Spirituality / religiosity of Elderly Front to Health Care: Scope of Review

Identify the published evidence on spirituality/religiosity of elderly people facing health care. It is a scope review, based on the recommendations of the JBI Manual for Evidence Synthesis and Prisma-ScR. Searches were performed by two reviewers in the PubMed, LILACS, Science Direct and BDTD databases by the association of descriptors, including studies according to the inclusion criteria. A total of 3,129 publications were identified, selecting 13 studies that highlighted spirituality/religiousness as a way to manage health care. Evidence revealed that religious practices, faith and beliefs feed spirituality with positive feelings, providing an understanding of the health-disease process for managing choices, self-care and coping with pathologies. This study contributes to the professionals' reflection, expanding the perspective of care in the spiritual dimension, as well as stimulating further future research.


Introduction
The human being develops concepts about facts and phenomena of life, through beliefs built on the sociocultural and religious roots in which they find themselves since birth, guided by the first social relationships (Cozier et al., 2018;Papathanasiou et al., 2020;Villani et al., 2019). These beliefs established by the individual can influence the direction of their decisions taken in face of the certainties and uncertainties of everyday life. First, it absorbs information from the social context of origin (family, church), evolving so it acquires more elaborate knowledge (schools, colleges) and from different places or environments. Thus, the individual will follow directions to exercise religiosity and/or spirituality (Gijsberts et al., 2020;Hajinejad et al., 2019;Litalien, Atari & Obasi, 2021).
Religiosity is attributed to the grouping of principles, beliefs and/or rituals of social groups, determined and conceived based on shared thinking about the divine being and the conviction of what they believe as truth Stroope et al., 2020). While spirituality arises in the relationship of the existence of the individual being and the transcendent values to face everyday situations, in the search for meanings for life, in connection with something greater, without including the formal participation of religion, but which mobilize unlimited positivity potential in a perspective beyond the circumstances/situations of daily life (Hirakawa et al., 2019;Maiko, Johns et al., 2019).
Aging is a dynamic process experienced in a particular way by the individual, observing the historical, cultural, economic and social environment in which he finds himself. In this aspect, the elderly person has differences and singularities in the aging process that must be known in order to receive adequate assistance in view of the specific needs and demands in different areas of health and knowledge (Maiko, Ivy et al., 2019). These differences are marked by age, gender, physical-functional capacity, sexual orientation, social relationships, financial situation, beliefs and attitudes, as well as the course of life in historical and cultural construction. In this context of differences experienced and constructed by the elderly, there are questions about faith, beliefs, religion and spirituality (Strabner et al., 2019).
The health care of the elderly person covers the specific challenges of age as age increases and depends on habits and lifestyle from childhood. Aging in an active and healthy way requires behaviors that promote longevity, including activities in the physical, mental, social and spiritual dimensions, providing well-being and quality of life (Riklikienė et al., 2019).
In this aspect, the multidisciplinary team must become aware to develop skills from the perspective of spirituality, religion and beliefs of the elderly person under their care, from a look sensitized to the issues of human suffering and, in this way, understand their needs and provide quality care and to life (Koper et al., 2019). Therefore, the practice of spirituality/religiosity provides opportunities for the elderly to adapt to challenging situations and/or to overcome the limits of care in the health/disease process, especially to make decisions regarding the procedures guided by professionals that allow the maintenance of health (Guerrero-Castaneda et al., 2019).
Review studies have been the expanding path to scientific evidence-based practices in healthcare. Given the types of review listed in the literature, it is clear that the scope review has been gaining ground in the interest of researchers in seeking to identify the types of evidence and gaps in specific areas of knowledge, as well as clarification, reporting or discussion of characteristics /concepts of a particular topic or field (Tricco et al., 2018), as this study proposes.
The review productions with the spirituality and health theme with the elderly population, correlate with characteristics of senility or senescence, such as the systematic review study carried out to analyze the association between religiosity/spirituality (R/S) and functionality in the elderly (Sousa et al., 2019). With regard to care, a systematic review study was found that sought to understand spirituality as a determining strategy for the well-being of the elderly, in order to present the importance of holistic care (Santos, Navarine & Costa, 2018).
Based on this assumption, it is understood the need to know whether the elderly person appropriates health care based on spirituality/religiousness, as evidenced by primary source research.
