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Background: Research has found that physical health decline in later life is associated with poor psychological well-being. This study aimed to examine the possible moderating effect of Islamic religiosity on the relationship between chronic medical conditions and psychological well-being.
Methods: The sample for this study consisted of 1415 elderly Malay Muslims. It was obtained from a cross-sectional survey entitled ‘Patterns of Social Relationship and Psychological Well-Being among Older Persons in Peninsular Malaysia’, which conducted from 2007 to 2009, using a multistage stratified sampling procedure. Data collection was performed through face-to-face interviews. A four-step moderated hierarchical regression analysis using SPSS software for Windows and the ‘ModGraph-2’ software program was used to test the hypothesis.
Results: Results of bivariate analysis showed, at certain levels of chronic medical conditions, older persons with a high level of religiosity reported significantly higher levels of psychological well-being compared to their counterparts with a low level of religiosity. Four-step moderated hierarchical regression analysis revealed that the negative effect of chronic medical conditions on psychological well-being is reduced by both personal and social religiosity (β= 0.07, P≤ 0.01), after controlling for selected sociodemographic factors.
Conclusion: Taken together, these findings indicate that the depressogenic effect of physical illness is decreased by religiosity in chronically ill elderly people. The implications and limitations of the current study are discussed and recommendations for future research are proposed.
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The increased aging of the population has been accompanied by a dramatic increase in the number of older persons suffering from multiple chronic medical conditions. There is a growing body of the literature suggesting poor physical health negatively affects quality of life, psychological well-being and life satisfaction of elderly people.1–4
Although these studies have found a negative relationship between poor physical health and psychological well-being in old age, there is additional evidence to suggest psychological well-being remains relatively stable among chronically ill older persons.5,6 For instance, Hopman et al. examined the correlations among chronic medical condition, age, and physical and mental health in a sample of 2418 chronically ill persons.5 They found that physical function is negatively influenced by chronic medical condition and advanced age. However, mental health remains slightly high and stable, after controlling for available confounders.
Similar findings were observed by Johnson.7 He found some elderly people were very well, felt quiet satisfied and had good psychological well-being, despite congestive heart failure, blindness or even institutionalization. Likewise, in a new study of older people in Vietnam, researchers found that while physical functioning declined with advancing age, psychological well-being remained slightly stable.8 Although these studies found that some elderly people with chronic medical conditions experience high levels of psychological well-being, they have not adequately examined why older persons have good psychological well-being in spite of poor physical health.
Religiosity as an important social and psychological factor in the lives of elderly people has received substantial attention in the gerontological literature,9–11 and it may attenuate the adverse effects of physical health decline on psychological well-being. However, the moderating effect of religiosity on the relationship between chronic medical conditions and mental health outcomes has resulted in inconclusive findings.12,13
This study was conducted to increase our understanding of whether religiosity reduces the negative effects of chronic medical conditions on psychological well-being in a sample of elderly Malay Muslims. Malay Muslims (indigenous people of Malaysia) believe that psychological problems are indicative of the loss of soul substances, which make them physically weak, resulting in confusion. They also believe that spiritual forces play a great role in physical and mental health.14 This strong influence of religion in Malay culture has resulted in the general belief that mental disorders are an outcome of abandoning or neglecting Islamic values.15
Theoretically, it is possible that religiosity may influence the relationship between chronic medical conditions and psychological well-being. Daaleman et al. have conceptualized that spirituality/religiosity influences the impact of medical diseases on believers' psychological well-being.16 They argue when people face physical health problems and a functional status decline, they start to gather and interpret information, including diagnosis and prognosis of their physical health problems. This process is influenced by an individual's core beliefs. In the Islamic worldview, there are several core beliefs such as belief in Allah, purpose of life, and life after death. Muslims believe that Allah is the one who gives them strength to survive. Belief in Allah motivates people to accept life as it is and attempt to achieve perfection related to the spirit of Allah.17 Belief in Allah deeply influences people's lives; Muslims surrender themselves completely to the will of Allah and, for the fulfilment of their needs, rely on none but Allah because they believe that Allah will take care of all their needs. They understand that they are part of the whole universe.18 Another fundamental belief is in life after death. Adherents to the Islamic faith believe that this world is temporary, and there is a life hereafter. Belief in life after death may help Muslims realize that life is meaningful, and it can enable them to view stressful experiences as less threatening and to cope more effectively. However, for chronically ill persons, the fear of death is often one of the most significant negative effects on their psychological well-being, though Muslims believe that when a person dies, life does not end; rather death is an entry into spiritual life.19 Therefore, belief in this notion helps Muslims to understand the continuity of the universe.20 Based on this point of view, it was hypothesized that religiosity may reduce negative effects of chronic medical conditions on the psychological well-being of elderly Malay Muslims (see Fig. 1).
