Introduction

Aging refers to the natural and progressive irreversible physiological changes that occur throughout each person's life (1). Although this process occurs in everyone, it is often accompanied by significant changes in health and nutritional needs; with increasing age, the biological effects gradually decrease (2). According to the World Health Organization, the world is facing a demographic revolution because there are about 600 million elderly aged 60 and over. This number will double by 2025 and increase to two billion people (3), Iran is not exempt from this law. According to the latest census, about 27.7% of the country's population are over 60 years old (4). Demographic forecasts suggest that this population will double in the next 25 years and the aging rate will reach ten percent. As the number of older people increases, their health problems become more important (5). The elderly needs long-term and expensive care due to the higher prevalence of chronic diseases such as diabetes, heart disease, blood pressure, and arthritis. This can significantly increase healthcare costs and place a heavy financial burden on healthcare systems and households (6).

Since people experience stress as they age, it is necessary to pay attention to mental health and resilience in elderly (7). Resilience improves human mental performance through thinking, creating, and behavior and increases the ability to deal with emotional and psychological problems (8). Resilience can reduce stress and disability under difficult living conditions, increase life satisfaction, and improve people's mental health (9). Studies show that elderly with higher resilience have better mental health to deal with difficult situations compared to people with lower resilience (10-12). On the other hand, elderly lose their physiological and psychosocial functions, and finally, non-participation in social activities increases the feeling of loneliness (13). Loneliness is a mental feeling of lack of quality and quantity in communication; Of course, feeling alone does not mean social isolation (14). Non-acceptance from others and social isolation are important causes of mental illness (15, 16). Studies have shown that loneliness  can affect physical health and overall well-being in the elderly (17, 18).

Humans are belief-oriented beings who act according to their beliefs at any given time regarding various phenomena. From this point of view, various beliefs in the field of human life are proposed. Belief in life after death and resurrection is one of the principles and pillars of the religion of Islam (19). On this basis, belief in the Islamic afterlife is belief in a just world in which the innocent are not punished instead of the guilty and in which hostility, punishment, stubbornness and enmity have no place; In contrast to belief in the afterlife, there is belief in a world full of justice, goodness, mercy and peace, where the good will have eternal peace and the wicked will suffer severe and painful punishments (20, 21). Studies have shown that by promoting the belief in the Day of Resurrection, useful measures can be taken to strengthen mental health and resilience among the elderly (22, 23).

The need and importance of the present research is primarily to lay the foundation for the project of transcendental beliefs such as belief in an afterlife and belief in a just life after death in the field of research and theory building. What becomes clear from the research texts and research documents in Iran is the neglect of belief in life after death and in a just world in previous theories and research. In addition, documenting and confirming the role of belief in the afterlife and belief in a fair afterlife for physical and mental health makes it possible to investigate the role of transcendental religious beliefs in the individual and social health, especially in the elderly. Since the task of nursing is to apply sufficient knowledge and skills to care for patients and to maintain and promote the health of the family and society, the present study was conducted with aim to determine the relationship between believing in resurrection and resilience and feeling of social and emotional loneliness in the elderly of Tehran.

Methods

This descriptive-analytical study was conducted on the elderly care center in Tehran in 2024. The sample size was determined using Cochran’s formula (24) (p=0.65, d=0.07) and considering the confidence level of 95%, 5% error and 10% dropout, therefore, the sample size was calculated for a total of 700 people. Based on the cluster random sampling method and considering an effect size of 4, the total sample size was determiuned as 712, of which 12 were sample size dropouts, and a total of 700 people participated in the study.

Multistage sampling was used in this study. At first, clusters were randomly selected (22 districts of Tehran) and, secondly, sample units within the selected clusters were randomly selected (3 regions and one municipal district from each region), and a list of public places, such as parks, mosques and retirement associations of that area were prepared and based on that sampling was done. In this design, random selection occurs at both the cluster or group level and at the sample unit level. The study included elderly individuals aged 60 and over who provided informed consent and were capable of participating in an interview. Individuals with cognitive dysfunction, mental disorders, or chronic illnesses were excluded from the study.