It is understood, therefore, that the relevance of this study lies in the fact that spirituality/religiosity has been identified as a strong ally for the elderly to manage the challenges regarding health problems, as faith and religious beliefs allow dialogue with the transcendent, providing the strengthening of positive positions, especially with regard to health care. Therefore, there was an interest in knowing how scientific publications have been addressing spirituality/religiousness in relation to health care for the elderly population, in order to fill gaps that still exist in this area of study, as well as to provide older people with a better understanding, which can improve their quality of life and health care. Therefore, the aim of this scope review is to identify the published evidence on spirituality/religiousness of elderly people facing health care.

Method
This is a scope review study, characterized by the purpose of mapping, compiling and disseminating existing research findings in the literature, identifying and/or describing gaps that contribute to the praxis of health professionals in their field of work.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for
Scoping Reviews (PRISMA-ScR) instrument was used to guide the report of this study (Tricco et al., 2018), following the recommendations described in the Joanna Briggs Institute Reviewer ´s Manual (Peters et al., 2020). The protocol for this study was published in the scientific repositor FigShare, identifier doi: https://dx.doi.org/10.6084/m9.figshare.15019992.
To define the title and elaborate the research question, the PCC strategy was used, an acronym for Population, Concept and Context (Peters et al., 2020), being P (elderly people); C (spirituality/religiosity regarding care) and C (health care assistance). Establishing the following question: What is the scientific evidence on the influence of spirituality/religiousness of elderly people on health care? Studies that met the criteria were included: primary source, English, Portuguese or Spanish, containing an instrument with the item spirituality/religiousness applied to elderly people in health care. Duplicate studies, review, editorials, reflections were excluded, as well as those that did not answer the research question and did not address decision-making in health care.
As a search strategy, the association of the terms "espiritualidade, religião, saúde and idoso" in Portuguese and "spirituality, religion, health, aged" in English was applied, retrieved from the Health Sciences Descriptors (DeCS) and Medical Subject Headings (Mesh), using the Boolean AND and OR, as shown in Figure 1.
The process of searching and selecting the studies was carried out in three phases, by two independent reviewers in a blinded manner, with disagreeing cases resolved through a third reviewer. Thus, in the first phase, titles and abstracts were read, identifying potentially eligible studies. The second phase consisted of a complete reading of the selected studies, complying with the inclusion criteria. In the third phase, the references of the selected studies were read, in order to identify and insert additional records.
To capture the sample information, a form was prepared in Excel spreadsheet format, version 2013, to record the data of interest: base/database, title, authors, year of publication, production language, place of origin of the study, sample characteristics (quantity and age), method used, data collection instrument, study objective, approach to analysis, main results and conclusions.
The analysis of the content expressed by the authors was carried out from the grouping of narratives identified regarding the choice of health care for elderly people, presented in Microsoft Office tables, reporting descriptively. An analysis of the quality of the articles and level of scientific evidence was not carried out, as the focus of the scope review is to identify the available evidence on the topic referred to.

Results
3,129 publications were identified; excluding duplicate productions, editorials, review articles and reflections, 65 publications remained to identify the data collection instrument used, as an eligibility criterion. Thus, 38 publications that used an instrument for data collection with the spirituality/religiousness theme were located, pointing out 13 studies that contained information on health care, according to the inclusion and exclusion criteria. The PRISMA-ScR flowchart contains the process of identification, screening, eligibility and inclusion of productions, with the respective quantities found, as shown in Figure 2.
Among the productions included for analysis (n=13) presented in Figure  The population/sample of the included studies totaled 3,304 elderly people, recording a minimum number of five participants and a maximum number of 1,942 participants. Data analysis is highlighted: three with a qualitative approach, six with a quantitative and four with a quantitative-qualitative approach. The qualitative and quantitative-qualitative analysis productions used the interview script (n=seven) as an instrument for data collection, including the spirituality/religiousness variable.
Considering that each study with a quantitative approach can use several collection instruments for the spirituality/religiousness variable, eight scales/instruments were found in order to assess, compare or associate, such as: Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being -FACIT-Sp; Ironson-Woods Spirituality/Religiousness Index-IW; Hoge's Intrinsic Religious Motivation Scale; Daily Spiritual Experience Scale, Spiritual Well-Being Scale (BEE). Each of these scales was present in only one study. Already, the Duke Religious Index DUREL was found in two publications, while the Brief Multidimensional Measure of Religiosity/Spirituality and the Spiritual Religious Coping questionnaire were found in three productions.