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This study consisted of a sample of 1415 Malay Muslims age 60 years and over in Malaysia. This sample was derived from a nationally representative cross-section survey entitled ‘Patterns of Social Relationship and Psychological Well-Being among Older Persons in Peninsular Malaysia’. Full details of this survey have already been reported elsewhere.21 In brief, after we obtained permission from the copyright holder, the original English versions of the scales were translated into Bahasa Malaysia separately by two researchers who are native speakers of Bahasa Malaysia and fluent in English. Next, the project leader reviewed the two translated versions and combined them into one. The first draft was then back-translated by two other researchers who had not had any previous contact with the scales in their original form. Finally, the original scale, the translated version and the back-translated version were compared by a committee to achieve the most suitable version. The project team finally carried out a pilot study to identify any confusing or ambiguous language and to assess instrument reliability with a convenience sample of 29 community dwelling older persons who were attending the University of the Third Age Malaysia. The questionnaire was presented in two languages, Bahasa Malaysia and English, to make it easier for the respondents to answer. The findings from the pilot study showed that the questionnaire was clear and understandable, and Cronbach's α revealed good reliability (0.65–0.90). For the purpose of the survey, the total geographical area of Peninsular Malaysia was grouped into four regions; North (including the states of Perlis, Kedah, Perak and Penang), Central (including the states of Selangor and Kuala Lumpur), South (including the states of Johor, Malacca and Negeri Sembilan), and East (including the states of Kelantan, Terengganu and Pahang). The survey employed a multistage stratified sampling procedure, where 20 enumeration blocks were randomly selected within each of the four regions. Face-to-face interviews were conducted in respondents' homes for data collection. Only one older person from each selected household was interviewed, and selection by gender (where available) was made on a sequential basis. Interviewers read all questions clearly and recorded each respondent's answers. The representativeness of the sample was assessed by comparing the demographic characteristics of the study sample with the national population of elderly Malays age 60 years, based on data from the National Census 2000.22
Data analysis was conducted with SPSS 13 (Chicago, USA) and the ModGraph-2 software program.23 The research hypothesis was tested using a four-step moderated hierarchical regression analysis. First, sociodemographic characteristics, including age, sex, marital status, employment status, level of education, household income, place of residence and living arrangement, were entered to control for their possible influence.
Second, chronic medical conditions were entered to test the strength and direction of the basic relationship with psychological well-being, before adding any potential moderators. The main effect of personal and social religiosity was entered in the third step. Finally, the two-way interactions, including chronic medical conditions × personal religiosity and chronic medical conditions × social religiosity, were entered.
In the next step, the ModGraph-2 was employed to display the form and pattern of interaction terms. The information required to display interaction terms – means and standard deviations of predictor (chronic medical conditions), moderator variables (social and personal religiosity), and the unstandardized regression coefficients of predictor, moderator variable, interaction term and the constant – was taken from the final regression equation and entered into ModGraph-2.