The data collection tool included a demographic form, standard questionnaire of resurrection belief and attitude to death (25), Connor-Davidson Resilience scale (26), and Social and Emotional Loneliness Scale for Adults (SELSA) (27). The demographic form included age, gender, marriage, occupation, and education level. The standard questionnaire of resurrection belief and attitude to death was designed and psychometrically evaluated in 2014 by Golparvar et al (25). The questionnaire includes 27 questions which is scored based on a 5-point Likert scale from 1 to 5 with a range of 27-135, and a higher score indicates more believing in resurrection. Validity of the questionnaire was confirmed by the form and content methods and its reliability was confirmed by Cronbach's alpha test method of 0.88 (25). The Connor-Davidson Resilience scale (CD-RISC) contains 25 items, all of which are scored on a 5-point range of responses, as follows: not true at all (0), rarely true (1), sometimes true (2), often true (3), and true nearly all of the time (4). The scale is rated based on how the subject has felt over the past month. The total score ranges from 0–100, with higher scores reflecting greater resilience. The CD-RISC has demonstrated good reliability (α=0.88 and 0.89), test-retest reliability (0.87), and convergent and divergent validity in the development of the scale (26). The validity and reliability of CD-RISC in Iranian population was 0.93 and 0.92, respectively (28). The Social and Emotional Loneliness Scale for Adults (SELSA) consists of 15 items, answered on a 7-point scale, ranging from 1 = Strongly Disagree to 7 = Strongly Agree, which indicate the degree of agreement or disagreement with each statement. The items cover three factors of loneliness, as follows: social (e.g., Item 09 - I feel part of a group of friends), family (e.g., Item 11 - I feel close to my family) and romantic (e.g., Item 02 - I would like to have a more satisfying love relationship). Internal consistency, as assessed by Cronbach's alpha (α), was satisfactory: social (α=0.90), family (α=0.89) and romantic (α=0.87). In addition, four items (1, 3, 7 and 14) have inverted scores. SELSA-S scale shows good reliability values as verified by Cronbach’s alpha (29). In Iran the ICC of 0.97 ranging from 0.90–0.98 were found for the whole scale and the subscales, respectively and its reliability was 0.90 (30).

At the time of the meeting, the study questionnaire was given to the elderly after providing the necessary information about the research and its objectives as well as the applications of the information received. The questionnaire was completed individually for each person while respecting their privacy. An interview was conducted for the elderly who could not read and write and the questionnaire items were completed based on their opinions and decisions. If the questionnaire contained incomplete information, the participant was asked to complete the information.

The data were coded and entered into the Statistical Package for the Social Sciences (version 22.0); descriptive and inferential statistics were generated to describe the distributions of personal characteristics and other variables using percentages, means, and standard deviations. Correlations between believing in resurrection and resilience and feeling of social and emotional loneliness were computed using a Pearson correlation analysis. Predicting the value of a dependent variable based on the value of an independent variable was done with regression analysis.

Ethical Consideration

The study was approved by the Ethics Committee of Neyshabur University of Medical Sciences (ethical code: IR.NUMS.REC.1403.038). The researchers explained about the potential participants, also the objectives, methods, benefits, and risks of the study. The researcher guarantees the confidentiality of the participants' information and gives respondents the right to withdraw from the research at any time.

Results

The mean age of the elderly was 72.83±6.74 years (60-90 years). The majority of participants (65.3%) were female, and (55.9%) were married. Moreover, most participants (36.3%) were illiliterate, and only 6.9% had a university degree (Table 1).

Table 1. Demographic characteristics of the elderly participants in the study

The mean score for belief in resurrection was 88.52±21.15, indicating a relatively high level of belief among the elderly. Mean score of resilience was 74.58±8.69, indicating a relatively high level of resilience among the elderly (Table 2). Mean score of the feeling of social and emotional loneliness was 50.03±14.21, showing a relatively high level of sense of loneliness; feeling of loneliness in romantic, family and social subgroups was considered high in the elderly (Table 2).

Table 2. The mean scores of believing in resurrection,  resilience and feeling of social and emotional loneliness in the elderly

The Pearson’s product-moment correlation analysis revealed a positive correlation between believing in resurrection and resilience (r=0.078, p=0.040), a negative correlation between believing in resurrection and feeling of social and emotional loneliness (r=-0.81, p=0.033), and a negative correlation between resilience and feeling of social and emotional loneliness among the elderly (r=-0.220, p<0.001) (Table 3). The Pearson’s product-moment correlation analysis revealed a negative correlation between believing in resurrection and romantic subgroup of feeling of social and emotional loneliness (r=-0.132, p<0.001), and negative correlation between resilience and all subgroups of feeling of social and emotional loneliness (p<0.001).

In the Multiple Linear Regression analysis, resilience and feeling of social and emotional loneliness were assessed as independent variables and believing in resurrection was considered a dependent variable (Table 4). Before performing the regression analysis, the assumptions of the regression analysis were examined. The Kolmogorov-Smirnov test was used to check the normality of the data and the results indicated the normality of the data (p>0.05). In order to check the assumption of independence of errors and non-collinearity of the predictor variables, the Durbin-Watson statistic was examined, and since the value of this index was calculated in the interval 2.19, it shows that the assumption of independence of errors has been observed. In addition, considering that the value of the tolerance coefficient index was 0.952 and the variance inflation index was 1.051, it can be said that the phenomenon of collinearity did not occur in the research variables. The overall regression model R2 was 27% (F=2.09, p<0.028). Resilience had a positive and significant influence on believing in resurrection (β=0.75, p<0.05). Then, the demographic variables, including age, gender, marital status, employment status, and education level were also entered into the model. However, none of these variables showed a significant relationship with the dependent variable in the presence of the main variables. Therefore, demographic characteristics did not play an interfering or confounding role in the observed relationships.  

