LIFE COURSE RELIGIOSITY AND SPIRITUALITY AND THEIR RELATIONSHIP TO HEALTH AND WELL-BEING AMONG HOMEBOUND OLDER ADULTS CAROLINE O.

Transcription

1 LIFE COURSE RELIGIOSITY AND SPIRITUALITY AND THEIR RELATIONSHIP TO HEALTH AND WELL-BEING AMONG HOMEBOUND OLDER ADULTS by CAROLINE O. ROBINSON JEFFREY M. CLAIR, CHAIR PATRICIA DRENTEA MARK E. LAGORY JULIE L. LOCHER DAVID L. ROTH A DISSERTATION Submitted to the graduate faculty of The University of Alabama at Birmingham, in partial fulfillment of the requirements for the degree of Doctor of Philosophy BIRMINGHAM, ALABAMA 2007

2 Copyright by Caroline Osborne Robinson 2007

3 LIFE COURSE RELIGIOSITY AND SPIRITUALITY AND THEIR RELATIONSHIP TO HEALTH AND WELL-BEING AMONG HOMEBOUND OLDER ADULTS CAROLINE O. ROBINSON MEDICAL SOCIOLOGY ABSTRACT The purpose of this study was to examine the relationships among religiosity, spirituality, physical health and mental well-being among a sample of homebound older adults. Taking a life course approach, this study explored how religiosity and spirituality across the life course influence homebound elders health and well-being. The sample consisted of 200 community-dwelling, homebound adults aged 60 and older (mean age 79, 62% White, 38% African American, 80% female, and 20% male). Participants completed a guided interview that measured physical health and mental well-being as well as involvement in three domains of religiosity and spirituality across the participants life history (extrinsic religious practices, intrinsic religious practices and faith). In separate models, structural equation modeling path analyses were utilized to examine the relationship among physical health and mental well-being and the three domains of life course religiosity/spirituality. Also included in the models were measures of religious support, forgiveness, instrumental support, emotional support, age, comorbidity, gender, race, religious affiliation, caregiver network and socioeconomic status. Findings indicated that life course extrinsic religious practices and religious support were positively associated with physical health. Life course extrinsic and intrinsic religious practices, instrumental and emotional support and being African American were positively associated with mental well-being. It appears that maintaining continuity in the frequency or intensity of praciii

4 tice of at least one form of religiosity or spirituality after becoming homebound is protective of health and well-being among homebound older adults. Furthermore, it appears that continuity in life course intrinsic religious practices is especially beneficial to mental well-being for older adults who become homebound. iv

5 DEDICATION Soli Gloria Deo v

6 ACKNOWLEDGMENTS I thankfully acknowledge Jeffrey Clair of the Department of Sociology at the University of Alabama at Birmingham for his unwavering support of this project. Without Dr. Clair s invaluable guidance, I would not have had the courage to attempt an examination of religiosity and spirituality two topics that are, by nature, particularized and subjective elements of the human experience. His enthusiasm for the study of this subject matter truly enriched the final project. I thank Julie Locher of the Department of Medicine at the University of Alabama at Birmingham for her continual and unwavering support of my graduate work and for the significant role of her mentorship in my academic achievement and professional development. I also thank Dr. Locher for the use of the data from her study, Eating Behaviors in Homebound Older Adults, a project funded by the National Institute on Aging (NIA) as a Mentored Research Scientist Developmental Award (K01 AG00994) to Dr. Locher. Additionally, I thank Dr. Locher for readily allowing the inclusion of several items measuring religious and spiritual factors into the protocol of the parent study, as these items ultimately became the measures of the primary variables of interest for my research. I acknowledge David L. Roth of the Department of Biostatistics at the University of Alabama at Birmingham for the importance of his role in advising me as to the best methods by which to address my primary research question as well as in assisting in my vi

