 21-item questionnaire about how the subject has been feeling in the last week, expressed as common symptoms of anxiety. Participants were asked to rate on a four-point scale (0 = rarely or none bothered, 1 = slightly bothered, 2 = moderately bothered, 3 = seriously bothered). The total score was calculated, with higher scores indicating a higher anxiety, with scores 07 representing normal, 815 representing mild anxiety, 1625 representing moderate anxiety and 2663 representing serious anxiety. For this study, Cronbachs alpha was 092. Centre for Epidemiological Studies-Depression Scale (CES-D) Depressive symptoms were measured by the Center for Epidemiological Studies-Depression Scale (CES-D Scale; Radloff & Locke 1986). Participants were ranked on a four-point scale (0 = rarely or none of the time, 1 = some or little of the time, 2 = occasionally or a moderate amount of time, 3 = most or all of the time) investigating perceived mood and level of functioning in the past seven days. Scores ranged from 060, with higher scores reecting greater depressive symptoms. Scores of CES-D scale at or above 16 were considered at risk or having a clinical depression (Radloff 1977). The CES-D has been used in Taiwan and was found to be reliable and

The study
Aims
The aims of this study were to examine the unique relationships among religion, religious involvement, anxiety, depressive symptoms and quality of life in older adults and whether religious involvement moderated anxiety and depressive symptoms on the outcome of quality of life. Evidence for the mechanism through which religion exerts its moderated effect on anxiety and depressive symptoms was provided.

Design
A cross-sectional and correlational research design was conducted in Taiwan, and data were collected over vemonths in 20072008. Ethical approval was granted from the participating hospital. Participants were informed of the voluntary nature of their participation, right to withdraw, condentiality of data and anonymity.

Sample and setting


An adequate sample of 115 participants was recruited from an outpatient clinic located in the southern Taiwan. This sample size was necessary as indicated by sample size calculation recommended by Cohen (1988) for correlation and regression analysis to achieve a power of 080 with a medium effect size of 015 and an alpha level of 005. A sample size of 98 was required. Therefore, the study sample
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valid, coefcient alpha for the translated scale was 089 (Huang et al. 2006). Coefcient alpha for the scale was 072 for caregivers of individuals with stroke and 084 for caregivers of individuals with Alzheimers disease in Huang et al.s (2009). Convergent validity and discriminate validity have been adequate. For this study, Cronbachs alpha was 091. Quality of life index The quality of life index (Ferrans & Powers 2003) was used to investigate the quality of life of older adults with mental illness included in four subscales: health and functioning, socio-economics, psychological/spiritual wellness and family life, which had high internal consistency (total alpha = 094; with alpha value for the four subscales as 087 of health and functioning subscale, 072 of social-economics subscale, 090 of psychological/spiritual wellness subscale, 088 of family life subscale) for this study.

dispersion (range, variance, standard deviation) of the scores. Pearson product-moment correlation, t-test, ANOVA and hierarchical multiple regression were used to analyse the predictors of health outcomes.

Results
Characteristics of the sample and study variables
A total of 115 participants were recruited. The characteristics of the sample and study variables were shown in Table 1. The average age of participants was 645, the majority of participants were women and married and most of their living arrangements were independent (n = 103, 896%). Eighty-ve participants had less than six years of education. The average duration of their psychological problems was 2257 months. Sixty-ve participants (565%) professed to

Procedures
To train the research team members and to ensure the reliability of the measure, the primary researcher conducted a brief training before the study. The patients were approached regarding study participation by the physician on the day of their arrival at the outpatient psychiatric department. An initial screening was used to determine study eligibility. The research team members then assess their willingness to participate. Participants who expressed interest were further interviewed. All participants received written and oral information about the study. Those who agreed to participate signed a written informed consent and responded to the instrument packet. Consenting participants were asked to complete the survey in the waiting room. Face to face interviews were used to assist with survey completion, to ensure participants understood what religious involvement, depressive symptoms and quality of life are and had the opportunity to discuss any unclear questions. Participants were free to have rest periods during the process of data collection to minimise the possible physical discomfort.

