Is there a relationship between spirituality/religiosity and resilience? A systematic review and meta-analysis of observational studies

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.

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https://doi.org/10.1177/1359105320984537
Journal of Health Psychology
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Introduction
According to Koenig et al. (2001) spirituality is
a personal quest to understand end-of-life
issues, their meaning, and relationships with the
sacred or transcendental that may or may not
lead to the development of religious practices or
religious community formations. Puchalski
et al. (2009) defines spirituality as the aspect of
humanity that refers to the way in which indi-
viduals seek and express meaning and purpose,
and the way in which they experience their con-
nection with the moment, with themselves, with
others, with nature, and with the environment—
significant or sacred. Religion, on the other
hand, is a more restricted concept, considered to
be an organized system of beliefs, practices,
and symbols designed to facilitate closeness to
the transcendent (Koenig, 2012).
Is there a relationship between
spirituality/religiosity and resilience?
A systematic review and meta-
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
1 Family Physician, Conceição Hospital Group - GHC,
Porto Alegre, RS, Brazil
2Family Physician, Porto Alegre, RS, Brazil
3 Federal University of Juiz de Fora, Juiz de Fora, MG,
Brazil
Corresponding author:
Fábio Duarte Schwalm, Family Physician, Conceição
Hospital Group - GHC, Av. Francisco Trein, 596 - Cristo
Redentor, Porto Alegre, RS 91350-200, Brazil.
Email: fschwalm@gmail.com
984537HPQ0010.1177/1359105320984537Journal of Health PsychologySchwalm et al.
review-article2020
Review article

2 Journal of Health Psychology 00(0)
There has been an increase in the number of
studies investigating the relationship between
spirituality/religiosity (S/R) and health in the last
decades (Lucchetti and Lucchetti, 2014), most of
them finding positive results. A previous review
found that S/R is usually associated with better
mental health including lower levels of depres-
sion, anxiety, stress, suicidal thoughts, and drug
use (Moreira-Almeida et al., 2014). In relation to
physical health, a nurses’ health study report,
which tracked more than 74,000 study partici-
pants for 16 years, found that women attending
weekly religious services had a lower death rate
compared to those who had never attended reli-
gious services; and those who attended religious
services more than once a week had an even
lower mortality rate, suggesting a possible dose–
response relationship (Li et al., 2016). Further
research suggests the impact of S/R in clinical
practice (VanderWeele et al., 2017). In a multi-
center prospective study (Balboni and Peteet,
2017) of 343 advanced cancer patients, those
whose medical staff (e.g. physicians, chaplains)
addressed their patients’ spiritual needs had end-
of-life quality of life scores 28% higher on aver-
age than those who did not receive spiritual care.
It seems that S/R is particularly important in
chronic diseases and in moments of recovery,
rehabilitation, and suffering (Koenig, 2012).
In this context, the concept of resilience
appears which is generally defined as the ability
of individuals to recover or cope satisfactorily
with adverse circumstances (Connor and
Davidson, 2003; Rutter, 2012), with reference to
the human capacity to adapt to tragedy, trauma,
adversity, difficulty, and significant stressors.
This is a dynamic process, influenced by life
events and challenges (Hardy et al., 2004).
Resilience is associated with many factors such
as coping ability, self-efficacy, optimism, social
support, flexibility, religious and spiritual beliefs,
positive emotions, self-esteem, and meaning and
purpose in life (Helmreich et al., 2017).
Spirituality, according to some authors
(Manning, 2013; Smith et al., 2012; Vieira, 2010),
is highlighted as one of the basic characteristics
that predict resilience, as well as several others
that have to do with both dimensions, such as
optimism and purpose, for example. In a study
including older women, Manning (2013)
described spirituality “as a path to resilience.”
Moreover, S/R seems to confer resilience, as
pointed out by Koenig’s (2009) review while cor-
relating S/R and mental health. Spirituality can
help cancer patients make sense of life and the
roles of spiritual and religious beliefs have been
widely recognized in coping with cancer and pro-
moting resilience (Hunter-Hernández et al.,
2015). In addition, many cancer patients have
been found to experience spiritual growth after
being diagnosed with the disease (Gall et al.,
2011) and a randomized controlled trial demon-
strated a significant increase in resilience from
spiritual-based interventions (Sood et al., 2011).
Within the Latin American context, a research
study of Central American migrants in a transit
shelter in Mexico concluded that the most impor-
tant factors that helped them build up their resil-
ience were: trustful relations; support from
religious organizations; hope for the future; value
systems and beliefs; creativity and persistence;
problem-solving; and self-awareness (Vinueza,
2017); according to Puchalski’s definition, all of
these aspects are related to spirituality.
Despite the importance of resilience in mod-
ern society and the growing literature on the
influence of S/R in suffering, to our knowledge,
there is a lack of systematic reviews on this sub-
ject. Understanding how resilience and S/R are
correlated or not could add to the current scien-
tific literature, helping in the development of
new preventive strategies to deal with chronic
conditions and deepening our knowledge con-
cerning how these concepts are overlapped in
clinical practice. Therefore, the present study
aims to investigate if there is a relationship
between spirituality/religiosity and resilience
when analyzing observational studies.
Methods
Type of study
This is a systematic review and meta-analysis,
following the parameters of the Preferred
Reporting Items for Systematic Reviews and

