984537

review-article2020
HPQ0010.1177/1359105320984537Journal of Health PsychologySchwalm et al.

Review article

Journal of Health Psychology

Is there a relationship between

1­–15
© The Author(s) 2021
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DOI: 10.1177/1359105320984537
https://doi.org/10.1177/1359105320984537
A systematic review and meta- journals.sagepub.com/home/hpq

analysis of observational studies

Fábio Duarte Schwalm1 ,

Rafaela Brugalli Zandavalli2,
Eno Dias de Castro Filho1
and Giancarlo Lucchetti3

Abstract
Resilience is the ability to recover or cope with adverse situations. Spiritual and religious beliefs may be
associated with important “resilience resources.” To investigate whether there is a relationship between
spirituality/religiosity (S/R) and resilience. This is a systematic review (observational studies) with meta-
analysis following the PRISMA guidelines. From a total of 2468 articles, 34 observational studies were
included. We identified a moderate positive correlation between S/R and resilience (r = 0.40 (95% CI, 0.32–
0.48], p < 0.01). When only high-quality articles were included, the results were maintained. Conclusion: A
moderate positive correlation was found between S/R and resilience.

Keywords
health, religion, resilience, spirituality, systematic review

Introduction hand, is a more restricted concept, considered to

be an organized system of beliefs, practices,
According to Koenig et al. (2001) spirituality is and symbols designed to facilitate closeness to
a personal quest to understand end-of-life the transcendent (Koenig, 2012).
issues, their meaning, and relationships with the
sacred or transcendental that may or may not
lead to the development of religious practices or 1
F amily Physician, Conceição Hospital Group - GHC,
religious community formations. Puchalski Porto Alegre, RS, Brazil
2
Family Physician, Porto Alegre, RS, Brazil
et al. (2009) defines spirituality as the aspect of 3
Federal University of Juiz de Fora, Juiz de Fora, MG,
humanity that refers to the way in which indi- Brazil
viduals seek and express meaning and purpose,
Corresponding author:
and the way in which they experience their con-
Fábio Duarte Schwalm, Family Physician, Conceição
nection with the moment, with themselves, with Hospital Group - GHC, Av. Francisco Trein, 596 - Cristo
others, with nature, and with the environment— Redentor, Porto Alegre, RS 91350-200, Brazil.
significant or sacred. Religion, on the other Email: [email protected]
2 Journal of Health Psychology 00(0)

There has been an increase in the number of optimism and purpose, for example. In a study
studies investigating the relationship between including older women, Manning (2013)
spirituality/religiosity (S/R) and health in the last described spirituality “as a path to resilience.”
decades (Lucchetti and Lucchetti, 2014), most of Moreover, S/R seems to confer resilience, as
them finding positive results. A previous review pointed out by Koenig’s (2009) review while cor-
found that S/R is usually associated with better relating S/R and mental health. Spirituality can
mental health including lower levels of depres- help cancer patients make sense of life and the
sion, anxiety, stress, suicidal thoughts, and drug roles of spiritual and religious beliefs have been
use (Moreira-Almeida et al., 2014). In relation to widely recognized in coping with cancer and pro-
physical health, a nurses’ health study report, moting resilience (Hunter-Hernández et al.,
which tracked more than 74,000 study partici- 2015). In addition, many cancer patients have
pants for 16 years, found that women attending been found to experience spiritual growth after
weekly religious services had a lower death rate being diagnosed with the disease (Gall et al.,
compared to those who had never attended reli- 2011) and a randomized controlled trial demon-
gious services; and those who attended religious strated a significant increase in resilience from
services more than once a week had an even spiritual-based interventions (Sood et al., 2011).
lower mortality rate, suggesting a possible dose– Within the Latin American context, a research
response relationship (Li et al., 2016). Further study of Central American migrants in a transit
research suggests the impact of S/R in clinical shelter in Mexico concluded that the most impor-
practice (VanderWeele et al., 2017). In a multi- tant factors that helped them build up their resil-
center prospective study (Balboni and Peteet, ience were: trustful relations; support from
2017) of 343 advanced cancer patients, those religious organizations; hope for the future; value
whose medical staff (e.g. physicians, chaplains) systems and beliefs; creativity and persistence;
addressed their patients’ spiritual needs had end- problem-solving; and self-awareness (Vinueza,
of-life quality of life scores 28% higher on aver- 2017); according to Puchalski’s definition, all of
age than those who did not receive spiritual care. these aspects are related to spirituality.
It seems that S/R is particularly important in Despite the importance of resilience in mod-
chronic diseases and in moments of recovery, ern society and the growing literature on the
rehabilitation, and suffering (Koenig, 2012). influence of S/R in suffering, to our knowledge,
In this context, the concept of resilience there is a lack of systematic reviews on this sub-
appears which is generally defined as the ability ject. Understanding how resilience and S/R are
of individuals to recover or cope satisfactorily correlated or not could add to the current scien-
with adverse circumstances (Connor and tific literature, helping in the development of
Davidson, 2003; Rutter, 2012), with reference to new preventive strategies to deal with chronic
the human capacity to adapt to tragedy, trauma, conditions and deepening our knowledge con-
adversity, difficulty, and significant stressors. cerning how these concepts are overlapped in
This is a dynamic process, influenced by life clinical practice. Therefore, the present study
events and challenges (Hardy et al., 2004). aims to investigate if there is a relationship
Resilience is associated with many factors such between spirituality/religiosity and resilience
as coping ability, self-efficacy, optimism, social when analyzing observational studies.
support, flexibility, religious and spiritual beliefs,
positive emotions, self-esteem, and meaning and
purpose in life (Helmreich et al., 2017). Methods
Spirituality, according to some authors
(Manning, 2013; Smith et al., 2012; Vieira, 2010),
Type of study
is highlighted as one of the basic characteristics This is a systematic review and meta-analysis,
that predict resilience, as well as several others following the parameters of the Preferred
that have to do with both dimensions, such as Reporting Items for Systematic Reviews and
Schwalm et al. 3