Table 1 Sample characteristics (n = 115) Variables Age Duration of symptoms (months) Mean 645 2257 SD 7 4344 Range 5582 0240

n (%) Gender Male Female Marital status Single Separated Widowed Divorced Married Education (school years) Illiterate 26 29 212 >12 Living arrangement Independent Supervised Frequency of religious involvement Never 12 times per year 1 time several months 12 times per month Once a week Several times a week Religion No Yes

50 (435) 65 (565) 4 3 11 2 95 41 44 11 12 7 (35) (26) (96) (17) (826) (357) (383) (96) (104) (61)

103 (896) 12 (104) 67 17 6 12 2 11 (583) (148) (52) (104) (17) (96)

Data analysis
The Statistical Package for Social Sciences (SPSS ) version 15.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. The data included descriptive analysis, preliminary data analysis and research hypotheses testing. For descriptive analysis, summary statistics for each variable were obtained to examine the shape of the distribution (normal, skewness, kurtosis), central tendency (mean, median, mode) and

50 (435) 65 (565)

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An exploratory study of religious involvement Table 3 The differences between sample characteristics and quality of life (n = 115) n Gender Female 65 Male 50 Marital status Single 4 Separated 3 Widowed 11 Divorced 2 Married 95 Living arrangement Independent 103 Supervised 12 Religion Without 50 With 65 M SD t or F

have a religious faith. However, regarding formal religious involvement, 67 subjects (583%) stated they had never attended a formal religious activity.

The prevalence of anxiety and depressive symptoms


The mean BAI score was 1903 (SD 1520). A total of 748% participants had mild to severe anxiety. About 252% of participants had mild anxiety; 209% had moderate anxiety; and 287% of the participants had severe anxiety. In addition, the mean CES-D score was 2883 (SD 1432). A total of 765% had scores of 16 or above on the CES-D and were considered at a risk or with clinical depression. Moreover, 678% of participants who had depressive symptoms also had comorbid anxiety.

6132 5886 4888 62 1495 17675 7503 6415 2683 709 10115 11797 5694 11607 15580 15512 15466 14040 15786 13696

t = 0085

F = 2265

t = 0798

t = 3416***

Correlations of demographic, anxiety, depressive symptoms and quality of life


Education had positive relationships with the overall quality of life (r = 0203, p < 005) and the quality of life in two major subscales: health and functioning (r = 0228, p < 005) and social and economic (r = 0253, p < 001) (Table 2). Frequency of religious involvement showed significant relationships with overall quality of life (r = 0214, p < 005) and three subscales of quality of life: social and economic (r = 0213, p < 005), psychological wellness (r = 0190, p < 005) and family life (r = 0283, p < 001). More religious involvement was associated with better quality of life. In Table 3, only a signicant difference existed between participants with and without religion (t = 3416, p = 0001). Religious patients have better quality of life than the non-religious patients.

*p < 005, **p < 001 (2-tailed), ***p < 0001.

No signicant gender differences were observed on anxiety (Table 4). There was a signicant difference between anxiety and marital status (F = 3137, p = 0035) (Table 5). Anxiety of divorced participants was greater than those of married, separated and single ones. Based on living arrangements, anxiety of independent participants was signicantly lower than supervised ones (t = 2007, p = 0047). Anxiety levels were found as signicantly lower in the patients with religion compared with the patients without religion (t = 36, p = 0001). For depressive symptoms, there was no signicant difference in gender, marital status and living arrangement (p > 005). For participants with religion, their depressive