Emphasizing multiple analyzes in the same study, the authors used the technique of thematic content analysis to analyze qualitative data in six productions and theoretical-methodological analysis in one study; quantitative data received descriptive (n=two), inferential (n=three), descriptive and inferential (n=two) statistical treatment.
The sample studies identified the spirituality/religiousness variable with: (1) selfmanagement of chronic disease (osteoarthritis, ischemic heart disease); (2) depression and quality of life in patients with chronic heart failure; (3) successful measures (resilience, stress, optimism, attitude and depression) in postmenopausal women; (4) depression in patients with type 2 diabetes mellitus; (5) positive aging in older people attending a London neighborhood association; (6) sociodemographic, economic and health variables in elderly people assisted in health services in Triangulo Mineiro; (7) Adventist group; (8) chronic disease management; (9) coping with chronic diseases in institutionalized elderly; (10) facing the challenges arising from chronic wounds; (11) quality of life of elderly people undergoing hemodialysis treatment; (12) elderly caregiver caring for dependent/weakened people; (13) coping with metabolic control in elderly people with type 2 diabetes mellitus.
It should be noted that, in view of the deepening of topics presented in the results, discussion and conclusion of some publications, the results with the greatest evidence on spirituality/religiosity were selected in view of the decision on health care for the elderly, as shown in Figures 4 and 5.
It is noteworthy that the researched productions involving health and spirituality/religiousness in elderly people are associated with coping with diseases, and are incipient with regard to the elements related to the influence of spirituality/religiousness in the choice of health care, especially in care of nursing.
Regarding the decision-making process, the person is surrounded by feelings that can direct them to different postures such as protection, promotion, prevention, treatment and/or rehabilitation of health, more effectively, with regard to the promotion of health be. Hence, spirituality/religiousness is reported as it contemplates feelings, emotions and affectivity that are important in defining behaviors for health care.
A study by Can, Duran and Dogan (2021) on 19 volunteers aged between 65 and 88 years old revealed that, as they enter old age, spirituality contributes to the orientation and meaning of life for the elderly and thus helps in dealing with the negative circumstances, such as those experienced in periods of recovery from illness, because it surrounds itself with good feelings.
Avelar-Gonzáles et al. (2020) carried out a cross-sectional study with 128 Mexican elderly people aged over 60 years who received outpatient care in a specific hospital unit, finding a positive association between religious practices and geriatric syndromes. The authors concluded that spirituality and religious practices positively impact the health status of elderly people with geriatric syndrome, In this study, it was found that spirituality provides inner feelings of peace and intrinsic strength capable of protecting them from negative feelings and attitudes, maintaining a higher performance for self-care behaviors (Lynch et al., 2012;Mesquita, 2018). In this sense, two spirituality instruments were comparedthe Functional Assessment of Chronic Illness

Therapy-Spiritual Well-Being (FACIT-Sp) and the Ironson-Woods Spirituality/Religiousness
Index (IW) -in elderly people with chronic heart failure and was found a relationship with spirituality/religiosity and the presence of feelings of peace in coping with depression, suggesting the promotion of psychological and spiritual well-being and better quality of life (Bekelman et al., 2010).
Thus, scholars (Malone & Dadswell, 2018;Rocha, 2011;Silva et al., 2019;Vahia et al., 2011) when associating active aging with spirituality/religiosity, identified dimensions as a positive source of coping in the daily lives of elderly people. As: comfort, hope, peace of mind and inner strength, all expressed by elderly people with health problems. Such positive feelings suggest that they contribute to calming worry, anxiety, tension and nervousness, promoting the adoption of better initiatives with the necessary care informed by professionals, ensuring more precise treatments, agility and tranquility in the person's recovery procedures.
We sought to understand the relationship between spirituality and successful aging in elderly women and found that the level of increased spirituality offers a coping strategy for negative life events, thus promoting resilience. Negative feelings such as anguish, fear, uncertainty and insecurity can generate conflict in the elderly, influencing inappropriate decision-making and enhancing care negligence in the health-disease process. In this way, the spirituality/religiosity adopted in religious practices and/or rituals and beliefs can generate positive feelings, capable of removing or minimizing negativity in the process of healthcare for the elderly (Vahia et al., 2011).
