The Spirituality and Quality of Life in the Elderly: The Mediating Role of Self-Compassion and Sense of Cohesion

Given the growing population of the elderly, it appears necessary to study the health-related factors of the elderly, which seem to be related to their quality of life (QOF). Recent researches have shown that spirituality, self-compassion, and sense of cohesion may improve health in this population. Therefore, this study aims to determine the model of QOF based on spirituality through mediating role of self-compassion and sense of cohesion in the elderly. The study population included all the elderly living in Zanjan, Iran, among which 370 were selected using convenience sampling method. The measures applied in the current study consisted of Parsian and Dunning’s Spirituality, Raes et al.’s Self-compassion, Antonovsky’s sense of coherence and The World Organization QOF Questionnaires. Path analysis was used to analyze the causal model. The results indicated the fit of the model with the data. The results also showed a direct and significant effect between spirituality (β=0.28, p < 0.05), self-compassion (β=0.23, p < 0.05) and sense of cohesion (β=0.40, p < 0.05) with the QOF. Moreover, the analysis of the role of multiple mediators using Preacher and Hayes’s approach confirmed the mediating role of self-compassion and sense of cohesion in the relationship between spirituality and QOF. These results contribute to the theoretical knowledge regarding how spirituality affects QOF in the elderly. The findings illustrated that spirituality has the power to predict QOF among the elderly through self-compassion and sense of cohesion. All the three above-mentioned predictor variables are thought to be extensible and can be applied in the form of interventions using to improve QOF in the elderly.

References
Abdollahzadeh, H., & shadin, N. (2020). Effectiveness of spiritual self-care training on nurses’ self-compassion and moral courage. RBS, 18(3), 393-402. [Persian]
Afrasiabi, M., Khorsand, M., & Mafi, M. (2015). Spiritual health and quality of life in the elderly. Contemporary Psychology, 12(special issue), 185-188. [Persian]
Aghayari hir, T., ghasemzade, D., & Ebrahimi Orang, A. (2017). A Study of relationship between social support and health-related quality of life among elderly people in Tabriz. Joge, 2(1), 20-28. [Persian]
Aglozo, E., Akotia, C. H., Osei-Tutu, A., & Annor, F. (2021). Spirituality and subjective well-being amang Ganaian older adults: optimism and meaning in life as mediators. Aging               & mental health, 25(2), 306-315.
Alipour, A. (2020). The Impact of spirituality and religion on the immune system: A Review article. Quran and Medicine, 5(2), 20-28. [Persian]
Allen, A. B., Goldwasser, E. R., & Leary, M. R. (2012). Self-compassion and well-being among    older adults. Self-Identity, 11(4), 428-453.
Aminayi, M., Asghari Ebrahimabad, M., Azadi, M., & Soltani Shal, R. (2015). Reliability and validity of Farsi version of Parsian and Dunning spirituality questionnaire. Journal of Fundamentals of Mental Health, 17(3), 129-134. [Persian]
Amiri, P., Vahedi Notash, G., Jalali Farahani, S., Karimi, M., Alamdari, S., & Azizi, F. (2019). The relationship between spiritual health and health-related quality of life in Tehran adults. Journal of Medical Ethics, 13(44), 1-5. [Persian]
Antonovsky, A. (1987). Unravelling the mystery of health: How people manage stress and stay well. San Francisco CA: Jossey-Bass.
 Antonovsky, A. (1993). The structure and properties of the sense of coherence scale.Social         Science & Medicine, 6 (36), 725- 733.  

Asgari, S., & Shafiee, H. (2017). Prediction of elderly quality of life based on internal coherence, mindfulness and spiritual intelligence. Positive Psychology Research, 3(3), 61-74. [Persian]
Bekke-Hansen, S., Pedersen, C. G., Thygesen, K., Christensen, S., Waelde, L. C., & Zachariae, R. (2014). The role of religious faith, spirituality and existential considerations among heart patients in a secular society: Relation to depressive symptoms 6 months post-acute coronary syndrome. Journal of Health Psychology, 19(6), 740–753.