Meta-analysis (PRISMA) and registered a pri- Assessment of studies

ori at PROSPERO (CRD42018110544).
After the literature search was carried out
according to the strategy previously presented,
Identification and selection of studies duplicate articles were excluded and two exam-
The review of the literature was intended to iners (FS and RZ) started the analysis indepen-
answer the research question “Is there an asso- dently, reading the titles and abstracts of each
ciation between levels of spirituality/religiosity article. The articles included were then submit-
(S/R) and resilience?” and on 24 April, 2019 the ted to a full reading. All deadlocks were
following electronic databases were used: resolved either by discussion and consensus of
Pubmed, Embase, Scopus, Web of Science, the examiners or, when in doubt, discussion
PsycInfo, CINAHL, and LILACS, without lan- with a third reviewer (EDCF or GL). The arti-
guage and publication date restrictions. In order cles, theses, or data not available in the original
to augment the number of articles, the gray lit- studies were searched in an attempt to contact
erature and the references from included arti- their authors via e-mail.
cles were also searched.
The keywords related to the subject were Data extraction
chosen based on prior systematic reviews and
guidelines. The search strategies in the data- The articles evaluated in full had their data
bases included the terms “spirituality,” “reli- recorded in an extraction table that was devel-
gion,” and “resilience” elaborated with the oped by the reviewers seeking to collect the rel-
definition of the subject descriptors of each evant information for the systematic review
database, MeSH in PubMed and Emtree in considering the possible subgroup analysis nec-
Embase, and also with the addition of syno- essary later, and aiming to meet the objectives
nyms and syntax when necessary. The use of of the work described. The results were synthe-
Boolean operators was applied for the construc- sized according to the parameters presented
tion of the strategies, these being the AND to below. Each association data of the studies
relate and the OR to add. An example of the between S/R and resilience was extracted in the
Boolean expression is visualized below: table. Thus, studies that used S/R scales with
more than one dimension were used separately,
(religion OR “spirituality”[Mesh] OR spiritual*) generating more than one measure in the same
AND (“resilience, psychological”[Mesh] OR article.
resilience* OR resilient*)
Risk of bias
Eligibility criteria All articles that met the inclusion criteria had
The inclusion criteria were designed to find their data analyzed through the Newcastle–
observational, quantitative studies that evalu- Ottawa scale (NOS) (Modesti et al., 2016), an
ated the relationship between spirituality and/or instrument adapted for observational studies,
religiosity with resilience in the most different which was used to assess the risk of cross-sec-
scenarios and populations, which used an infer- tional bias. These studies were assessed by two
ential statistical analysis. independent reviewers with further discussion
Exclusion criteria were designed to exclude of the impasses and a third reviewer for remain-
comments, editorials, books, qualitative arti- ing questions. This instrument derives from the
cles, and those that mentioned spirituality/relig- Newcastle–Ottawa scale for observational case-
iosity or resilience without an objective measure control and cohort studies, using an adaptation
(validated scale) of these variables, as well as of the cohort scale for cross-sectional studies,
studies of different non-observational designs. as described in previous studies published in the
4 Journal of Health Psychology 00(0)