7 instruction in those methods. I also acknowledge Mark LaGory and Patricia Drentea, both of the Department of Sociology at the University of Alabama at Birmingham, for their advisory roles in this project. Their guidance on the project as a whole and, particularly, their counsel on how to scientifically examine religiosity and spirituality lent immensely to the scope of the final product. I thank Drs. Clair, Locher, Roth, LaGory, and Drentea for their comments in reviewing several drafts of this work. Additionally, I thankfully acknowledge the support for the design and management of the teleform data as provided by the staff of the University of Alabama at Birmingham James A. Pittman General Clinical Research Center (NIH M01-RR00032); the thorough coding work on the Religious/Spiritual History Scale performed by Cullen Clark and Lynn Shanks; and the careful interview work conducted for the parent study by Lynn Shanks and Lisa Harvey. vii

8 TABLE OF CONTENTS Page ABSTRACT... iii DEDICATION...v ACKNOWLEDGMENTS... vi LIST OF TABLES... xii LIST OF FIGURES....xiii CHAPTER 1 INTRODUCTION REVIEW OF THE LITERATURE...9 Relationships among Spirituality, Religiosity and Physical Health...12 Religiosity and Health Behavior...12 Religiosity as a Form of Social Capital...16 Relationships among Spirituality, Religiosity and Mental Well-Being...20 Religious Coping...20 Religiosity and Spirituality as Protective Mechanisms of Mental Well-Being...24 Negative Effects of Religiosity and Spirituality on Health and Well-Being...30 Limitations within the Current Literature on Religiosity, Spirituality, Health and Well-Being...30 The Multidimensionality of Religiousness Effects on Health and Well-Being...30 Life Course Approach to Religiosity, Spirituality, Health and Well-Being...32 Measurement of Religiosity and Spirituality Variables...34 The John E. Fetzer Institute/National Institute on Aging Working Group...34 viii

9 TABLE OF CONTENTS (continued) Page CHAPTER 3 THEORETICAL FRAMEWORK...37 The Life Course Perspective and Theories of Aging...37 The Continuity Theory of Aging...43 Religiosity, Spirituality and the Frail or Ill Older Adult...47 Hypotheses...50 Religious/Spiritual History...51 Religious Support...57 Instrumental Support...58 Emotional Support...59 Forgiveness...60 Caregiver Network...61 Socioeconomic Status...62 Other Hypothesized Relationships among the Model Variables...62 Age...62 Gender...62 Race...63 Fundamentalist Religious Affiliation...63 Comorbidity...64 Modeled Indirect Relationships among the Variables...65 Longitudinal Physical Health and Mental Well-Being...66 Significance RESEARCH DESIGN AND METHODS...70 Sample...70 Instrumentation...74 Endogenous Variables Three Religious/Spiritual History Variables: Extrinsic Practices, Intrinsic Practices, and Faith...74 Endogenous Variable Religious Support...79 Endogenous Variable Instrumental Support...80 Endogenous Variable Emotional Support...81 Endogenous Variable Forgiveness...83 Endogenous Variable Caregiver Network...84 Endogenous Variable Socioeconomic Status...85 Exogenous Variable Age...89 Exogenous Variables Gender and Race...90 Exogenous Variable Fundamentalist Religious Affiliation...90 Exogenous Variable Comorbidity...91 ix

10 TABLE OF CONTENTS (continued) Page CHAPTER Dependent Variables Physical Health and Mental Well-Being...94 Physical Functioning (PF) Subscale...96 Role Physical (RP) Subscale...97 Bodily Pain (BP) Subscale...97 General Health (GH) Subscale...98 Vitality (VT) Subscale Social Functioning (SF) Subscale Role Emotional (RE) Subscale Mental Health (MH) Subscale Transforming SF-36v2 Subscale Scores into Physical and Mental Components Summary Measures Longitudinal Dependent Variables Physical Health and Mental Well-Being at 6 Months Structural Equation Modeling Path Analysis RESULTS Descriptive Findings Methodological Issues Related to Data Analysis Structural Equation Modeling Path Analysis of the Baseline Models Structural Equation Modeling Path Analysis of the Longitudinal Models Post Hoc Analysis of Life Course Religious Practices Variables and Health and Well-Being DISCUSSION Discussion of Study Hypotheses and Research Findings Life Course Extrinsic Religious Practices, Intrinsic Religious Practices, and Faith Religious Support Instrumental Support Emotional Support Forgiveness Caregiver Network Socioeconomic Status Age Gender Race Fundamentalist Religious Affiliation x