In moderation analysis, the problem of multicollinearity may lead to ‘bouncing betas’, in which the direction of the beta terms can change from positive to negative or vice versa.24 To avoid this, we centred all variables before examining the moderation analysis. Centring is done by subtracting the sample mean from all individual variable scores.25 This method reduces the multicollinearity between predictors and any interaction terms among them, and facilitates the testing of simple slopes. It should be noted that centring does not change the significance of the interaction and the values of the simple slopes.26
A significant moderation indicates that the association between the predictor and dependent variable is conditional on values of the moderator. However, it does not show whether either of the simple slopes is significantly different from zero. In other words, based on the initial significant interaction effect, a significant moderation does not indicate that the relationship between the predictor and outcome is significant for a specific level of moderation.26 To find the significance for a specific level, post-hoc analysis of the interaction effect was conducted.
Chronic medical conditions
A checklist of 16 chronic medical conditions most commonly encountered by the elderly was used to assess physical health status of the respondents during the previous 12 months. This method has been used in several previous studies.27–32 Respondents were asked whether they had specific chronic medical conditions including hypertension, joint pain (arthritis), heart disease, diabetes, visual problems, hypercholesterolemia, hearing problems, gastritis, asthma, kidney disease, skin disorders, tuberculosis, cancer, effect of stroke, liver disease and psychiatric problems. Then, the medical conditions were added to measure the physical health status of the respondents. The total number of medical conditions was used in multivariate analysis.
Findings from previous studies show that self-reported chronic medical conditions are a useful and valid epidemiological tool for estimating the presence of chronic diseases in health studies,33 but we need to assess accuracy of these self-reported data. To do this, we compared these data with results from the Third National Health and Morbidity Survey 2006.34 We found a close prevalence rate for life-threatening diseases between our results and national prevalence rates.
The results were consistent with previous studies, which have shown the health interview method to be a useful and valid tool for assessment the population's health status.35–37 Similar findings from other studies show acceptable agreements between self-reporting and medical record for diabetes, hypertension, myocardial infarction, stroke and life-threatening diseases.38,39
The revised Intrinsic/Extrinsic Religiosity scale was employed to measure religiosity. The scale is a well-known 2-D measurement of intrinsic and extrinsic religiosity.40 The intrinsic dimension involves personal convictions and a commitment to religious beliefs. This means that people live their lives based on their religious beliefs and pursue meaning in life through religion. According to the extrinsic dimension of religious orientation, persons pursue individual self-centred goals and use religion to gain social standing and support.41 In other words, people use religion for social purposes. It is noteworthy to mention that in the Islamic faith intrinsic religiosity is considered as iman (Islamic belief) and extrinsic religiosity is referred to amal (Islamic behavioural practices).
This scale has been found to be appropriate for use with religious samples of all age groups, and it leads to clearer results.40,42–45 In addition, it has been noted that this scale is a useful instrument for researching the relationship between religiosity and psychological well-being.46
Scale validation procedures have been discussed in detail elsewhere.47 Briefly, two factors emerged from the results of exploratory factor analysis using principal component extraction and varimax rotation. The first factor is personal religiosity, which includes items pertaining to private prayer and faith. This subscale consists of eight statements with which subjects express varying levels of agreement or disagreement; the statements include ‘I enjoy reading the Koran and Hadith’, ‘I have often had a strong sense of Allah's presence’, ‘My whole approach to life is based on my religion’ and ‘It is important to me to spend time in private thought and prayer’. The second factor included three statements: ‘I go to the masjid [mosque] because it helps me to make friends’, ‘I go to the masjid mainly because I enjoy seeing people I know there’ and ‘I go to the masjid mostly to spend time with my friends’. This subscale was called social religiosity. Both subscales showed good evidence of reliability, with internal consistency ranging from 0.82 (social religiosity) to 0.92 (personal religiosity).
