Authors: Konstantinos GIANNOULIS (1), Vaitsa GIANNOULI (2)
Keywords: elderly, religious beliefs, self-esteem, anxiety, depression.


Konstantinos GIANNOULIS (1), Vaitsa GIANNOULI (2)

(1) School of Theology, Aristotle University of Thessaloniki, Thessaloniki, Greece;

(2) Bulgarian Academy of Sciences, Sofia, Bulgaria

Address correspondence to: Vaitsa Giannouli, Bulgarian Academy of Sciences, Acad. G. Bonchev str., bl. 23, 1113, Sofia, Bulgaria, Ph.: +35928719109; E-mail:


Objectives. The purpose of this preliminary study is to determine the relationship between religious beliefs, self-esteem, anxiety, and depression in Greek elders.

Material and methods. Thirty healthy older adults, all members of the Greek Orthodox Church, participated voluntarily in this research. Participants completed four relevant self-report questionnaires: 1) Beck Depression Inventory, 2) State -Trait Anxiety Inventory, 3) The Royal Free Questionnaire for Religious and Spiritual Beliefs, and 4) Rosenberg Self-esteem Scale.

Results. Results indicated no significant differences on the basis of gender (p > 0.05). The vast majority of the participants (n = 25) stated a strong religious and/or a spiritual belief, as measured by the Royal Free Questionnaire for Religious and Spiritual Beliefs.  High scores on the Royal Free Questionnaire for Religious and Spiritual Beliefs were moderately and positively correlated with increased self-esteem, as measured by the total scores in the Rosenberg Self-esteem Scale (p < 0.05). In addition to that, the Royal Free Questionnaire for Religious and Spiritual Beliefs scores were negatively correlated with depression, as measured by the Beck Depression Inventory (p < 0.05). The Royal Free Questionnaire for Religious and Spiritual Beliefs was negatively correlated with state anxiety (p < 0.05), as well as anxiety, as personality trait (p < 0.05), both measured by the State and Trait subscales of the Anxiety Inventory.

Conclusions. This study shows that there is a number of statistically moderate correlations between religious beliefs and other mental health variables in older adults living in Greece. The findings indicated a need for further research in this field.

Keywords: elderly, religious beliefs, self-esteem, anxiety, depression.


The meaning of faith is central to the Orthodox Church (Ware, 1979). Despite numerous studies, mainly in Catholic and Protestant individuals, supporting that religious or spiritual beliefs are conductive to better physical health and psychological well-being (AbdAleati, Zaharim and Mydin, 2016; Ahrenfeldt et al., 2017; Ahrenfeldt et al., 2018; Vitorino et al., 2018), religious and spiritual beliefs have been little investigated in Greek Orthodox older adults, in relation to health-related behaviors and mortality rates (Chliaoutakis et al., 2002; Darviri et al., 2016). Between 2011-2012, in a sample of 1215 subjects aged between 18-74 years old from Romania, was found that “84% of the subjects pray, meditate or take part in similar activities outside the church. In reference to the church as institution, the respondents stated it responded first to people’s spiritual needs. Half of the respondents considered that church had an important role in the individual’s and the family’s morality. The lowest results the church obtained refer to its capacity of resolving the social problems throughout the country, more than ¾ stating that church did not offer answers to these problems” (Rada, 2013, p. 339). Studies mainly in the U.S.A. have found that there is no significantly important relationship between religiousness and depression or self-esteem in older nursing home residents (Commerford and Reznikoff, 1996), while other researchers have found that religious participation significantly increases self-esteem, but no significant effect has been found on depression among older individuals who are suddenly bereaved (Sherkat and Reed, 1992), and that religious involvement and self-esteem, especially in older adults, may be influenced by the belief in a supportive higher power- ” divine support” (Schieman et al., 2017). In addition to that, caregivers of dementia patients, who participated more in religious activities and used religion as positive coping, reported less caregiver burden and depression (Shin et al., 2017). In cancer family caregivers, the finding of an association between attendance at religious services and depressive symptoms, despite no association between prayer and depressive symptoms, indicates the hidden importance of social factors that may contribute to the association (Williams et al., 2015). Other researchers support that spirituality in older adults, seeking outpatient mental health treatment, attenuates the association between depression symptom severity and meaning in life (Bamonti et al., 2016), and also religious affiliation has a protective effect on suicide rates in older age (Lawrence, Oquendo and Stanley, 2016; Nisbet et al., 2000; Norko et al., 2017). In older women, higher frequency of religious service attendance has been found to decrease the risk of incident depression, while women with a diagnosis of depression were less likely to subsequently attend services (Li et al., 2016). Finally, frequency of religious attendance and the belief in an afterlife are inversely associated with feelings of anxiety and positively associated with feelings of tranquility (Ellison, Burdette and Hill, 2009; Shreve-Neiger and Edelstein, 2004).