Bengtsson, A., & Lars, H. (2008). The Validity of Antonovsky sense of coherence measure in a sample of schizophrenic patients living in the community. Journal of Advanced Nursing, 33(4), 432-438.
Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., Segal, Z. V., Abbey, S., Speca, M., Velting, D., & Devins, G. (2004). Mindfulness: A proposed operational defi nition. Clinical Psychology. Science and Practice, 11, 191–206.
Bonzanini, L. I. L., Soldera, E. B., Ortigara, G. B., Schulz, R. E., Knorst, J. K., Ardenghi, T. M., & Ferrazzo, K. L. (2020). Effect of the sense of coherence and associated factors in the quality of life of head and neck cancer patients. Brazilian oral research, 7(34), Article e009. https://doi.org/10.1590/1807-3107bor-2020
 Borges, C. C., Santos, P. R. D., Alves, P. M., Borges, C. M., Lucchetti, G., Barbosa, M. A., & Porto,           C. C. (2020). Association between Spirituality/religiousness and Quality of Life among            Healthy Adults: A Systematic Review. Research Square. https://doi.org/10.21203/rs.3.rs-105884/v1
Chumbler, N. R., Kroenke, K., Outcalt, S., Bair, M., Krebs, E., Wu, J., & Yu, Z. (2013). Association between sense of coherence and health-related quality of life among primary care patients with chronic musculoskeletal pain. Health Quality of Life   Outcomes, 11, Article 216.          
Couzner, L., Ratcliffe, J., Lester, L., Flynn, T., & Crotty, M. (2013). Measuring and valuing quality of life for public health research: application of the ICECAP‐O capability index in the Australian general population. International Journal of Public Health, 58(3), 337‐367.
Dowd, A. J., & Jung, M. E. (2017) Self-compassion directly and indirectly predicts dietary adherence and quality of life among adults with celiac disease. Appetite, 11(3), 293–300.
Dunne, S., Sheffield, D., & Chilcot, J. (2018). Brief report: Self-compassion, physical health and the mediating role of health promoting behaviours. Journal of Health Psychology, 23(7), 993–999.
Ebrahimi Meymand, H. A., Askarizadeh, G., Bagheri, M., & Arabnejad, M. (2020). The Role of spiritual intelligence, sense of coherence, and cognitive flexibility as internal resources in predicting perceived stress in patients with multiple sclerosis.The Horizon of Medical Sciences, 27(1), 114-129. [Persian]
Eriksson, M., & Mittelmark, M. B. (2017). The sense of coherence and its measurement. The handbook of salutogenesis, Springer, Cham. https://doi.org/10.1007/978-3-319-04600-6_12
Farokhzadian, A., & Mirderekvand, F. (2018). The Effectiveness of Self-Compassion Focused Therapy on Increase of Psychological Well-Being and Reduction of Depression in the Elderly. Aging Psychology, 3(4), 293-302. [Persian]
Fei Wan, N. (2019). Relationships between menopausal symptoms, sense of coherence, coping strategies, and quality of life. Menopause, 26(7), 758-764.
Forbes, D. A. (2001). Enhancing mastery and sense of coherence: Important determinants of       health in older adults. Geriatric Nursing, 22(1), 29–32.
Fradelos, E. C., Alikari, V., Tsaras, K., Alikari, V., Tsaras, K., Papathansious, I. V., Tzavella, F.,          Papagiannis, D., & Ziga, S. (2021). The Effect of Spirituality in Quality of Life             of Hemodialysis Patients. Journal of Religion and Health. https://doi.org/10.1007/s10943-020-01153-x 
Gallardo-Peralta, L. P. (2017). The relationship between religiosity/ spirituality, social support, and quality of life among elderly Chilean people. International Social Work, 60(6), 1498–1511.
Ghadampour, E., Moshrefi, S. (2017). Relationship between Spiritual Health, Mental Well-Being and Quality of Life with Death Anxiety in the Elderly. Aging Psychology, 3(2), 97-106. [Persian]
Ghorbani, N., Christopher, J., Watson, P. J (2010). Comparative analysis of integrative self-knowledge, mindfulness, and private self-consciousness in predicting responses to stress in Iran. International Journal of Psychology, 45(2), 147-154.