Psychological well-being was defined as a positive mood (good spirits, relaxation), vitality (being active and waking up fresh and rested) and general interests (being interested in things),48 which was measured by WHO-5 Well-Being Index.49 This scale consists of the following statements with which subjects express varying levels of agreement or disagreement: (i) ‘I have felt cheerful and in good spirits’; (ii) ‘I have felt calm and relaxed’; (iii) ‘I have felt active and vigorous’; (iv) ‘I woke up feeling fresh and rested’; and (v) My daily life has been filled with things that interest me'. It was developed for the WHO Collaborating Centre for Mental Health. The scale is useful for assessing the psychological well-being of elderly subjects and has been used by several studies.50 Each of the five items is rated on a 6-point Likert scale from 0 to 5. The theoretical raw score ranges from 0 to 25 and is transformed into a scale from 0 to 100. A higher score indicates a higher level of psychological well-being.49 This scale has already been found to be a valid measure of psychological well-being in older Malaysians.51 Cronbach's α, the most common measure of reliability, for this scale was 0.84.
Several sociodemographic characteristics including age, sex, marital status, employment status, level of education, household income, place of residence, family size and living arrangement were controlled. Sex was dummy-coded as female = 0 (reference category) and male = 1. Marital status was dichotomized as married = 1, unmarried = 0 (single, divorced, widowed or separated; reference category). Place of residence was dummy-coded as urban = 1 and rural = 0 (reference category). Employment status was dichotomized as employed = 1 and unemployed = 0 (reference category). Living arrangement was coded into two dummy variables: living with a spouse, children and grandchildren = 1 and other living arrangements = 0. Educational attainment included non-formal education, primary education and secondary/tertiary education. For purposes of this study, all these sociodemographic characteristics were controlled.
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This study included 722 women and 693 men, with an average age of nearly 70 years. Approximately one-third of the sample did not have formal education. Approximately 83% of the respondents lived above the Malaysian poverty line (i.e. had a monthly household income of less than 529 Malaysian ringgit).52 Details of the sociodemographic characteristics of the sample have been previously presented elsewhere and are summarized in Table 1.53
Table 1. Percentage distribution of the sample by sociodemographic characteristics
|Age group (yr)|| || || |
| Young–old (60–74)||73.1 (528)||77.5 (537)||75.3 (1065)|
| Old–old (75–84)||22.2 (160)||19.9 (138)||21.1 (298)|
| Oldest–old (85+)||4.7 (34)||2.6 (18)||3.7 (52)|
|Marital status|| || || |
| Unmarried||71.5 (516)||21.8 (151)||47.1 (667)|
| Married||28.5 (206)||78.2 (542)||52.9 (748)|
|Place of residence|| || || |
| Rural||63.2 (456)||62.6 (434)||62.9 (890)|
| Urban||36.8 (266)||37.4 (259)||37.1 (525)|
|Living arrangement|| || || |
| Living with children/grandchildren and spouse||17.7 (128)||55.3 (383)||36.1 (511)|
| Others||82.3 (594)||44.7 (310)||63.9 (904)|
|Family size|| || || |
| >4 persons||48.3 (349)||47.5 (329)||47.9 (678)|
| 4+ persons||51.7 (373)||52.5 (364)||52.1 (737)|
|Employment status|| || || |
| Unemployed||85.5 (617)||63.6 (441)||74.8 (1058)|
| Employed||14.5 (105)||36.4 (252)||25.2 (357)|
|Level of education|| || || |
| No formal education||51.4 (371)||17.0 (118)||34.6 (489)|
| Primary education||44.6 (322)||66.7 (462)||55.4 (784)|
| Secondary / tertiary education||4.0 (29)||16.3 (113)||10.0 (142)|
|Household income|| || || |
| Below the poverty line*||21.5 (155)||11.8 (82)||16.7 (237)|
| Above the poverty line||78.5 (567)||88.2 (611)||83.3 (1178)|
The results of a series of t-tests comparing the psychological well-being of older persons according to their physical health status across two levels of religiosity (low religiosity: less than mean; high religiosity: greater than or equal to mean) revealed that psychological well-being for those with a high level of religiosity was higher than for those with a low level of religiosity. As shown in Table 2, older persons without a chronic medical condition and who had a high level of personal religiosity demonstrated a statistically higher level of psychological well-being compared to the group with a low level of personal religiosity (t(463)=−5.17, P≤ 0.01). Further results indicated that the psychological well-being of older persons with one chronic medical condition and who rated their personal religiosity as high was significantly greater than the group with low levels of personal religiosity (t(445)=−4.72, P≤ 0.01).