Schwalm et al. 3
Meta-analysis (PRISMA) and registered a pri-
ori at PROSPERO (CRD42018110544).
Identification and selection of studies
The review of the literature was intended to
answer the research question “Is there an asso-
ciation between levels of spirituality/religiosity
(S/R) and resilience?” and on 24 April, 2019 the
following electronic databases were used:
Pubmed, Embase, Scopus, Web of Science,
PsycInfo, CINAHL, and LILACS, without lan-
guage and publication date restrictions. In order
to augment the number of articles, the gray lit-
erature and the references from included arti-
cles were also searched.
The keywords related to the subject were
chosen based on prior systematic reviews and
guidelines. The search strategies in the data-
bases included the terms “spirituality,” “reli-
gion,” and “resilience” elaborated with the
definition of the subject descriptors of each
database, MeSH in PubMed and Emtree in
Embase, and also with the addition of syno-
nyms and syntax when necessary. The use of
Boolean operators was applied for the construc-
tion of the strategies, these being the AND to
relate and the OR to add. An example of the
Boolean expression is visualized below:
(religion OR “spirituality”[Mesh] OR spiritual*)
AND (“resilience, psychological”[Mesh] OR
resilience* OR resilient*)
Eligibility criteria
The inclusion criteria were designed to find
observational, quantitative studies that evalu-
ated the relationship between spirituality and/or
religiosity with resilience in the most different
scenarios and populations, which used an infer-
ential statistical analysis.
Exclusion criteria were designed to exclude
comments, editorials, books, qualitative arti-
cles, and those that mentioned spirituality/relig-
iosity or resilience without an objective measure
(validated scale) of these variables, as well as
studies of different non-observational designs.
Assessment of studies
After the literature search was carried out
according to the strategy previously presented,
duplicate articles were excluded and two exam-
iners (FS and RZ) started the analysis indepen-
dently, reading the titles and abstracts of each
article. The articles included were then submit-
ted to a full reading. All deadlocks were
resolved either by discussion and consensus of
the examiners or, when in doubt, discussion
with a third reviewer (EDCF or GL). The arti-
cles, theses, or data not available in the original
studies were searched in an attempt to contact
their authors via e-mail.
Data extraction
The articles evaluated in full had their data
recorded in an extraction table that was devel-
oped by the reviewers seeking to collect the rel-
evant information for the systematic review
considering the possible subgroup analysis nec-
essary later, and aiming to meet the objectives
of the work described. The results were synthe-
sized according to the parameters presented
below. Each association data of the studies
between S/R and resilience was extracted in the
table. Thus, studies that used S/R scales with
more than one dimension were used separately,
generating more than one measure in the same
article.
Risk of bias
All articles that met the inclusion criteria had
their data analyzed through the Newcastle–
Ottawa scale (NOS) (Modesti et al., 2016), an
instrument adapted for observational studies,
which was used to assess the risk of cross-sec-
tional bias. These studies were assessed by two
independent reviewers with further discussion
of the impasses and a third reviewer for remain-
ing questions. This instrument derives from the
Newcastle–Ottawa scale for observational case-
control and cohort studies, using an adaptation
of the cohort scale for cross-sectional studies,
as described in previous studies published in the