To know the influence of spirituality on the perception of decision-making in health, Rego et al. (2020) carried out a study in 95 outpatients with palliative care aged 35 to 93 years, verifying greater spiritual well-being associated with a less decision conflict and less uncertainty. However, it cannot be affirmed that these results refer to the elderly, as the sample was heterogeneous in terms of age, including people under the age of 60 years.
Studies in the spiritual dimension must address, with greater rigor, the age group, including to know differences or similarities between generations.
The sense of religiosity as a practice of spirituality in establishing rules, anchored in the belief in the conviction of faith in God, permeated by the positive experience of aging comes from some studies (Malone & Dadswell, 2018;Silva et al., 2019). The authors agree in the understanding that active aging as a dynamic process generates the protagonist role of the elderly person with autonomy, independence and security to perform physical, cognitive and social activities with active participation.
In this aspect, the elderly person, the protagonist of their life, chooses actions that help to remain active, determining routines with times that involve prayer or meditation, in addition to the adoption of health care, strengthened by faith and hope to improve the problems, restoration of health and healing.
The study of Harvey and Silverman (2007) involving 47 elderly african-American and 41 white correlated management of chronic diseases aided by spirituality, noting that the african-American elderly were more likely to support the belief in divine intervention, compared with white elderly people. However, it was observed that white elderly people were more prone to spirituality in various self-management practices to the detriment of African-American elderly people: believing in the restoration or acceptance of their health status.
It is known that the elderly person lives experiences in the course of life that will provide different behaviors and thoughts, positive or not, being the main actor of their preferences. It should be noted that dealing with a stressful situation requires greater resilience, skill and understanding, which will influence the conduct and effectiveness of health care. Evidence illustrated the positive experience of aging, when it is centered on the belief in God and religious practices, as stimulating principles for resolution in terms of health care (Malone & Dadswell, 2018;Silva et al., 2019;Vahia et al., 2011).
Higher spirituality/religiosity was associated with faster recovery from illnesses, as they are stressful situations in life that require the adoption of higher coping strategies and greater need for resilience. In this sense, religiosity, from the perspective of practice, combines with the belief as a protective agent in stressful and/or adverse moments of life, strengthening the concept that events can be faced individually according to the experiences lived by each person elderly (Vahia et al., 2011).
On the one hand, spirituality/religiosity can allow the apprehension and strengthening of the meaning of life from a positive experience of aging with the perception that the ways to reduce the symptoms and severity of a disease can occur through mediated care by religion and belief in God. On the other hand, the belief associated with God, as one who is able to provide means to overcome the disease through a healing process based on the treatment he performs, considering him as one who has control of their lives, centering if in faith and prayer, mediated by the elderly person with God (Malone & Dadswell, 2018;Rocha, 2011;Silva et al., 2019).
The studies pointed to the effectiveness of care as an important dimension in the conservation, maintenance and/or preservation of health, to reduce possible symptoms, improve the disease and promote quality of life. Therefore, spirituality/religiosity can generate permanence/continuity in care, providing safer behaviors in decision-making regarding therapeutic procedures, thus generating greater trust and credibility.
In this sense, it is worth reflecting on the need for adequate guidance on procedures by professionals with the elderly so that they assimilate and understand their problem and possible resolution, in the choice of different and varied possibilities, centered on more effective actions to improvement of your health condition.
The study by Tavares-Moura (2010) found that Adventist elderly people need to obtain prior information, provided by the church, on how to implement this care that promotes health as they age, both in protection, prevention and treatment and in the rehabilitation of pathologies.
Adopted, thus enabling decisions to be made about the care that should be implemented.
Still, it is observed during old age, that people are prone to acquire awareness and spiritual recognition, in the promotion of well-being. In this sense, despite the decrease in physical strength, the spiritual aspect becomes more intense, and can lead to the strengthening of personal skills, especially in health issues (Selman et al., 2018).
It is noteworthy that the adoption of preventive or therapeutic procedures are important in enabling appropriate practices in daily life, allowing to choose the corresponding action expected in health care, minimizing the symptoms and severity of the disease. Thus, health care requires continuous and frequent action planning, implementing routines for a long time, such as chronic diseases, as a challenge to be faced (Pereira, 2012;Rocha, 2011).