11 TABLE OF CONTENTS (continued) Page CHAPTER Comorbidity Auxiliary Hypothesized Relationships among the Variables A Synthesized Approach to Religiosity and Spirituality using Continuity Theory Limitations and Future Directions CONCLUSION LIST OF REFERENCES APPENDICES A INSTITUTIONAL REVIEW BOARD FOR HUMAN USE APPROVAL FORM B EATING BEHAVIORS IN HOMEBOUND OLDER ADULTS SURVEY INSTRUMENT C RELIGIOUS/SPIRITUAL HISTORY SCALE D RELIGIOUS PREFERENCE CATEGORIES E SUMMARY CLASSIFICATION OF ALL RELIGIONS xi

12 LIST OF TABLES Table Page 1 Characteristics of the Study Sample (n = 200) High and Low Raw Scores for SF-36v2 Subscales and Raw Score Ranges Formulas for z-score Standardization of SF-36v2 Subscale Scores Formulas for Aggregating Subscales for the Physical and Mental Component Scores Formulas for T-score Transformation of Physical and Mental Component Scores Means and Standard Deviations for the Modeled Variables at Baseline (n = 200) Pearson Product-Moment Correlations between Model Variables Goodness of Fit Indices for Original Baseline and Reduced, Modified Models Decomposition of Standardized Effects for the Baseline Model of Physical Health Decomposition of Standardized Effects for the Baseline Model of Mental Well-Being Summarization of Significant Findings as They Relate to the Study Hypotheses Decomposition of Standardized Effects for the Longitudinal Model of Physical Health Decomposition of Standardized Effects for the Longitudinal Model of Mental Well-Being xii

13 LIST OF FIGURES Figure Page 1 Model of relationships between religious/spiritual history variables, sociodemographic and social support variables and physical health Model of relationships between religious/spiritual history variables, sociodemographic and social support variables and mental well-being Number of homebound older adults interviewed at each assessment point for the parent and current study Life course extrinsic religious practices of the sample Life course intrinsic religious practices of the sample Life course faith of the sample Life course extrinsic religious practices by race and gender Life course extrinsic religious practices by Fundamentalism Life course intrinsic religious practices by race and gender Life course intrinsic religious practices by Fundamentalism Percentages of life course religious practices categories that are Fundamentalist Religious support by life course extrinsic and intrinsic religious practices categories Reduced, modified structural baseline physical health model with standardized LISREL estimates Reduced, modified structural baseline mental well-being model with standardized LISREL estimates xiii

14 LIST OF FIGURES (continued) Figure Page 15 Structural longitudinal physical health model with standardized LISREL estimates Structural longitudinal mental well-being model with standardized LISREL estimates Baseline physical health and life course extrinsic and intrinsic religious practices Baseline mental well-being and life course extrinsic and intrinsic religious practices Longitudinal health and well-being and life course extrinsic and intrinsic religious practices xiv