4 Journal of Health Psychology 00(0)
literature (Herzog et al., 2013). The final score
ranging from 0 to 10 and a cutoff value of 5 or
more (satisfactory studies) (Luchini et al., 2017)
was used for inclusion in the quantitative analy-
sis and 7 or more (top quality studies) for high-
quality ones (Aibana et al., 2019).
Data synthesis
The data correlation of study variables, such as
spirituality or religiosity scale, age, country of
study, and population characteristics (healthy or
in distress—physical or mental disorders) listed
from the original articles were combined in this
study for meta-analysis. The analysis was per-
formed using the Review Manager Program
version 3.6.1, Meta package (version 4.95). The
correlation meta-analysis was calculated based
on the random-effects model using Fisher’s Z
transformation of correlations. The random-
effects model was chosen because we are deal-
ing with studies including different scales,
samples, and settings and, for this reason, it is
possible that the effect size varies from study to
study (Borenstein et al., 2010). For the combi-
nation of regressions, the inverse variance
weighting method was used. Heterogeneity was
measured by the I² statistic. The analysis of het-
erogeneity between groups was performed
based on the Q statistic and funnel plots were
reported to assess potential publication bias
visually. The confidence level used was 95%,
and significance level was 5%. The analyses for
the correlation between R/S and resilience were
performed for the total sample (all studies were
included), for those studies with a satisfactory
quality (NOS⩾5) and for those studies with the
highest quality (NOS > 7). Likewise, subgroup
analyses were carried out according to scales,
age groups, countries, and disease. Finally, fun-
nel plots were used to assess potential publica-
tion bias visually.
Results
From a total of 4193 articles found (4183
through databases and 10 through other
sources—five published scientific articles and
five dissertation theses), 1715 articles were
excluded due to duplication, with 2478 remain-
ing ones which were evaluated by the two
researchers of the review. After the first analy-
sis, 2403 studies did not meet the proposed
inclusion criteria according to the title and
abstract of the study and thus were excluded. Of
these, 75 papers underwent full content evalua-
tion, and the remaining doubts were clarified by
joint discussion and, when still not resolved,
were evaluated by a third reviewer. In this phase
of the research, 34 articles that did not meet the
elaborated criteria were excluded. Thus, the
remaining 41 studies underwent quality analy-
sis (risk of bias), using the cutoff of 5 points or
more in the Newcastle–Ottawa (NOS) instru-
ment. This procedure excluded a further seven
articles, leaving 34 articles (Figure 1).
The final 34 articles (NOS ⩾ 5) published
between 2007 and 2019, were composed of a
sample of 6653 persons, and including the quan-
titative analysis generated 44 associations/corre-
lations (i.e. one study could have more than one
association depending on the scale used and the
groups analyzed) (Table 1). In the descriptive
analysis, most measures used were for spiritual-
ity (70.4%), from Latin America (22.7%) and the
Middle East (20.4%), in persons experiencing
stressful life events (72.7%) and adults (79.5%)
(Table 2). Concerning the quality of studies,
seven out of 34 (20.5%) were considered high-
quality studies (NOS ⩾ 7) and all studies were
cross-sectional (there were no cohort studies).
The meta-analysis was conducted in the fol-
lowing ways:
(a) Including all studies independent of the
study quality (n = 41): there was a statis-
tically significant positive correlation
between S/R and resilience of r = 0.43
(IC 95%, 0.35–0.50; p < 0.01), with a
high degree of heterogeneity (I2 = 94%)
(Figure 2);
(b) Including all studies with quality assess-
ment of 5 points or more (satisfactory):
there was a statistically significant posi-
tive correlation between S/R and resil-
ience of r = 0.40 (IC 95%, 0.32–0.48;