literature (Herzog et al., 2013). The final score five dissertation theses), 1715 articles were
ranging from 0 to 10 and a cutoff value of 5 or excluded due to duplication, with 2478 remain-
more (satisfactory studies) (Luchini et al., 2017) ing ones which were evaluated by the two
was used for inclusion in the quantitative analy- researchers of the review. After the first analy-
sis and 7 or more (top quality studies) for high- sis, 2403 studies did not meet the proposed
quality ones (Aibana et al., 2019). inclusion criteria according to the title and
abstract of the study and thus were excluded. Of
these, 75 papers underwent full content evalua-
Data synthesis
tion, and the remaining doubts were clarified by
The data correlation of study variables, such as joint discussion and, when still not resolved,
spirituality or religiosity scale, age, country of were evaluated by a third reviewer. In this phase
study, and population characteristics (healthy or of the research, 34 articles that did not meet the
in distress—physical or mental disorders) listed elaborated criteria were excluded. Thus, the
from the original articles were combined in this remaining 41 studies underwent quality analy-
study for meta-analysis. The analysis was per- sis (risk of bias), using the cutoff of 5 points or
formed using the Review Manager Program more in the Newcastle–Ottawa (NOS) instru-
version 3.6.1, Meta package (version 4.95). The ment. This procedure excluded a further seven
correlation meta-analysis was calculated based articles, leaving 34 articles (Figure 1).
on the random-effects model using Fisher’s Z The final 34 articles (NOS ⩾ 5) published
transformation of correlations. The random- between 2007 and 2019, were composed of a
effects model was chosen because we are deal- sample of 6653 persons, and including the quan-
ing with studies including different scales, titative analysis generated 44 associations/corre-
samples, and settings and, for this reason, it is lations (i.e. one study could have more than one
possible that the effect size varies from study to association depending on the scale used and the
study (Borenstein et al., 2010). For the combi- groups analyzed) (Table 1). In the descriptive
nation of regressions, the inverse variance analysis, most measures used were for spiritual-
weighting method was used. Heterogeneity was ity (70.4%), from Latin America (22.7%) and the
measured by the I² statistic. The analysis of het- Middle East (20.4%), in persons experiencing
erogeneity between groups was performed stressful life events (72.7%) and adults (79.5%)
based on the Q statistic and funnel plots were (Table 2). Concerning the quality of studies,
reported to assess potential publication bias seven out of 34 (20.5%) were considered high-
visually. The confidence level used was 95%, quality studies (NOS ⩾ 7) and all studies were
and significance level was 5%. The analyses for cross-sectional (there were no cohort studies).
the correlation between R/S and resilience were The meta-analysis was conducted in the fol-
performed for the total sample (all studies were lowing ways:
included), for those studies with a satisfactory
quality (NOS⩾5) and for those studies with the (a) Including all studies independent of the
highest quality (NOS > 7). Likewise, subgroup study quality (n = 41): there was a statis-
analyses were carried out according to scales, tically significant positive correlation
age groups, countries, and disease. Finally, fun- between S/R and resilience of r = 0.43
nel plots were used to assess potential publica- (IC 95%, 0.35–0.50; p < 0.01), with a
tion bias visually. high degree of heterogeneity (I2 = 94%)
(Figure 2);
(b) Including all studies with quality assess-
Results ment of 5 points or more (satisfactory):
From a total of 4193 articles found (4183 there was a statistically significant posi-
through databases and 10 through other tive correlation between S/R and resil-
sources—five published scientific articles and ience of r = 0.40 (IC 95%, 0.32–0.48;
Schwalm et al. 5

IDENTIFICATION
Records identified through database Additional records identified
searching through other sources
(n = 4183) (n = 5+5)
=

Records after duplicates removed

(n = 2468+10)
SCREENING

Records screened Records excluded

(n =2478) (n = 2403)
ELIGIBILITY

Full-text articles assessed Full-text articles excluded

for eligibility (n = 34)
(n = 75)
Reasons:
- Duplicate data: 1
-Incomplete arcle: 2
-Scale not validated: 12
All studies included -Does not correlate the variables: 19
(n = 41)
INCLUDED