15 CHAPTER 1 INTRODUCTION In November 2003, the cover story of Newsweek entitled God & Health: Is Religion Good Medicine? Why Science is Starting to Believe explored the connection between religion, spirituality and health (Newsweek, 2003). Results from a poll conducted by the news magazine include the findings that 70 percent of Americans report they pray often for family members health and 84 percent of U. S. adults believe that praying for the sick will improve the prospects of their recovery (Kalb, 2003). In their comprehensive examination of studies of religion and health, Koenig, McCullough, and Larson (2001) point to three reasons why researchers and medical practitioners, as well as popular media, are taking a closer look at religiosity and spirituality as influences on health and well-being. First, they point to the continued importance of religion in the lives of most Americans as well as the growth in the proportion of older adults, who tend to be quite religiously-oriented, within the American population. As a consequence, the correlation between the well-being of congregants and the religious communities in which they are involved is increasingly being examined, as churches and other religious groups have historically played a significant role in providing care and assistance to the aged and infirm. And, finally, scientists and physicians are increasingly taking note of evidence-based research that assert that medicine, to be most effective,

16 2 must focus on the holistic nature of the individuals who are being treated, and this necessarily includes the spiritual aspects of patients. A growing body of literature has explored the association between religiosity, spirituality and physical and mental health (Ellison & Levin, 1998; Ellison & Sherkat, 1995; Koenig, McCullough, & Larson, 2001; and Sherkat & Ellison, 1999); yet, there remains much confounding of the causal links between aspects of religiosity, spirituality and health as well as a great degree of ambiguity concerning the manner in which components of religion and spirituality are defined and measured. The variance in the extent to which religiosity and spirituality are an integral part of individuals lives is as great as the degree of diversity between religious and spiritual practices and traditions. The manner in which an individual observes his or her own religiosity and spirituality may even take on different forms and meanings across the life course. Based on the fact that religious and spiritual practices and beliefs are so multifarious, it is important to clarify the definitions of religiosity and spirituality as they will be applied within this study. Following definitions provided by Koenig, McCullough, and Larson (2000) in the Handbook of Religion and Health, religiosity is defined as behaviors and attitudes that reflect an organized system of beliefs, rituals and symbols designed a) to facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality) and b) to foster an understanding of one s relationship and responsibility to others in living together in a community (p. 18). Spirituality is defined as the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship to the sacred or transcendent, which may (or may not) lead to or arise

17 from the development of religious rituals and the formation of community (Koenig, 3 McCullough & Larson, 2000, p. 18). Because the practices of religiosity and spirituality are many and varied, and may fluctuate in intensity and routine for a single individual across time, it seems unlikely that a single scale could effectively assess spirituality or religiosity. Therefore, developing and implementing valid and reliable techniques of measuring religiosity and spirituality are tasks that continue to motivate research on religion. Leaders in the field of religious research point to multidimensional measures of religiosity and spirituality as necessary to capture the range and breadth of religiousness, including religious beliefs, values and meaning, religious and spiritual coping, private and public religious practices, and commitment to religious traditions (Fetzer Institute, 1999). Over the last two decades, there has been an expansion in the number and range of measurement tools developed to assess religiosity and spirituality (Hill & Hood, 1999). This is a positive indication that more sensitive and reliable instruments are being developed and validated for use in research to better conceptualize the processes by which religiousness is cultivated in the lives of individuals. Such measures are being applied to examine how religiousness and spirituality, in turn, have an impact on other aspects of life, such as social networks, health behaviors, worldviews, and coping (Ellison, Boardman, Williams, & Jackson, 2001). Interest in more comprehensive measures of religiosity and spirituality reflect growing regard among social scientists that religiosity is not for religious persons a distinct, separate sphere of one s life; instead, religiosity and spirituality tend to shape, as well as to be shaped by, other realms of being (Benjamins, Musick &