Schwalm et al. 5
p < 0.01), with a high degree of hetero-
geneity (I2 = 93%) (Figure 3);
(c) Including all studies with quality assess-
ment of 7 points or more (top-quality
studies): there was a statistically signifi-
cant positive correlation between S/R
and resilience of r=0.37 (IC 95%, 0.23–
0.49; p < 0.01), with a high degree of
heterogeneity (I2 = 87%) (Figure 4).
(d) Subgroup analyses according to scales,
age groups, countries, and disease (Table
2). The results of the individual analysis
of studies using scales measuring spiritu-
ality and those using scales measuring
religiosity showed a statistically different
result in favor of the correlation in the
subgroup spirituality r = 0.46 (IC 95%,
0.37–0.54; p < 0.01) compared to those
of religiosity r = 0.24 (IC 95%, 0.11–0.37;
p < 0.01). The analysis of the countries in
which the study was conducted showed
differences with the weakest correlation
in the Americas, moderate in Europe, the
Middle East, and Asia and moderate/
strong in Oceania (only 1 study). The
analysis of age groups and the healthy
versus people experiencing stressful life
events showed no differences.
Records identified through database
searching
(n = 4183)
SCREENING
INCLUDED ELIGIBILITYIDENTIFICATION
Additional records identified
through other sources
(n = 5+5)
=
Records after duplicates removed
(n = 2468+10)
Records screened
(n =2478)
Records excluded
(n = 2403)
Full-text articles assessed
for eligibility
(n = 75)
Full-text articles excluded
(n = 34)
Reasons:
-Duplicate data: 1
-Incomplete arcle: 2
-Scale not validated: 12
-Does not correlate the variables: 19
All studies included
(n = 41)
Studies with a Newcastle–
Ottawa score of more than
5 points
(n = 34)
Figure 1. PRISMA flow diagram from identification to article selection.

6 Journal of Health Psychology 00(0)
Table 1. Data extraction and results synthesis (NOS ⩾ 5).
Author/year Condition of the study
population
nResilience scale Spirituality scale/religiosity Country Correlation p value
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
black population
175 Wagnild and Young Santa Clara (SCSORF) USA 0.1 NS
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
(SISRI)
Iran 0.313 ⩽0.01
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
Intelligence
Iran 0.35 <0.01
White (2010) Spinal cord injury 42 CD-RISC Intrinsic Spirituality (ISS) USA 0.35 <0.05
Pessotti (2018) Caregivers of patients with
dementia
50 Wagnild and Young DUREL Brazil 0.37 <0.05
Howell etal. (2014) Students who suffered
childhood violence
321 CD-RISC Daily Spiritual Experiences (DSES) USA 0.38 <0.01
Hatami (2019) Pregnant women 134 CD-RISC King’s Spiritual Intelligence Iran 0.394 <0.05
(Continued)

Schwalm et al. 7
Author/year Condition of the study
population
nResilience scale Spirituality scale/religiosity Country Correlation p value
Han etal. (2016) Qiang ethnicity after
earthquake 2008
898 CD-RISC Spiritual Beliefs (SBQ) China 0.407 <0.01
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
with SCI
50 CD-RISC FACIT-Sp Australia 0.51 <0.01
Darvishzadeh (2017) Women college students 200 Wagnild and Young Spiritual intelligence
(Abdollahzadeh)
Iran 0.512 <0.001
Fangauf (2014) General pop. from 3
different ethnicities
343 Wagnild and Young Spiritual Attitude and Engagement
(SAIL)
Netherlands 0.53 <0.01
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
Resiliente
Questionnaire GES Spain 0.577 <0.001
Mizuno (2017) Bipolar and paranoid
schizophrenia
225 Wagnild and Young FACIT-Sp Austria/
Japan
0.584 <0.001
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
violence
54 Wagnild and Young Spirituality Scale (SIWB) USA 0.648 <0.001
Kolaei (2013) Pregnant women 211 CD-RISC King’s Spiritual Intelligence Iran 0.659 <0.001
Veysi (2017) Mothers of children with
mental retardation
100 CD-RISC Allport Religious Search Iran 0.68 0.001
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
test
Spain 0.853 <0.001
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.
Table 1. (Continued)