Studies with a Newcastle–

Ottawa score of more than
5 points
(n = 34)

Figure 1.  PRISMA flow diagram from identification to article selection.

p < 0.01), with a high degree of hetero- religiosity showed a statistically different

geneity (I2 = 93%) (Figure 3); result in favor of the correlation in the
(c) Including all studies with quality assess- subgroup spirituality r = 0.46 (IC 95%,
ment of 7 points or more (top-quality 0.37–0.54; p < 0.01) compared to those
studies): there was a statistically signifi- of religiosity r = 0.24 (IC 95%, 0.11–0.37;
cant positive correlation between S/R p < 0.01). The analysis of the countries in
and resilience of r=0.37 (IC 95%, 0.23– which the study was conducted showed
0.49; p < 0.01), with a high degree of differences with the weakest correlation
heterogeneity (I2 = 87%) (Figure 4). in the Americas, moderate in Europe, the
(d) Subgroup analyses according to scales, Middle East, and Asia and moderate/
age groups, countries, and disease (Table strong in Oceania (only 1 study). The
2). The results of the individual analysis analysis of age groups and the healthy
of studies using scales measuring spiritu- versus people experiencing stressful life
ality and those using scales measuring events showed no differences.
 6

Table 1.  Data extraction and results synthesis (NOS ⩾ 5).

Author/year Condition of the study n Resilience scale Spirituality scale/religiosity Country Correlation p value
population

Medeiros (2016) Hemodialysis 188 Wagnild and Young DUREL Brazil –0.253 <0.001
Bhattarai (2018) Spinal cord injury (SCI) 82 CD-RISC Spi. intrinsic (ISS) Nepal –0.12 NS
Medeiros (2016) Hemodialysis 188 Wagnild and Young DUREL Brazil 0.071 NS
Walker (2013) Gay, lesbian, or bisexual 175 Wagnild and Young Santa Clara (SCSORF) USA 0.1 NS
black population
Hong (2015) Teenagers with leukemia 199 Haase Spiritual perspective of REED Korea 0.17 0.016
Burnett (2013) University students 79 Wagnild and Young Religious Orientation Scale (ROS) Haiti 0.18 NS
Harris (2016) General population 94 Neill’s Spiritual perspective of REED USA 0.19 NS
Fradelos (2018) Breast cancer 152 CD-RISC Religious Centrality (CRS-15) Greece 0.194 <0.05
Mosqueiro (2015) Depression 143 Wagnild and Young DUREL Brazil 0.2 0.02
Barreto (2013) Palliative care 121 Brief scale Coping Resilient Questionnaire GES Spain 0.208 <0.05
Medeiros (2016) Hemodialysis 188 Wagnild and Young DUREL Brazil 0.218 0.002
Barreto (2013) Palliative care 121 Brief scale Coping Resilient Questionnaire GES Spain 0.231 <0.05
Burnett (2013) University students 79 Wagnild and Young Religious Orientation Scale (ROS) Haiti 0.25 0.03
Consoli (2015) Latin students 121 CD-RISC Spiritual Transcendence (STS) USA 0.27 <0.01
Mosqueiro (2015) Depression 143 Wagnild and Young DUREL Brazil 0,27 0.02
Simmons (2012) Listed officers and NCOs 350 CD-RISC Spiritual Perspective (REED) USA 0.3 ⩽0.001
Canaval (2007) Mistreated women 100 Wagnild and Young Spiritual Perspective (REED) Colombia 0.301 0.004
Barreto (2013) Palliative care 121 Brief scale Coping Resilient Questionnaire GES Spain 0.305 <0.01
Khosravi (2014) University students 307 CD-RISC Spiritual Intelligence Inventory Iran 0.313 ⩽0.01
(SISRI)
Jenaabadi (2019) Hemodialysis 140 CD-RISC Trust in God Questionnaire Iran 0.337 0.01
Ebrahimi (2012) University students 100 CD-RISC Abdollah-Zadeh Spiritual Iran 0.35 <0.01
Intelligence
White (2010) Spinal cord injury 42 CD-RISC Intrinsic Spirituality (ISS) USA 0.35 <0.05
Pessotti (2018) Caregivers of patients with 50 Wagnild and Young DUREL Brazil 0.37 <0.05
dementia
Howell et al. (2014) Students who suffered 321 CD-RISC Daily Spiritual Experiences (DSES) USA 0.38 <0.01
childhood violence
Hatami (2019) Pregnant women 134 CD-RISC King’s Spiritual Intelligence Iran 0.394 <0.05