Table 2. Mean psychological well-being according to chronic medical conditions and levels of religiosity
|Number of chronic medical conditions||Religiosity|
|More than one CMC||226||55.4||23.05||277||62||22.97||501||−3.20**||234||56.4||23.12||269||61.4||23.1||501||−2.42*|
The main objective of this study was to examine the moderating effect of religiosity on the relationship between chronic medical conditions and psychological well-being of elderly Malay Muslims. We conducted this study using a four-step moderated hierarchical regression analysis.
The first step of moderated hierarchical regression analysis revealed a significant model (F(9, 1398)= 16.35, P≤ 0.01, R2= 0.10). This model explained 10% of the variance in outcome. As shown in Table 3, age, sex, marital status, living arrangement and household income were statistically associated with psychological well-being.
Table 3. Results of four-step moderated hierarchical regression analysis to test moderating effect religiosity on the relationship between chronic medical conditions and psychological well-being
|Variable||Step 1||Step 2||Step 3||Step 4|
|Level of education||1.14||1.08||0.03||1.17||1.07||0.03||0.31||1.04||0.01||0.12||1.04||0.00|
|Place of residence||0.46||1.20||0.01||1.12||1.20||0.02||1.95||1.16||0.04||1.83||1.16||0.04|
|Chronic medical conditions|| || || ||−2.13||0.43||−0.13**||−1.93||0.42||−0.11**||−1.97||0.42||−0.12**|
|Personal religiosity|| || || || || || ||1.10||0.14||0.20**||1.10||0.14||0.20**|
|Social religiosity|| || || || || || ||0.52||0.18||0.08**||0.50||0.18||0.07**|
|Interaction term for personal religiosity|| || || || || || || || || ||0.25||0.11||0.06*|
|Interaction term for social religiosity|| || || || || || || || || ||0.39||0.13||0.07**|
Chronic medical conditions were included in the second step. A significant model (ΔF(1, 1397)= 24.33, P≤ 0.01, R2= 0.11, ΔR2= 0.02) emerged from the results of this step, which confirmed that older persons reporting a higher number of chronic medical conditions had lower levels of psychological well-being. The third step consisted of adding personal and social religiosity. The addition of these predictors significantly increased the fit of the model to the data (ΔF(2, 1395)= 42.81, P≤ 0.01, R2= 0.16, ΔR2= 0.05). Findings from this step revealed that personal religiosity (β= 0.20, P≤ 0.01) and social religiosity (β= 0.08, P≤ 0.01) positively and significantly contributed toward psychological well-being. This means that having higher levels of both social and personal religiosity is related to higher levels of psychological well-being. The fourth and final step involved adding interaction terms, which significantly increased the model's R2 (ΔF(2, 1393)= 5.27, P≤ 0.01, R2= 0.17, ΔR2= 0.01). Of most interest, the interaction term was statistically significant (P≤ 0.01), indicating that personal and social religiosities do function as moderators of the relationship between chronic medical conditions and psychological well-being.
ModGraph moderation by personal and social religiosity
The findings from ModGraph were divided into three levels of religiosity – low religiosity (one SD below the mean), moderate religiosity (within one SD of the mean) and high religiosity (one SD above the mean) – which showed that the relationship between chronic medical conditions and psychological well-being was strongest in the case of low religiosity and weakest in the case of high religiosity. Individuals of different levels of religiosity had differing levels of psychological well-being. Older persons reporting high levels of religiosity reported higher levels of psychological well-being than individuals reporting low levels of religiosity at certain levels of chronic medical conditions. Certain levels of religiosity under certain conditions of chronic medical conditions showed different levels of psychological well-being.
Figure 2 shows that when social religiosity was at low levels, there was a strong negative relationship between chronic medical conditions and psychological well-being. However, when social religiosity was high, there was a weak negative relationship between chronic medical conditions and psychological well-being.