18 Gold, 2003; Drevenstedt, 1998; Ellison & Levin, 1998; Fetzer Institute, 1999; Idler & 4 Kasl, 1997; and Jang & Johnson, 2004). Religiosity and spirituality are often dynamically observed by individuals as religious and spiritual beliefs, habits, and meanings are developed, tested, and reflexively practiced over a lifetime (Atchley, 1999). However, religiosity and spirituality are most often measured cross-sectionally (Ellison, 1999; Ellison, Boardman, Williams, & Jackson, 2001; Fry, 2000; George, 1999; Idler, 1995; Idler, 1999b; Krause, 1999; Krause, 2000; Krause & Ellison, 2003; Krause & Wulff, 2004; Koenig, 1998; Levin, 1999; and Pargament, 1999b), and only now are a handful of instruments to assess religious and spiritual history across time being constructed (Benson & Elkin, 1990; Fowler, 1981; and George, 1999). Much of the current thrust toward measure development in this area is motivated by interest in learning more about how religiosity and spirituality shape behavioral, social and psychological mechanisms of health (Fetzer Institute, 1999). Koenig, McCullough and Larson (2001) point to the importance of assuming an historical perspective when examining religiosity and spirituality and their relationship to personal well-being: An accurate measure of religious history is essential for determining one s degree of exposure to religious influences across the life span and the reasons for increases or decreases in religiousness; it also helps researchers achieve a greater understanding of the mechanisms by which religion influences health and vice versa (503). Elder (1998) describes research that takes an approach to human development and aging from a historical point of view or the life course perspective as one in which the focus is on how individuals grow and adapt across time within changing socio-historical contexts. I propose that taking a life course perspective is necessary to adequately exam-

19 ine how spirituality and religious networks, beliefs and behaviors are fostered, utilized 5 and maintained. I assert that a life course perspective is also essential to understand the causal relationship between religiosity, spirituality and health and well-being. As stated above, one of the primary stimuli to the growing interest in religiosity is the importance of religion to most Americans, which is especially evident within the older adult segment of the population. Furthermore, medical practitioners are increasingly recognizing that they will be better enabled to promote overall health when the connections between an individual s well-being and spiritual and religious beliefs are more adequately understood. By taking a life course approach to religiosity and spirituality that is, conceptualizing religiousness from a perspective that considers all of an individual s lifetime religious experiences as well as the salience of spirituality across time it is possible to examine how religious exposure and spiritual maturation across the life history influence health. Furthermore, this approach allows a better understanding of how wellbeing is affected by distinct aspects of religiosity and spirituality. By exploring the role of religiosity and spirituality within individuals lives, especially as it relates to health over time, we may attain a more complete knowledge of the link between physical and mental health, religiosity and spirituality. Developed as an extension of the life course perspective, continuity theory is a social theory that focuses primarily on how continuity in attitudes and behaviors are maintained and developed over an individual s lifetime (Atchley, 1989, 1999). According to continuity theory, individuals develop worldviews and habits that tend to remain intact over time and, when confronted by circumstances that force adaptation, learned coping mechanisms are used to protect the individual s sense of continuity of self. Rather than

20 6 being a theory that promotes a view of individual development that is static and inflexible, however, continuity theory presumes that most people learn continuously from their life experiences and intentionally continue to grow and evolve in directions of their own choosing (Atchley, 2005, p. 1). As persons mature and move through time, ways of looking at and interpreting the world tend to remain reflective of ideas and attitudes developed early in life. And, as individuals manage their changing circumstances as they move through their life course, they are likely to creatively adapt their responses in a manner consistent with their enduring attitudes and beliefs. According to Atchley (1999), older individuals display continuity by using their learned coping methods, worldviews and attitudes to adapt to their changing bodies and environments as they age. Atchley (2005) writes: Continuity is conceived of flexibly, as strong relationships between past, present and anticipated patterns of thought, behavior, and social arrangements Most aging adults use continuity to create and maintain a personal system that provides direction and life satisfaction. (p.1-2). A central component of Atchley s (1999, 2005) work on continuity theory is his application of the theory to explain the importance of religiosity and spirituality across the life course and its amplified significance among older adults. Continuity in spirituality has been described as a steadfast resource that provides direction and ways of coping in the face of adversity, particularly among older adults who may find growing interest and satisfaction in the spiritual and religious aspects of their lives as they are witnessing declines in their physical, mental and social realms (Atchley 1999, 2005). In this study, I examined how individuals develop and sustain religiosity and spirituality across time by use of a measure designed to assess the salience of spirituality