(Continued)
Journal of Health Psychology 00(0)
Table 1. (Continued)

Author/year Condition of the study n Resilience scale Spirituality scale/religiosity Country Correlation p value
Schwalm et al.

population

Han et al. (2016) Qiang ethnicity after 898 CD-RISC Spiritual Beliefs (SBQ) China 0.407 <0.01
earthquake 2008
Kim (2018) University students 219 CD-RISC Spiritual Wellbeing (SWB) Korea 0.437 <0.001
Mosqueiro (2015) Depression 143 Wagnild and Young DUREL Brazil 0.44 <0.001
Keshavarzi (2012) Postgraduate students 354 Res. For adults (Hjemdal) King’s Spiritual Intelligence Iran 0.45 0.001
Jones (2017) Family members of patients 50 CD-RISC FACIT-Sp Australia 0.51 <0.01
with SCI
Darvishzadeh (2017) Women college students 200 Wagnild and Young Spiritual intelligence Iran 0.512 <0.001
(Abdollahzadeh)
Fangauf (2014) General pop. from 3 343 Wagnild and Young Spiritual Attitude and Engagement Netherlands 0.53 <0.01
different ethnicities (SAIL)
Mizuno (2016) Control 60 Wagnild and Young FACIT-Sp Japan 0.535 <0.001
Sogolitappeh (2018) University students 100 CD-RISC King’s Spiritual Intelligence Iran 0.54 <0.05
Redondo-Elvira (2017) Palliative care 105 Escala Breve Coping Questionnaire GES Spain 0.577 <0.001
Resiliente
Mizuno (2017) Bipolar and paranoid 225 Wagnild and Young FACIT-Sp Austria/ 0.584 <0.001
schizophrenia Japan
Bang (2017) Elderly with gastric cancer 65 CD-RISC Spiritual Wellbeing (SWB) Korea 0.59 <0.001
Mizuno (2016) Schizophrenia 59 Wagnild and Young FACIT-Sp Japan 0.626 <0.001
De la Rosa (2015) Women victims of domestic 54 Wagnild and Young Spirituality Scale (SIWB) USA 0.648 <0.001
violence
Kolaei (2013) Pregnant women 211 CD-RISC King’s Spiritual Intelligence Iran 0.659 <0.001
Veysi (2017) Mothers of children with 100 CD-RISC Allport Religious Search Iran 0.68 0.001
mental retardation
Jones (2017) Spinal cord injury 50 CD-RISC FACIT-Sp Australia 0.712 <0,01
Mizuno (2016) Bipolar disorder 58 Wagnild and Young FACIT-Sp Japan 0.728 <0.001
Romero (2017) Cancer patients 521 Wagnild and Young Parsian and Dunning Spirituality Spain 0.853 <0.001
test

CD-RISC: Connor–Davidson resilience scale; FACIT-sp: spiritual well-being scale; DUREL: duke religious index; USA: United States of America; NCOs: non-commissioned officers.
7
8 Journal of Health Psychology 00(0)

Table 2.  Subgroup correlation between spirituality/religiosity and resilience in the meta-analysis
(NOS ⩾ 5).

Number of Correlation 95%CI p I2 % Q p

analyses
Total (Quality > 5 points) 0.40 0.32–0.48 <0.01 94  
Measure
 Spirituality 31 0.46 0.37–0.54 <0.01 94 7.86 <0.05
 Religiosity 13 0.24 0.11–0.37 <0.01 88  
Continent
  North America 6 0.27 0.18–0.36 0.05 56 18.58 <0.05
  Latin America 10 0.25 0.10–0.38 <0.01 86  
 Europe 7 0.46 0.13–0.70 <0.01 98  
  Middle East 9 0.48 0.38–0.57 <0.01 82  
 Asia 8 0.44 0.29–0.57 <0.01 89  
 Oceania 2 0.62 0.38–0.78 0.11 62  
Disease
 Healthy 12 0.44 0.37–0.51 <0.01 78 2.36 0.5
  Experiencing stress 32 0.38 0.27–0.49 <0.01 95  
Age
  <40 years 19 0.35 0.28–0.42 <0.01 84 0.58 0.74
  40–60 years 16 0.43 0.21–0.61 <0.01 97  
  >60 years 5 0.39 0.21–0.54 <0.01 80  