Table 2 Correlation matrix for demographic, anxiety, depressive symptoms and quality of life (n = 115) Variables 1. Age 2. Education 3. Duration 4. FRI 5. Anxiety 6. DS 7. OQOL 8. HF 9. SE 10. PS 11. Family 1 100 0237* 0077 0079 0001 0012 0003 0029 0004 0014 0054 2 3 4 5 6 7 8 9 10 11

100 0179 0137 0142 0102 0203* 0228* 0253** 0084 0101

100 0211* 0074 0040 0013 0067 0012 0044 0014

100 0061 0064 0214* 0109 0213* 0190* 0283**

100 0675** 0559** 0567** 0457** 0520** 0261**

100 0575** 0529** 0450** 0543** 0383**

100 0911** 0866** 0868** 0703**

100 0690** 0742** 0472**

100 0681** 0647**

100 0442**

100

FRI, Frequency of religious involvement; DS, Depressive symptoms; OQOL, Overall Quality of Life; HF, Health and Functioning; SE, Social and Economic; PS, Psychological/Spiritual; Family, Family subscale. *p < 005, **p < 001 (2-tailed), ***p < 0001.

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n Gender Female 65 Male 50 Marital status Single 4 Separated 3 Widowed 11 Divorced 2 Married 95 Living arrangement Independent 103 Supervised 12 Religion Without 50 With 65

SD

t or F

Scheffes test

2071 1684 1375 933 2573 485 1816 1807 2725 2456 1477 96 95 1535 495 1487 1494 1552 1541 1369

t = 1358

F = 3137*

Divorced > married Divorced > separate Divorced > single

t = 2007*

t = 36***

*p < 005, **p < 001 (2-tailed), ***p < 0001.

symptoms level was signicantly lower than those without religion (t = 4532, p < 0001).

Moderating effects of religious involvement


Because of the signicant ndings pertaining to anxiety, depressive symptoms and quality of life outcomes of correlation matrix (Table 2), the researchers further examined the following regression model. This includes (6a) the moderating effect of religious involvement between anxiety and overall quality of life and four subscales: health functioning, social economic, psychological/spiritual and family quality of life and (6b) the moderating effect of religious involvement
Table 5 The differences between sample characteristics and depressive symptoms (n = 115) n Gender Female Male Marital status Single Separated Widowed Divorced Married Living arrangement Independent Supervised Religion Without With M SD t or F

65 50 4 3 11 2 95 103 12 50 65

2817 2968 295 17 35 535 2794 2757 3208 3442 2314

1513 1962 1737 1212 117 007 1752 1440 1359 1254 1374

t 0466

F 1866

t 1033

t 4532***

*p < 005, **p < 001 (2-tailed), ***p < 0001.

between depressive symptoms and overall quality of life and four subscales: health functioning, social economic, psychological/spiritual and family quality of life. If a moderating effect occurred, two situations should exist: (1) a signicant nding of interaction term, (2) weakened (moderated) or increased strength or direction found in the relationship between anxiety/depressive symptoms and quality of life. Before computing interaction term, centring was applied to minimise the multicollinearity between the main effects and the interaction term. The interaction term indicated the moderator variables (anxiety religious involvement and depressive symptoms religious involvement), which buffered the relationships between the independent and dependent variables. Ten hierarchical multiple regression analyses were used to examine moderating effects and thus four moderating effects of religious involvement occurred. For testing the moderating effect of religious involvement on the relationship between anxiety and overall quality of life (and four subscales), only one interaction term for family subscale was signicant. In model 6a, shown on the Table 6, the moderating effect of religious involvement occurred between anxiety and family subscale of quality of life. The incremental R2 change was 0193, which indicated that the interaction term (religious involvement anxiety) explained 193% of variance in family subscale of quality of life. For testing the moderating effect of religious involvement on the relationship between depressive symptoms and overall quality of life (and four subscales), three interaction terms for quality of life were signicant. In model 6b, shown in Table 7, the moderating effect of religious involvement

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Table 6 Hierarchical regression analysis for the moderating effect of religious involvement on the relationship between anxiety and family quality of life Model 6a Step 1 2 Predictor Constant Depression Constant Depression Depression religious involvement b 22829 0128 23815 0184 005 b R2 0183 0281*** 0214 0406*** 0315* 0193 4361* Adjusted R2 0169 F-change 12579***

*p < 005, **p < 001 (2-tailed), ***p < 0001.