More specifically, although spirituality and religiousness are increasingly gaining attention as old age research variables, especially related to physical health and health problems/diseases (Cheadle and Dunkel Schetter, 2017; Miller and Thoresen, 2003), there are no extensive research attempts regarding the connection that there may exist between psychological variables and religiousness-spirituality when concurrently examined (Underwood, 2006) not in older individuals with diagnosed chronic health problems and their caregivers (Giannoulis and Giannouli, in press, 2020; Lucette et al., 2016), but in physically healthy older adults. Additionally, different features not only of national, but also of cultural contexts may strengthen or attenuate the relationship of religion and spirituality with subjective well-being (Bond, Lun and Li, 2012; Diener, Tay and Myers, 2011; Giannouli, 2017a; Giannouli, 2017b), but also with other psychological variables and the relationship between them (Stoyanova, Giannouli and Gergov, 2017). Thus, based on the findings of a previous study on students that stated a strong religious and/or a spiritual belief strongly positively correlated with increased self-esteem and negatively correlated with depression, current stress, and stress as personality trait (Papazisis et al., 2014), the specific objective of this study is to determine the relationship between religious beliefs, self-esteem, anxiety, and depression in physically healthy older adults living in Greece. Therefore, it was expected to find on the one hand strong positive correlations for religious/spiritual beliefs and self-esteem, and on the other hand strong negative correlations of the abovementioned variables with anxiety and depression. In addition to that, it was examined whether the gender of the participants could differentiate the above variables – depression, state anxiety, trait anxiety, and religious/spiritual beliefs -, as the religious-spiritual beliefs are very little investigated in Orthodox Greek elders (Giannoulis and Giannouli, in press).

Material and methods


Thirty healthy older adults (15 females), all members of the Greek Orthodox Church, participated voluntarily in this research. The sample size for this preliminary and exploratory study was sufficient (minimum n = 30 rule of thumb) (Hogg, Tanis and Zimmerman, 1977). All participants came from a specific city in Northern Greece and the examination was completed in one session in 2018. Participants were recruited through printed advertisements on notice boards at various city sites. Their mean age was 75.58 years (SD = 7.50, range 61-90 years old), and level of education 15.47 years (SD = 3.82). There were no statistically significant differences regarding age and education between males and females (p > .05). 15 participants were married, 10 were widowers, and 5 were divorced. All participants received information about the study prior to participating, and signed the informed consent form. In addition to that, participants were given the opportunity to ask questions about the study, and were informed that participation in the study was voluntary.  They were also informed that they could withdraw at any time without any repercussions.

Inclusion criteria were: age 65 years and older, no previous or current diagnosis of chronic physical illness based on recent (not more than 3 months) medical tests – as this is a crucial point in this study – to focus only on individuals free from diseases, no diagnosis of neurological diseases and psychiatric disorders, and taking no medication regarding any physical disease. Exclusion criteria were: being a member of any other Christian Church other than the Greek Orthodox Christian, being younger than 65 years old at the time of recruitment, not speaking adequately the Greek language or present cognitive and especially even mild language impairments, not having a permanent residence in Greece, and not giving a response to all the questions from the administered questionnaires.