Discussion of 0.38. Despite the fact that there is a wide

array of evidence linking S/R and resilience, so
The results presented in this review showed a far we have not identified systematic reviews on
moderate correlation between S/R and resilience, the topic. These previous studies corroborate
and these findings were maintained even when our meta-analysis, which found a moderate cor-
only high-quality studies were included in the relation between S/R and resilience, even when
meta-analysis. In addition, subgroup analyses including only high-quality studies.
revealed that spirituality measures seem to be Although the mechanisms for this relation-
strongly correlated with resilience as compared ship are unknown, it can be explained, at least
to religiosity measures. Understanding this asso- in part, by the existence of common factors
ciation can help researchers, health profession- underlying resilience and religious/spiritual
als, and administrators to develop preventive qualities, such as optimism, positive emotions,
strategies to stimulate resilience in their patients social support, and the search for meaning and
and to design future studies in this area. purpose. Likewise, it is important to underscore
Many studies have evaluated the association that some instruments used to assess resilience
between S/R and resilience presenting similar could have spiritual components that may have
results. Fangauf (2014), evaluated 343 persons an influence in this correlation. As an example,
from three different ethnicities and found a cor- the item “Sometimes fate or God can help”
relation of 0.53; Han et al. (2016) measured this from the Connor–Davidson resilience scale and
association in 898 Chinese volunteers after the the item “my life has meaning” from the
2008 Qiang earthquake and found a correlation Wagnild and Young resilience scale can overlap
of 0.40, and Howel and Miller-Graff (2014) with religiosity and spirituality respectively.
assessed 321 American students who were vic- In addition, the transformation process that
tims of childhood violence, finding a correlation can occur after traumatic events and suffering,
Schwalm et al. 9

Figure 2.  Forest plot demonstrating the overall meta-analysis result for the correlation between
spirituality/religiosity and resilience in total sample (41 studies).
10 Journal of Health Psychology 00(0)

Figure 3.  Forest plot demonstrating the overall meta-analysis result for the correlation between
spirituality/religiosity and resilience (NOS ⩾ 5).

known as post-traumatic growth, is also linked understood as closely intertwined concepts,

to both concepts (Gall et al., 2011). Based on connected to the idea of a meaning and a higher
these considerations, it becomes clearer how purpose of life as a source of motivation and
spirituality, inner strength, and resilience can be overcoming (Vieira, 2010).
Schwalm et al. 11

Figure 4.  Forest plot demonstrating the meta-analysis result for the correlation between spirituality/
religiosity and resilience in high-quality studies (NOS ⩾ 7).

Despite the existing correlation, spirituality picture of the complex ways that religion and
and resilience are considered different con- spirituality may be related to resilience.
cepts, each having its own characteristic. Smith Another interesting finding in our study is
et al. (2012) argued that spirituality may the fact that there were studies from all over the
increase resilience in at least four ways, includ- world, including all continents with the excep-
ing through relationships, life values, personal tion of Africa. Nine studies were conducted in
meaning, and coping; they conclude that there Iran, where Islam predominates and the popu-
are more plausible ways that spirituality may lation has different religious habits compared
influence resilience and positive emotions than to Christian populations (which constituted
the reverse. Thus, resilient individuals may not most studies according to the predominant reli-
have S/R, however people with S/R will proba- gion in the country). However, in the all regions
bly have higher levels of resilience. subgroup, the favorable results of the relation-
In our subgroup analyses, there was a ship between S/R and resilience were main-
higher correlation between spirituality and tained, highlighting the representativeness of
resilience than religiosity and resilience. the theme and results. These results reinforces
Since the literature points to meaning and pur- the fact that resilience is an important tool used
pose as being one of the most important com- by many cultures and populations and that its
ponents of resilience strengthening (Smith relationship with S/R seems to transcend cul-
et al., 2012) and these aspects are generally tural differences.
measured on scales that address spirituality, The comparison between ages showed no
we can at least partly attribute this result to differences; this coincides with data in the lit-
this. Religiosity may offer more social sup- erature that point to this variable as controver-
port while spirituality may be more related to sial for resilience (Gheshlagh et al., 2016).
intrinsic factors concerned with meaning, for However, some studies show results of resil-
example. Studies investigating spirituality ience increasing with age. A meta-analysis
and religion often do not precisely measure or assessing resilience factors and mental health,
differentiate between them (Lucchetti et al., with a sample of more than 68,000 participants
2013), which makes it difficult to get a clear found increased resilience in the adult group
12 Journal of Health Psychology 00(0)