Table 7 Hierarchical regression analysis for the moderating effect of religious involvement on the relationship between depressive symptoms and total quality of life Model 6b Step 1 2 Predictor Constant Depression Constant Depression Depression religious involvement b 266872 7303 265373 8304 0644 b R2 0458 0676*** 0496 0744*** 0208** 0487 8744** Adjusted R2 0453 F-change 96999***

*p < 005, **p < 001 (2-tailed), ***p < 0001.

occurred between depressive symptoms and overall quality of life. The incremental R2 change was 0496, which indicated that the interaction term (religious involvement depressive symptoms) explained 496% of variance in overall quality of life. In model 6c, shown in Table 8, the moderating effect of religious involvement occurred between depressive symptoms and social and economic subscale of quality of life. The incremental R2 change was 0234, which indicated that the interaction term (religious involvement depressive symptoms) explained 234% of variance in social and economic quality of life. In model 6d, shown in Table 9, the moderating effect of religious involvement occurred between depressive symptoms and family subscale of quality of life. The incremental R2 change was 0235, which indicated that the interaction term (religious involvement depressive symptoms) explained 235% of variance in family quality of life.

Discussion
Religion may be an especially critical factor for older adults because older people tend to be more deeply involved in religion than younger people. Moderating effects of religious involvement occurred in the relationship between anxiety/ depressive symptoms and quality of life. The results indicate that those high in levels of anxiety or depression tend to have poor quality of life; religious involvement, in turn, seems to affect how those patients globally perceive their own health and quality of life. A theoretical implication of this is that religious involvement seems to buffer the older adults from depression or anxiety on quality of life by offering a religious community. One possible explanation for these ndings is that religious involvement acts as a coping resource to cope and adapt with stressful situations. As such, this research provides evidence to the counterbalancing model (Krause & Tran 1989).

Table 8 Hierarchical regression analysis for the moderating effect of religious involvement on the relationship between depressive symptoms and social and economic quality of life Model 6c Step 1 2 Predictor Constant Depression Constant Depression Depression religious involvement b 21207 0147 21163 0168 0019 b R2 0210 0458*** 0247 0525*** 0204* 0234 5615* Adjusted R2 0203 F-change 30579***

*p < 005, **p < 001 (2-tailed), ***p < 0001.

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C-Y Huang et al. Table 9 Hierarchical regression analysis for the moderating effect of religion on the relationship between depressive symptoms and family quality of life Model 6d Step 1 2 Predictor Constant Depression Constant Depression Depression religious involvement b 26087 0160 25976 0215 0048 b R2 0127 0356*** 0249 0476*** 0369*** 0235 18519*** Adjusted R2 0119 F-change 16670***

*p < 005, **p < 001 (2-tailed), ***p < 0001.