Grill, K. B., Wang, J., Cheng, Y. I., & Lyon, M. E. (2020). The role of religiousness and spirituality in health-related quality of life of persons living with HIV: A latent class analysis. Psychology of Religion and Spirituality, 12(4), 494–504.
Hochwälder, J. (2019). Sense of Coherence: Notes on Some Challenges for Future Research. SAGE Open. https://doi.org/10.1177/2158244019846687
Hoseini mehr, A., Azimzadeh Parsi, A., & rahmani, A. (2020). Structural model of the relationship between religious orientation and mental health symptoms mediated by optimism. Quarterly of psychology and religious, 1(49), 95-110. [Persian]
Hsieh, C.-T., Yamazaki, H., Wang, J., Kamitani, T., Yamamoto, Y., & Fukuhara, S. (2021).     Quality of Life and Disability-free Survival in the Elderly: The Locomotive Syndrome and Health Outcome in Aizu Cohort Study. Journal of Aging and              Health, 33(3–4), 197–204.
Kim, C., & Ko, H. (2018). The impact of self-compassion on mental health, sleep, quality of life and life satisfaction among older adults. Geriatric Nursing, 39(6), 623-628.
 Lima, S., Teixeira, L., Esteves, R. (2020). Spirituality and quality of life in older adults: a           path analysis model. BMC Geriatr, 20(1), Article 259.
Magnus, C. M. R., Kowalski, K. C., & McHugh, T. L. F. (2010). The role of self- compassion in women’s self-determined motives to exercise and exercise-related outcomes. Self and Identity, 9(4), 363-382.
Mathad, M. D., Rajesh, S. K., & Pradhan, B. (2019). Spiritual well-being and its relationship with mindfulness, self- compassion and satisfaction with life in baccalaureate nursing students: A Correlation study. Journal of Religion and Health, 58, 554–565.  
Mikaeili, N., Einy, S., & Tagavy, R. (2017). Role of self-compassion and sense of coherence             and thought action fusion in prediction of psychological well-being among post-traumatic stress disorder veterans. Iranian Journal of War and Public Health, 9(1), 33-39.
Mohammadzadeh, A. (2010). Evaluation of psychometric properties of the 13-item antonowski cohesion test (Unpublished Master Thesis). Payam Noor University. [Persian]
Myers, V., Drory, Y., & Gerber, Y. (2011). Sense of coherence predicts post-myocardial infarction trajectory of leisure time physical activity: A prospective cohort study. BMC         Public Health, 11(1), 708–717
Neff, K. (2003). Self-Compassion: An Alternative Conceptualization of a Healthy Attitude      toward Oneself, Self and Identity, 2(2), 85-102.
Neff, K. D., & Dahm K. A. (2015). Self-Compassion: What It Is, What It Does, and How It Relates to Mindfulness. In B. Ostafin, M. Robinson & B. Meier (eds.), Handbook of Mindfulness and Self-Regulation. Springer.
Neff, K. D., Toth-Kiraly, I., & Colosimo, K. (2018). Self-compassion is best measured as a global construct and is overlapping with but distinct from neuroticism: a response to Pfattheicher, Geiger, Hartung; Weiss, and Schindler (2017). European Journal of Personality, 32(4), 371–392.
Nejat, S. A., Montazeri, A., Holakouie Naieni, K., Mohammad, K. A., & Majdzadeh, S. R. (2006). The World Health Organization quality of Life (WHOQOL-BREF) questionnaire: Translation and validation study of the Iranian version. Journal of School of Public Health and Institute of Public Health Research, 4(4), 1-12. [Persian]
Nery-Hurwit, M., Yan, J. & Ebbeck, V. (2018). Examining the roles of self-compassion and resilience on health-related quality of life for individuals with Multiple Sclerosis health. Disability and Health, 11, 256-261.
Nguyen, L., Murphy, K., & Andrews, G. (2019). Cognitive and neural plasticity in old age: a systematic review of evidence from executive functions cognitive training. Ageing Research Reviews, 53, Article 100912.             