8 Journal of Health Psychology 00(0)
Discussion
The results presented in this review showed a
moderate correlation between S/R and resilience,
and these findings were maintained even when
only high-quality studies were included in the
meta-analysis. In addition, subgroup analyses
revealed that spirituality measures seem to be
strongly correlated with resilience as compared
to religiosity measures. Understanding this asso-
ciation can help researchers, health profession-
als, and administrators to develop preventive
strategies to stimulate resilience in their patients
and to design future studies in this area.
Many studies have evaluated the association
between S/R and resilience presenting similar
results. Fangauf (2014), evaluated 343 persons
from three different ethnicities and found a cor-
relation of 0.53; Han et al. (2016) measured this
association in 898 Chinese volunteers after the
2008 Qiang earthquake and found a correlation
of 0.40, and Howel and Miller-Graff (2014)
assessed 321 American students who were vic-
tims of childhood violence, finding a correlation
of 0.38. Despite the fact that there is a wide
array of evidence linking S/R and resilience, so
far we have not identified systematic reviews on
the topic. These previous studies corroborate
our meta-analysis, which found a moderate cor-
relation between S/R and resilience, even when
including only high-quality studies.
Although the mechanisms for this relation-
ship are unknown, it can be explained, at least
in part, by the existence of common factors
underlying resilience and religious/spiritual
qualities, such as optimism, positive emotions,
social support, and the search for meaning and
purpose. Likewise, it is important to underscore
that some instruments used to assess resilience
could have spiritual components that may have
an influence in this correlation. As an example,
the item “Sometimes fate or God can help”
from the Connor–Davidson resilience scale and
the item “my life has meaning” from the
Wagnild and Young resilience scale can overlap
with religiosity and spirituality respectively.
In addition, the transformation process that
can occur after traumatic events and suffering,
Table 2. Subgroup correlation between spirituality/religiosity and resilience in the meta-analysis
(NOS ⩾ 5).
Number of
analyses
Correlation 95%CI p I2 % Q p
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

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)
known as post-traumatic growth, is also linked
to both concepts (Gall et al., 2011). Based on
these considerations, it becomes clearer how
spirituality, inner strength, and resilience can be
understood as closely intertwined concepts,
connected to the idea of a meaning and a higher
purpose of life as a source of motivation and
overcoming (Vieira, 2010).
Figure 3. Forest plot demonstrating the overall meta-analysis result for the correlation between
spirituality/religiosity and resilience (NOS ⩾ 5).

Schwalm et al. 11
Despite the existing correlation, spirituality
and resilience are considered different con-
cepts, each having its own characteristic. Smith
et al. (2012) argued that spirituality may
increase resilience in at least four ways, includ-
ing through relationships, life values, personal
meaning, and coping; they conclude that there
are more plausible ways that spirituality may
influence resilience and positive emotions than
the reverse. Thus, resilient individuals may not
have S/R, however people with S/R will proba-
bly have higher levels of resilience.
In our subgroup analyses, there was a
higher correlation between spirituality and
resilience than religiosity and resilience.
Since the literature points to meaning and pur-
pose as being one of the most important com-
ponents of resilience strengthening (Smith
et al., 2012) and these aspects are generally
measured on scales that address spirituality,
we can at least partly attribute this result to
this. Religiosity may offer more social sup-
port while spirituality may be more related to
intrinsic factors concerned with meaning, for
example. Studies investigating spirituality
and religion often do not precisely measure or
differentiate between them (Lucchetti et al.,
2013), which makes it difficult to get a clear
picture of the complex ways that religion and
spirituality may be related to resilience.
Another interesting finding in our study is
the fact that there were studies from all over the
world, including all continents with the excep-
tion of Africa. Nine studies were conducted in
Iran, where Islam predominates and the popu-
lation has different religious habits compared
to Christian populations (which constituted
most studies according to the predominant reli-
gion in the country). However, in the all regions
subgroup, the favorable results of the relation-
ship between S/R and resilience were main-
tained, highlighting the representativeness of
the theme and results. These results reinforces
the fact that resilience is an important tool used
by many cultures and populations and that its
relationship with S/R seems to transcend cul-
tural differences.
The comparison between ages showed no
differences; this coincides with data in the lit-
erature that point to this variable as controver-
sial for resilience (Gheshlagh et al., 2016).
However, some studies show results of resil-
ience increasing with age. A meta-analysis
assessing resilience factors and mental health,
with a sample of more than 68,000 participants
found increased resilience in the adult group
Figure 4. Forest plot demonstrating the meta-analysis result for the correlation between spirituality/
religiosity and resilience in high-quality studies (NOS ⩾ 7).