compared to the child and adolescent groups meta-analysis, we suggest that future resilience
(Hu et al., 2015). It is possible that memories of interventions should investigate S/R aspects in
life experiences contribute to strengthening order to see if they are effective in the promotion
resilience with age. The wide range of age of resilience.
between study participants for each study may
explain our data, since the sub analysis was car-
Limitations
ried out including the mean age of the sample.
With regard to the comparison between The present systematic review has some limita-
healthy and distressed subgroups (study popula- tions that should be considered while interpreting
tions with physical, mental, or vulnerable condi- our results. First, the terms used in the search
tions), both groups showed a positive correlation strategy may not have covered all the literature on
without a significant difference between groups. the topic and not all databases were consulted.
Our hypothesis when evaluating this item was Although this is a potential limitation, it is true for
that the correlation between S/R and resilience practically all review studies. In order to mini-
would be higher in the group experiencing stress- mize this problem, the gray literature was
ful life events, because, according to the literature searched. Second, the high heterogeneity of the
review, resilience appears in moments of adver- studies included in the analyses decreases the
sity. Most studies on resilience use populations in reliability/robustness of our conclusions which
distress, such as those diagnosed with serious ill- should therefore be interpreted with caution.
ness or who are dealing with a traumatic event. Third, all the studies found were cross-sectional,
The theory suggests that resilience is most rele- which may not provide definite information
vant among populations at a greatest risk of expe- about cause-and-effect relationships. Finally,
riencing stress or trauma (Mancini and Bonanno, some resilience scales evaluate faith and trust,
2010). Thus, the data presented in this review, characteristics that are also evaluated by S/R
which included studies where resilience scales scales. Thus, the measurement of similar domains
were applied to healthy populations, such as stu- may contribute to the association found.
dents, supports the hypothesis that S/R levels cor-
relate with resilience equally in both the general Conclusion
and the population experiencing stressful life
events. In the present systematic review we identified a
Our results also point to important clinical moderate positive correlation between S/R and
implications. Resilience is a resource for coping resilience, even while evaluating only high-
with adversity which increases quality of life and quality studies. In the subgroup analyses,
decreases the chances of falling ill (Gheshlagh although both were significant, spirituality
et al., 2016; Rutten et al., 2013). Based on this showed a greater correlation coefficient as com-
evidence, strengthening resilience may be a good pared to religiosity. Despite these findings, it is
strategy to prevent these problems and various important to highlight that the sample showed
health care programs and settings are beginning high heterogeneity, which should be considered
to incorporate resilience interventions (Joyce when interpreting the results.
et al., 2018; Leppin et al., 2014; Sood et al.,
2011). A better understanding of the factors driv- Declaration of conflicting interests
ing resilience is important for optimizing The author(s) declared no potential conflicts of inter-
resources. Several authors have pointed out the est with respect to the research, authorship, and/or
role of spiritual and religious beliefs in strength- publication of this article.
ening resilience (Brewer-Smyth and Koenig,
2014). However, clinical trials assessing if spirit- Funding
ually-based interventions could lead to higher The author(s) disclosed receipt of the following finan-
levels of resilience are lacking. Based on our cial support for the research, authorship, and/or
Schwalm et al. 13

publication of this article: This study is part of activities das que denuncian su situación de violencia de
of the post-graduation program in Health Technology pareja. Colombia Medica 38(Supl 2): 72–78.
Assessment of the School of the Conceição Hospitalar Connor KM and Davidson JRT (2003) Development
Group, and has no external sources of funding. of a new Resilience scale: The Connor-Davidson
Resilience scale (CD-RISC). Depression and
ORCID iDs Anxiety 18(2): 76–82.
Consoli MLM, Delucio K, Noriega E, et al. (2015)
Fábio Duarte Schwalm https://orcid.org/0000-
Predictors of resilience and thriving among
0003-4581-8941
Latina/o undergraduate students. Hispanic
Giancarlo Lucchetti https://orcid.org/0000-0002-
Journal of Behavioral Sciences 37(3): 304–318.
5384-9476
Darvishzadeh K and Bozorgi ZD (2017) Relationship
between the resilience and psychological hardi-
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