Table 3. Correlation between believing in resurrection, resilience and feeling of social and emotional loneliness among elderly

            *Correlation is significant at the 0.05 level; **Correlation is significant at the 0.01 level

Table 4. Results of multiple regression analysis to predict total resilience score and social-emotional loneliness based on family, social, and romantic subscales

Discussion

The purpose of the present study was to evaluate the impact of resurrection beliefs on resilience and feeling of social and emotional loneliness in the elderly of Tehran. The results showed that belief in resurrection is prevalent among the elderly. The results of other studies also demonstrated that religious beliefs and convictions are stronger in the elderly than in different periods of life (31). Tendency to spiritual thoughts and spiritual actions at the end of life improves mental health (32).  Remembering God and believing in resurrection strengthens the psychological dimensions in the elderly (33). In the present study, there was a significant and positive relationship between believing in resurrection and resilience, so that with the increase of believing in resurrection, the resilience of the elderly also increased. By believing in resurrection and afterlife, the elderly have come to the belief that their actions will be taken care of after death. This belief may significantly contribute to their enhanced resilience (34), which was also confirmed in the present study.

With increasing age, human thinking about the phenomenon of death increases, so thinking about death and afterlife can increase resilience (35). Some elderly consider the concept of death as a natural stage of life, while some consider death to be the end of life (36). In the present study, most of the elderly felt lonely and there was a significant negative relationship between believing in resurrection and feeling of social and emotional loneliness. So that by increasing believing in resurrection in the elderly, the feeling of social and emotional loneliness can be reduced. Elderly people feel more lonely than other people due to the increase in life expectancy and witnessing the death of their loved ones. On the other hand, they are more familiar with the concept of death, so a person who pays more attention to death will have less fear of death (37), and believing that the other world is waiting for him makes he feels less lonely.

Believing in resurrection leads to a deeper understanding of life, therefore, the more believing in resurrection increases in the elderly, the more their resilience increases and the feeling of loneliness decreases. Considering the cultural and religious differences in different cities and countries, it is necessary to conduct more studies with different cultures in all parts of Iran,; moreover, conducting the studies in other countries is also suggested. One of the limitations of the current research is the way of collecting information, which was a questionnaire and a self-report method, that could cause tiredness of the elderly; they should also be examined in the study of the religious and spiritual beliefs of the elderly. Another limitation was that all the elderly were Muslim and there were no participants from other religions. Therefore, it is necessary to perform more studies to evaluate the different ethnicities and religions in Iran. Also, further research should be conducted with a larger population and equal conditions in terms of gender, because in the current study, most of the participants were female. There is a need to conduct studies that investigate the relationship between believing in resurrection and cognitive variables.

In the present study, believing in resurrection in the elderly and their resilience were considered high, while the elderly felt extremely lonely. There was a positive and significant relationship between believing in resurrection and resilience, as well as a significant negative relationship between believing in resurrection and feeling of loneliness. Special attention should be paid to believing in resurrection as one of the integral aspects of human life, especially in old age. Therefore, the officials and health care workers should pay special attention to this spiritual need of the elderly, and by strengthening the spiritual dimensions and believing in resurrection, it is possible to help make the life of the elderly meaningful. The significant negative relationship between belief in resurrection and feelings of social and emotional loneliness suggests that fostering such beliefs may help mitigate loneliness among the elderly.

Implications for practice

Healthcare providers should incorporate discussions about spiritual beliefs, including belief in resurrection, into their care plans for elderly patients. This approach may enhance the overall well-being and quality of life for this population. Self-awareness, cognitive-behavioral interventions or special programs can be implemented to support the spiritual needs of the elderly, so it is suggested to use appropriate interventions in next studies. Future research should explore how cultural and religious diversity within Iran and beyond may shape the relationship between belief in resurrection and mental health outcomes.

Acknowledgments

The authors would like to thank Neyshabur University of Medical Sciences and all the nurses who helped us to perform this study.

Conflicts of interest

The authors declare that they have no competing interests.

Funding

There was no financial support for this study.

Authors' Contributions

Peiman Fereidouni Sarijeh contributed to the conception and design, and data analysis. Ali Khatib performed data collection, conception and design of the study. All authors contributed to the writing of the manuscript and discussed on the manuscript.