Figure 2. The effect of social religiosity on the interaction between chronic medical conditions and psychological well-being.
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As shown in Figure 2 across all the conditions of religiosity, a chronic medical condition is negatively related to psychological well-being. However, older persons with moderate to high levels of religiosity reported higher levels of psychological well-being at certain levels of chronic medical conditions.
Figure 3 graphically presents the linear relationship between chronic medical conditions and psychological well-being at three values of personal religiosity. Older persons with low religiosity reported the lowest psychological well-being across all levels of chronic medical conditions.
Figure 3. The effect of personal religiosity on the interaction between chronic medical conditions and psychological well-being.
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Post-hoc analysis for the effects of social religiosity on chronic medical conditions
Table 4 presents the results of post-hoc analysis of the effects of chronic medical conditions on psychological well-being at low, medium and high levels of social religiosity. Although the slopes for low (β=−3.24, P≤ 0.01) and medium (β=−1.97, P≤ 0.01) levels of social religiosity were significantly different from zero, the slope for low levels of social religiosity was steeper than medium. No significant slope for high levels of social religiosity was observed. Conceptually, what this means is that chronic medical conditions were more negatively associated with psychological well-being across low levels of social religiosity compared to medium and high levels of social religiosity.
Table 4. Effects of chronic medical conditions on psychological well-being at low, medium and high levels of social religiosity
|High level social religiosity||−0.70||0.61||−1.15|
|Medium level social religiosity||−1.97||0.60||−3.28**|
|Low level social religiosity||−3.24||0.60||−5.38**|
Post-hoc analysis for the effects of personal religiosity on chronic medical conditions
Table 5 shows the results of post-hoc analysis ofthe effects of chronic medical conditions on the psychological well-being at low, medium and high levels of personal religiosity. As can be seen from this table, no significant slope for high levels of personal religiosity was observed. Although the slopes for medium and low levels of personal religiosity were found to be significant, it should be noted that the slope for low levels of personal religiosity is steeper than the slope for medium levels of religiosity.
Table 5. Effects of chronic medical conditions on psychological well-being at low, medium and high levels of personal religiosity
|High level personal religiosity||−0.95||0.64||−1.47|
|Medium level personal religiosity||−1.97||0.51||−3.89**|
|Low level personal religiosity||−2.99||0.58||−5.16**|
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The main hypothesis of this study was that the religiosity moderates the relationship between chronic medical conditions and psychological well-being among elderly Malay Muslims. The examination of this hypothesis was carried out among a sample of 1415 elderly Malay Muslims. The results of moderation analysis indicated that the relationship between chronic medical conditions and psychological well-being is statistically moderated by social religiosity and personal religiosity.
This finding is consistent with previous studies that have found that religiosity/spirituality has moderating effects on the psychological well-being and quality of life of non-Muslim older persons with chronic medical conditions.54–57 For example, Wink et al. investigated the buffering effect of religiosity on the connection between physical health status and depression among a community-based sample of older men and women born in the San Francisco Bay Area in the 1920s.57 The researchers found that poor physical health was significantly connected to depression only among the low religiosity group, but in the high religiosity group, poor physical health status was not significantly associated with depression. Also, these findings supported those from a study conducted by Tarakeshwar and Vanderwerker.55 They examined the effects of religious-coping on the quality of life of 170 patients with advanced cancer. They found that religious-coping was associated with a better overall quality of life, while controlling for several confounding factors such as sociodemographic variables, lifetime history of depression and sense of self-efficacy. A study by Vannemreddy et al. examined the effect of prayer on the recovery of unconscious patients admitted after traumatic brain injury; results revealed that patients with prayer habits recovered better following severe head injury.56
Similarly, Branco found that public and private religiosity moderated the depressive effects of health stressors in the relationship between disability and depression among elderly black people in nursing homes.58 Moreover, the findings from a recent study exploring the effects of religiosity on the fear of death and death acceptance among a sample of 257 community dwelling elderly persons with chronic illness, from North Carolina in the USA, showed that chronically ill older adults with greater religiosity and closeness to God had less fear of death and greater acceptance of death.59 Additionally, a mail survey conducted with responses 111 rural residents with chronic illness, from Oregon and Montana in the USA, indicate that spirituality reduced some of the problems following chronic illness and enhanced quality of life despite the presence of chronic illness.60
It should be noted that the number of scientific investigations that have examined the effects of religiosity on the psychological well-being of elderly Muslims is very limited. We found a study which had assessed the effect of religiosity on the subjective well-being of Muslims in a sample of 2909 respondents aged 18 years and over with a health condition, from Algeria. The results of this study revealed that two religiosity dimensions, religious practice and religious altruism, significantly contributed to subjective well-being.61
The relationship between medical conditions and psychological well-being can be influenced by core beliefs. According to Daaleman and Dobbs, core beliefs are sources that maintain an interpretative structure through which participants view their life events and positively shape their experiences.59 Patients use a power through belief, which leads to their experiencing good subjective well-being.59 Within an Islamic perspective, ‘Allah's will’ and ‘belief in life after death’ might influence adherents' perception of diseases, consequently enabling followers to experience better psychological well-being.