Nodehi Moghadam, A., Rashid, N., Hosseini Ajdad Niaki, S. J., & Hosseinzadeh, S. (2019). Evaluation of Quality of Life and its Related Factors in Elderly in Mashhad in 1396. Iranian Journal of Ageing, 14(3), 310-319. [Persian]
Panzini, R. G., Mosqueiro, B. P., Zimpel, R. R., Bandeira, D. R., Rocha, N., & Fleck, M. P. (2017). Quality-of-life and spirituality. International Review of Psychiatry, 29(3), 263-282.
Parsian, N., & Dunning, T. (2009). Developing and validating a questionnaire to measure spirituality: A psychometric process. Global Journal of Health Science, 1(1), 2-11.
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879-891.
Puchalski, C. M., Vitillo, R., Hull, S. K., & Reller, N. (2014). Improving the spiritual dimension of whole person care: Reaching national and international consensus. Journal of Palliative Medicine, 17(6), 642-56.
Raes, F., Pommier, E., Neff, K. D., & Van Gucht, D. (2011). Construction and factorial validation of a short form of the Self-Compassion Scale. Clinical Psychology & Psychotherapy, 18, 250-255.
Saffari, M., Lin, C.Y., Chen, H., Pakpour, A. (2019). The role of religious coping and social support on medication adherence and quality of life among the elderly with type 2 diabetes. Quality of Life Research, 28, 2183–2193.
Sasani, K., Seirafi, M., Meschi, F., Sarami, G., & Peymani, J. (2020). Modeling of health-related quality of life based on self-approach to body image by mediating of self-compassion and shame in overweight and obese people. IJNR, 14 (6), 78-87. [Persian]
Schoenefeld, S. J. & Webb, J. B. (2013) Self-compassion and intuitive eating in college women: Examining the contributions of distress tolerance and body image acceptance and action. Eating Behaviors 14(4), 493–496
Schultz, D. P., & Schultz, S. E. (2016). Theories of personality. Cengage Learning.
Shahbazi, M., Rajabi, G., Maghami, E and Jelodari, A. (2015). Confirmatory Factor Analysis of the Persian Version of the Self-Compassion Rating Scale-Revised. Psychological Methods and Models, 6 (19), 31-46. [Persian]
Sharif Nia, H., Lehto, R.H, Seyedfatemi, N., Mohammadinezhad, M (2021). A path analysis             model of spiritual well-being and quality of life in Iranian cancer patients: a mediating             role of hope. Support Care Cancer. https://doi.org/0.1007/s00520-021-06172-2   
Sirois, F. M., Kitner, R., & Hirsch, J. K, (2015). Self-compassion, affect, and helth-promoting      behaviors. Helth psychology, 34(6), 661-672.
St. John, P. D., Jiang, D., & Tate, R. B. (2018). Quality of Life Trajectories Predict Mortality in Older Men: The Manitoba Follow-Up Study. Journal of Aging and Health, 30(2), 247–261.
Terry, M.L., Leary, M.R., Mehta, S. (2013). Self-compassionate reactions to health threats. Personality and Social Psychology Bulletin, 39(7), 911–926.
 Tourani, S., Behzadifar, M., Martini, M., Aryankheal, A., Taheri Mirghaed, M., Salemi, M.,   Behzadifr, M. & Bragazzi, N. L. (2018). Health-related quality of life among healthy elderly Iranians: a systematic review and meta-analysis of the literature. Health and Quality of Life Outcomes, 16(1), Article 18.
Yadegari, R., Hayati, M., Yousefi afrashteh, M. (2018). The Relationship between Spiritual Health and Religious Orientation with Death Obsession in Elderly: The Mediation role of Ambiguity Tolerance. Aging Psychology, 4(1), 39-50. [Persian]
Yousefi Afrashteh, M., Sharifi, K. (2015). The Relationship between Depression, Perceived Stress and Social Support with Quality of Life in Elderly with Alzheimer's disease. Aging Psychology, 1(2), 1-10. [Persian]
Žganec, N., Rusac, S., Laklija, M. (2008). Trends in care for the elderly in theRepublic of Croatia and in the countries of the European Union. Revija za socijalnu politiku, 15(2), 171-188.