Thus, it is observed that the studies listed demonstrate that spirituality is linked to the personal search for meaning, explanations and reflections on life and its relationship with the sacred or transcendent, regardless of professing religion (Cozier et al., 2018). The authors Coulibaly (2015), Silva (2015), Mesquita (2018) and Pilger (2015) agree that spirituality provides support for people's lives in the face of stressful challenges. Therefore, believing in God works as an important support for coping with unpredictable, distressing or painful situations, as it allows the processing and judgment of information, values and principles experienced based on culture, social relationships and historical context (Selman et al., 2018;Vitorino et al., 2018).
This triggers the reasoning that the elderly person considers the health professional to be responsible for knowing the instructions regarding the care to be carried out in the preventive and therapeutic path, the issues related to their disease, needing these and God through prayer to strengthen self-management in health decision-making processes. In this aspect, spirituality/religiosity is conceived as a motivational and driving factor, which gives meaning to choices according to the expectation of information provided by health professionals (Mesquita, 2018;Pilger 2015).
In this perspective, the intervention of the professional team is essential to identify the need for spiritual care as an ally of health care processes. In nursing, the care process is essential and involves the systematization of care plans in an organized manner, providing quality assessment and clinical reasoning for decision-making and judgment about the health problems faced by patients, which allows for facilitation and integration of communication between the interdisciplinary team, bringing security to the care (Chagas et al., 2021;Oliveira & Peres, 2021;McDonnell-Naughton, Gaffney & Fagan, 2020).
The study by Lima and Silva (2020) points out that the dimension of care in the context of spirituality/religiousness can even influence the minimization of possible cases of omission of care, when referring to the lack or delay in providing patient care, specifically in a hospital setting. The omission of care leads to negative consequences for care providers, such as dissatisfaction or intention to leave the work environment, as well as, for patients, such as infections, falls, pressure injuries, poor hygiene, medication mistakes.
Elderly people seek to rely on spirituality/religiousness when they assume the role of caregiver in the family, as they find it difficult to reconcile the task of self-care and caring for the other, emphasized by the lack of time, support and/or motivation (Silva, 2015). Thus, the elderly person, who cares, throws to God, their suffering regarding physical (pain, tiredness/fatigue, stiffness) and emotional (irritability, sadness) symptoms, believing that their strength will be renewed in caring for the other, but not themselves, thus postponing the search for professionals who bring solutions to health problems. Or even, deceiving oneself that one is careful, by continuing with the guidelines given for a long time for their symptoms/pathology, without professional monitoring and, in this way, surrendering to God in the daily conduct of supporting and improving what they feel.
The selected articles dealt superficially with spirituality/religiousness in relation to health care for elderly people, limiting the analysis of this study. It is also believed that the predominance of quantitative analysis in the results led to the focus on the objective of each study, as a final product, presenting texts in an incipient way, which addressed spirituality/religiousness in the planning or choice of health care for the elderly.
It is believed that this study can strengthen the understanding of spirituality/religiosity and health, thus stimulating qualifications for the academic and scientific community, as well as the practical applicability of professionals and the daily handling of demands in the relationship between society and the elderly population. Therefore, it mainly contributes to the reflection of nursing professionals, so it broadens the perspective of care considering the spiritual dimension, extending to the teams under their management. Thus, the elderly person benefits from the decisions and measures of managers, public or private, considering the health policies articulated in the context of spirituality.

Conclusion
It was identified that spirituality/religiousness influences older people in terms of health care, so it provides physical and emotional support, centered on positive feelings associated with religious beliefs and practices. The studies evidenced the spirituality/religiosity of elderly people as a way capable of managing choices of therapeutic self-care procedures and mechanisms for coping with pathologies and/or symptoms, in different situations. It was also elucidated that the elderly person grants knowledge about the disease and the means of cure, to health professionals and to God, as sources of strengthening, cure and/or self-management of the health procedures to be adopted.
There were few studies that addressed the spirituality/religiosity of elderly people in terms of health care, pointing out new perspectives for future studies. This study alerts to the need for greater academic-scientific investment on this topic, which includes different levels of Health     Units of analysis selected in the dissertations (n=six) and thesis (n=one) on spirituality/religiosity of elderly people facing health care. João Pessoa, PB, Brazil, 2021.