Participants completed four self-report questionnaires (all previously translated and validated in Greece), which are easy to complete by elderly: 1) Beck Depression Inventory – a multiple-choice self-report inventory, 2) State and Trait Anxiety Inventory – a psychological inventory based on a 4-point Likert scale which consists of 40 questions on a self-report basis, used to measure trait and state anxiety, 3) The Royal Free Questionnaire for Religious and Spiritual Beliefs – an instrument which has the form of a self-report questionnaire, and 4) Rosenberg Self-esteem Scale – a widely used self-esteem measure.

  1. Beck Depression Inventory: The Beck Depression Inventory (BDI) is used to measure depression as it examines somatic as well as cognitive aspects of depression not only in young adults, but also in older adults (Segal et al., 2008). The BDI is a 21-item scale that has been used as a self-report instrument, which apart from its original purpose (assessment of the severity of known depression), for screening purposes (Michopoulos et al., 2008). The Greek version has been translated, validated, and widely used to date (Jemos, 1984).
  2.  State and Trait Anxiety Inventory: The State-Trait Anxiety Inventory (STAI) –is a brief self-rating scale for the assessment of state and trait anxiety, standardized and used mainly in adults (Spielberger, 1970). “State anxiety refers to the subjective and transitory feeling of tension, nervousness, worry and may be characterized by activation of the autonomous nervous system, at a given moment. Trait anxiety refers to relatively stable individual differences in anxiety proneness as a personality trait, that is, in the tendency to perceive and respond to stressful situations with elevations in the intensity of state anxiety reactions” (Fountoulakis et al., 2006). STAI consists of 40 self-report items (20 state and 20 trait) pertaining to anxiety symptoms, which are scored on 4-point Likert-type response scale, and scores range from 20 to 80, with higher scores suggesting greater levels of anxiety. According to Spielberger’s criteria, a score of 40 or higher reflects clinically relevant symptoms of anxiety. STAI is reported to be reliable and valid and has been used extensively in research and clinical practice in diverse populations (Giannouli and Stoyanova, 2018).
  3. The Royal Free Questionnaire for Religious and Spiritual Beliefs:  This is a questionnaire that can take also the form of an interview designed to measure religious and spiritual belief by examining various aspects of religiousness as well as spirituality (King, Speck and Thomas, 2001). In addition to that, it is brief and simple to complete in the Greek population (Sapountzi-Krepia et al., 2005). High scores (from 0 to 10 points to specific closed-ended questions) in this questionnaire indicate that respondents hold strongly to their beliefs, and that these beliefs have a major role in their everyday lives.
  4. Rosenberg Self-esteem Scale: Self-esteem is the positive or negative attitude toward self (Rosenberg, 1979). This specific scale consists of 10 questions rated on a Likert scale from 1 – 4, having 1 = strongly disagree to 4 = strongly agree, as shown in a previous large-scale study in Greece (Galanou et al., 2014). A scale of 0-30 is used, where a score less than 15 may indicate a problematic low self-esteem (Rosenberg, 1979).


Participants first answered demographic questions about gender, age, and their health status. Then, they completed the Beck Depression Inventory, the State and Trait Anxiety Inventory, the Royal Free Questionnaire for Religious and Spiritual Beliefs, and the Rosenberg Self-esteem Scale. The collected data was first processed in Excel, and then in SPSS. In order to control confounding, that is a variable or variables whose presence may affect the variables being studied so that the results do not reflect the actual relationship, matching was used, which involves selection of participants with respect to the distribution of one or more potential confounders (in our case age, gender, social, economic, health and family status of the first 15 participants, so the rest formed a homogeneous identical comparison group). Independent samples t-tests were used to compare the scores in all the above mentioned questionnaires, when gender (male/female) was used an independent variable. In addition to that, Pearson’s correlation coefficient was used to assess associations between the four questionnaires. A statistical significant level was considered for p < 0.05.


Results indicated no significant differences on the basis of gender regarding depression (t (28) = 3.790, p = .870), state anxiety (t (28) = 2.355, p = .300), trait anxiety (t (28) = 1.345, p = .206), religious-spiritual beliefs (t (28) = 1.417, p = .841), and self-esteem (t (28) = .032, p = .322) (Table 1). The majority of the participants had scores over 50/70 and stated a strong religious and/or a spiritual belief (close to the maximum10 points), as measured by the Royal Free Questionnaire for Religious and Spiritual Belief (n = 25).