12 Journal of Health Psychology 00(0)
compared to the child and adolescent groups
(Hu et al., 2015). It is possible that memories of
life experiences contribute to strengthening
resilience with age. The wide range of age
between study participants for each study may
explain our data, since the sub analysis was car-
ried out including the mean age of the sample.
With regard to the comparison between
healthy and distressed subgroups (study popula-
tions with physical, mental, or vulnerable condi-
tions), both groups showed a positive correlation
without a significant difference between groups.
Our hypothesis when evaluating this item was
that the correlation between S/R and resilience
would be higher in the group experiencing stress-
ful life events, because, according to the literature
review, resilience appears in moments of adver-
sity. Most studies on resilience use populations in
distress, such as those diagnosed with serious ill-
ness or who are dealing with a traumatic event.
The theory suggests that resilience is most rele-
vant among populations at a greatest risk of expe-
riencing stress or trauma (Mancini and Bonanno,
2010). Thus, the data presented in this review,
which included studies where resilience scales
were applied to healthy populations, such as stu-
dents, supports the hypothesis that S/R levels cor-
relate with resilience equally in both the general
and the population experiencing stressful life
events.
Our results also point to important clinical
implications. Resilience is a resource for coping
with adversity which increases quality of life and
decreases the chances of falling ill (Gheshlagh
et al., 2016; Rutten et al., 2013). Based on this
evidence, strengthening resilience may be a good
strategy to prevent these problems and various
health care programs and settings are beginning
to incorporate resilience interventions (Joyce
et al., 2018; Leppin et al., 2014; Sood et al.,
2011). A better understanding of the factors driv-
ing resilience is important for optimizing
resources. Several authors have pointed out the
role of spiritual and religious beliefs in strength-
ening resilience (Brewer-Smyth and Koenig,
2014). However, clinical trials assessing if spirit-
ually-based interventions could lead to higher
levels of resilience are lacking. Based on our
meta-analysis, we suggest that future resilience
interventions should investigate S/R aspects in
order to see if they are effective in the promotion
of resilience.
Limitations
The present systematic review has some limita-
tions that should be considered while interpreting
our results. First, the terms used in the search
strategy may not have covered all the literature on
the topic and not all databases were consulted.
Although this is a potential limitation, it is true for
practically all review studies. In order to mini-
mize this problem, the gray literature was
searched. Second, the high heterogeneity of the
studies included in the analyses decreases the
reliability/robustness of our conclusions which
should therefore be interpreted with caution.
Third, all the studies found were cross-sectional,
which may not provide definite information
about cause-and-effect relationships. Finally,
some resilience scales evaluate faith and trust,
characteristics that are also evaluated by S/R
scales. Thus, the measurement of similar domains
may contribute to the association found.
Conclusion
In the present systematic review we identified a
moderate positive correlation between S/R and
resilience, even while evaluating only high-
quality studies. In the subgroup analyses,
although both were significant, spirituality
showed a greater correlation coefficient as com-
pared to religiosity. Despite these findings, it is
important to highlight that the sample showed
high heterogeneity, which should be considered
when interpreting the results.
Declaration of conflicting interests
The author(s) declared no potential conflicts of inter-
est with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) disclosed receipt of the following finan-
cial support for the research, authorship, and/or

Schwalm et al. 13
publication of this article: This study is part of activities
of the post-graduation program in Health Technology
Assessment of the School of the Conceição Hospitalar
Group, and has no external sources of funding.
ORCID iDs
Fábio Duarte Schwalm https://orcid.org/0000-
0003-4581-8941
Giancarlo Lucchetti https://orcid.org/0000-0002-
5384-9476
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