Religious involvement brings people together and thus religion serves to counteract feelings of frustration, isolation and loss of faith and may assist people to rebuild their sense of well-being. This could also suggest that in the moderation model, religious involvement may provide protection against depression. Through participation in religious activities, one can establish positive relationships and acquire a variety of support and mental health outcomes. This study found that patients having more religious involvement are associated with low levels of anxiety and depressive symptoms than those without religion, which was consistent with previous studies (Koenig et al. 2001, Chen et al. 2007, Hebert et al. 2007, Aranda 2008). Accordingly, anxiety and depression is not restricted only to the physical dimension. When disease is considered an inner imbalance, the body, along with the mind, soul and spiritual aspects of the person, should be integrated during treatment. Religion may give the person a clear framework within which to explain and cope with life and hardship, which may mean less worry and stress (Hahn et al. 2004). As already indicated, Taiwanese people place a priority on treating the whole person and not just the symptoms to get the best results. If older adults who have more social contacts and support in the community that result from religious involvement, this could explain why they are protected from anxiety or depression. The study also found the evidence for an association of religion and quality of life. Taiwanese older adults with religion had a better quality of life than patients without religion. This result is consistent with the previous studies (Koenig et al. 1997, Hahn et al. 2004, Lauder et al. 2006, Shih et al. 2009), who suggested that religion is related to the psychological well-being of older adults. Specically, Wang (2000a) noted that religion can have a positive inuence on Taiwanese when needing to cope with psychological disorders. Moreover, a survey indicated that 53% of psychiatric patients reported the importance of including spirituality or religion as part of their psychiatric treatment (Baetz et al. 2004). In Chinese traditional culture, spiritual concern is an important factor in the therapeutic process and often cannot

be separated from health practices and beliefs and concepts of predestination and fatalism (Lo 1991, Lin 1992). Religion can improve feelings of well-being, energy levels and other aspects that contribute to quality of life. In Taiwan, most hospitals provide a comprehensive array of spiritual care services. The hospitals offer separated prayer rooms to staff and visitors of all faiths at the hospital for spiritual activities, meditation and reection for them. Visitors are welcome to come and sit and enjoy the peaceful, tranquil atmosphere. This effort is made to meet each patients spiritual needs. Health care professionals are dedicated to respecting every patients individual right to practice his or her spiritual beliefs through symbolism and other expressions of faith. Finally, the knowledge gained in this study and the moderation model identied may also empower nurse educators to develop culturally valid spiritual care courses. A possible criticism about using a convenience sample is the limitation in generalisation and inference making about the entire population. For future research, we suggest longitudinal studies of representative populations with diverse religious beliefs in religious involvement to better investigate the effects of putative moderational relations. It will be meaningful for researchers to demonstrate that health outcomes of older adults with psychological problems can be signicantly changed by manipulating religious involvement.

Conclusion
Addressing the spiritual needs of the older adults with psychological problems may enhance outcomes from illness. The present cohort of older adults considered religion a strong cultural force in their lives. Religion serves as a helpful method for older adults in dealing with the negative impacts of depressive symptoms on health outcomes and quality of life. Religious involvement can provide an alternative treatment method for those who had health problems. The ndings of this study suggest that religion or religious involvement is benecial implications on individuals mental and physical health.
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Relevance to clinical practice


People may have greater spiritual needs particularly during illness. Given the importance of religious involvement as a buffer, it may be necessary to give more importance to religion in nursing interventions. This study emphasises the importance of religious involvement in terms of its religious power and the improvement of quality of life. This study found a relationship between religion, anxiety, depression and quality of life in older adults. Because of the positive effects seen in those older adults who claim to have a religious faith, nurses can encourage patients or family caregivers to attend religious events, pray and perform other religious duties. As many people in Taiwan are involved in their religious communities, it is important that nursing educational programmes include strategies for incorporating religious community values and beliefs into their nursing practice. These can serve as coping strategies to deal with their mental discomfort and promote their quality of life. In addition, the researcher can apply a religious intervention to the patients who had anxiety or were at risk of depression.

Short spiritual interviews are suggested. Acknowledging the patients care needs for their illness, expanding the consultative networks and social support, considering all aspects of our patients lives and being aware of spiritual interventions may be important for open spiritual dialogue and inquiry.

Acknowledgements
This study was supported by the NSC grant (2007-2314-B214-008). The authors thank all participants and nurses from outpatient department of the E-Da Teaching Hospital.

Contributions
Study design: C-YH, T-JC; data collection and analysis: C-YH, M-CH and manuscript preparation: C-YH, M-CH.

Conict of interest
No conict of interest has been declared by the authors.

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An exploratory study of religious involvement

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