Table 1. Mean and Standard Deviations for the Scales

Scales Gender N Mean S.D.
Beck Depression Inventory men 15 7.80 3.93
women 15 2.73 3.36
State Anxiety men 15 24.40 2.29
women 15 23.80 3.60
Trait Anxiety men 15 26.00 2.59
women 15 24.53 3.33
Royal Free Religious and Spiritual Beliefs men 15 53.46 14.99
women 15 60.66 12.74
Rosenberg Self-esteem Scale men 15 34.73 6.15
women 15 34.80 5.40

High scores on the Royal Free Questionnaire for Religious and Spiritual Beliefs were moderately correlated with increased self-esteem as measured by the total scores in the Rosenberg Self-esteem Scale (r = .429, p = .018). In addition to that, the Royal Free Questionnaire for Religious and Spiritual Beliefs scores were negatively correlated with depression, as measured by the Beck Depression Inventory (r = -.430, p = .018). Finally, the Royal Free Questionnaire for Religious and Spiritual Beliefs was negatively correlated with state anxiety (r = -.553, p = .002), as well as anxiety as personality trait (r = -.469, p =.009), both measured by the State and Trait subscales of the Anxiety Inventory.


Religiousness and spirituality have been defined variously in the literature something that may play the role of an obstacle in research (Chatters, 2000; Hill and Pargament, 2003; Koenig, 2008; Oman, 2013). In contrast to this theory gap, most of the empirical research use specific self-assessment measures of religiosity and spirituality that include parameters such as service attendance, prayer, Scripture reading, mediation, spiritual experience, and specific beliefs (Hill and Hood, 1999; Idler et al., 2003).

Given that multiple studies focus only on the relationship between religious involvement and depression (one of the most widespread problems in mental healthcare in the 21st century) (Koenig et al., 2012), while several yield either no association or a positive correlation (Paine and Sandage, 2017; Smith, McCullough and Poll, 2003), and although there is still debate as to the importance of religiousness and spirituality in healthcare, this study includes the measurement of additional psychological variables in healthy older adults, and confirms previous findings coming from a study on students (Papazisis et al., 2014). A number of statistically moderate correlations were found between religious beliefs and other mental health variables in older adults who live during a time period characterized by the financial crisis and social changes in Greece. The research indicated a need for further research in this field as simultaneous testing of psychological constructs in healthy elders is not thoroughly examined so far (Tillich, 1958), and may support future interventions in old age that focus on improving psychological-emotional life by taking into account aspects of religious life.

The study had some shortcomings which could be eliminated in future studies. The main limitation of this research is concerned with the sample size, which impedes generalisability of the results and which is not representative for the Greek population. Of course, the results of this preliminary study should be interpreted in light of giving directions for a future large-scale research. In addition to that, self-report questionnaires may be subject to response bias, something that must be taken into account and checked with reliable sources of information (e.g. the opinion that others have regarding the expressed emotions and behavior of the individuals) (Giannouli, 2017c). Finally, the study could be repeated on a clinical sample of people with health problems and people with psychiatric diagnoses, and be compared to a general non-clinical sample, in future cross-cultural studies (Giannouli, Stamovlasis and Tsolaki, 2018).


In conclusion, this research contributes in a theoretical and methodological way in the understanding of a growing body of evidence about religious beliefs, self-esteem, anxiety, and depression in Greek elders. This preliminary study supports that positive dimensions of psychology, such as self-esteem and low levels of depression and anxiety, especially in older individuals, may be linked to their religious and spiritual beliefs, therefore, rendering necessary in future research attempts the reconsideration of the simultaneous inclusion and examination of these variables (Eichhorn, 2011), while the beliefs about the statistical relationships of these variables in healthcare professionals and in the elders themselves could be also examined (Giannouli et al., 2019).


A summary of this paper was presented at International Conference: Individual, family, society – contemporary challenges, 3rd edition, 9 to 10 October 2019, Bucharest, Romania, and published in the journal Studii şi Cercetări de Antropologie, No. 6/2019.


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