To summarize, these findings supported our hypothesis, which assumed that religiosity moderates the relationship between chronic medical conditions and psychological well-being among elderly Malay Muslims, after controlling for socioeconomic and demographic factors.
Implications of the study
Based on the findings of this study, it is possible to suggest several practical implications for enhancing psychological well-being of chronically ill older Muslims. As Islamic religiosity significantly reduced the adverse effects of chronic medical conditions on the psychological well-being, this implies that social workers, counsellors and other mental health professionals working with older Muslims should integrate religiosity as an important resource into their therapeutic work to develop and maintain the psychological well-being of those facing age-related problems. Therapists should be trained to integrate their clients' religiosity into therapy and to consider the ethical issues of integrating religiosity into the psychotherapy process.62 Another implication for the current findings is that, given social religiosity significantly moderated the relationship between poor physical health and psychological well-being, interventions that focus on promoting social religiosity could be implemented to enhance the psychological well-being of elderly Malay Muslims. For example, local religious organizations should begin or continue to provide facilities and services to older persons to enable them to participate in social religious activities. Lastly, it is suggested that professionals involved in providing gerontological services to older Muslims should encourage them to employ Islamic religiosity as an important resource for enhancing psychological well-being and quality of life.
Limitations of the study
The first potential limitation that should be acknowledged is related to the self reports of chronic medical conditions without supporting medical records; this may lead to an underestimation of chronic medical conditions. Additionally, the use of a dichotomous measurement to assess chronic medical conditions is limiting because it does not provide information on the severity of disease. Another potential limitation that should also be considered pertains to social religiosity, which only focused on mosque attendance and not other Islamic social religious practices. Even though attendance to places of worship is considered an inaccurate measure of religiosity due to variability of attendance among religious groups,63 the focus of the item ‘I go to the masjid because it helps me to make friends’ was on social religiosity. In this case, attendance at masjid, or the mosque, would be a valid construct of social religiosity because being part of a range of religious activities promotes social interaction and support among the members. In the spatial sense, a mosque can be seen to promote social religiosity because of its architectural design and familiar surroundings. A mosque represents an open, public space in which the majority of religious practices occurs, especially prayer in the main assembly space (or musalla).64,65 Furthermore, Shamsudin and Ujang's study affirmed that an attachment to familiar meeting places evokes people's sense of place and identity that arguably would contribute to enhancing the sense of belonging and solidarity among worshippers.66 Therefore, mosque attendance, as the most important aspect of Islamic religious practice, is associated with Muslims' sense of religious identity.
Recommendation for future studies
Since this study had a cross-sectional design, a longitudinal study is needed to clarify the causal relationship between religiosity and psychological well-being among chronically ill older persons. Given there are several social religious practices in Islam such as hajj, or pilgrimage, to Mecca, future research will need to consider other aspects of social religious practices beyond mosque attendance.