21 and religious practices throughout the life course. Continuity theory offers an approach 7 to understanding how older adults cope with poor health by placing attention on how religious and spiritual resources are used to cope with negative changes in health and wellbeing. The sample for the present study consisted of older adults who were homebound due to physical and/or mental illness, and therefore, allowed an examination of how continuity of religiosity and spirituality may be maintained when adaptation to trying circumstances is necessary. Furthermore, I observed how individuals use their religious and spiritual beliefs, practices and resources to cope with illness in later life as well as how their health and well-being are impacted by these multiple aspects of religiosity. The purpose of the present study is to test hypotheses that religiosity and spirituality over the life course are associated with health and well-being in later life. I used a structural equation modeling path analysis method of statistical analysis to examine the influence of Religious/Spiritual History on physical health and mental well-being, controlling for the effect of the intermediary variables of extrinsic religious practices, intrinsic religious practices, religious support, and forgiveness, as well as instrumental support, emotional support, age, comobidity, gender, race, religious affiliation, caregiver network and socioeconomic status. A strength of the research design is that the outcome variables were measured at two points in time (a baseline measurement, followed by an additional measurement 6 months later). This longitudinal design allowed an examination of the effect of religious and spirituality variables over time among the sample. Based on the fact that the sample consisted of older adults who were homebound due to illness, the longitudinal nature of the study offered the opportunity to observe the impact of continuity of spirituality on

22 health and well-being as the study subjects coped with their illnesses. Furthermore, I 8 was able to examine how religious and spiritual resources, such as religious social networks and private religious practices such as prayer, are used among sick and frail older adults to meet their physical, psychological and social needs while ill. This study addresses important areas that remain ill-defined within the current literature on religiosity, spirituality and health. The multidimensional measures of religiosity and spirituality incorporated within the project will offer clarification on the influence of different forms of religious practices, beliefs and spirituality on health and well-being. As a significant improvement over cross-sectional studies of religion and health, wellbeing outcomes were assessed longitudinally in order to observe how aspects of religiosity and spirituality may be related to health among ill persons over time. Finally, as a response to calls among social and physical scientists that a life course perspective should be integrated into studies of religion and health (Fetzer Institute, 1999), the present study examined multiple aspects of spirituality and religiosity continuity across subjects lifetimes and offers a unique glimpse into how older adults lifelong experiences with spirituality and religion are utilized to cope with illness and frailty in old age.

23 9 CHAPTER 2 REVIEW OF THE LITERATURE Religiosity and spirituality are important elements in the lives of most Americans. Recent research has documented that 95 percent of Americans maintain a belief in God, and more than 40 percent attend religious services at least weekly (Matthews, McCullough, Larson, Koenig, Swyers, & Milano, 1998). Because religiosity and spirituality are salient forces in shaping perceptions and attitudes, it is understandable that individuals approaches to health and well-being are influenced by religious and spiritual beliefs. A recent survey has indicated that more than three out of four American adult patients believe their physicians should attend to spiritual issues within their role as medical care providers (Matthews et al., 1998). Certainly, patient viewpoints on medical matters are influenced by religious and spiritual convictions: religious beliefs often determine health behaviors and attitudes, which, in turn, affect health and well-being outcomes. The relationships among religion, spirituality and health have been of escalating interest to contemporary researchers and clinicians (Ellison & Sherkat, 1995; Koenig, McCullough & Larson, 2001; and Sherkat & Ellison, 1999). As the population of older American adults swells, much attention has been focused on maintaining the health and well-being of this segment of our society. Appeals for research that examines the role of religious practices and beliefs in physical and mental health outcomes have been increasingly present, and there is special interest in how the effect of religiosity and spirituality

24 10 may differ by social factors, such as age, gender, race, social class, and geographic region (Ellison, Boardman, Williams, & Jackson, 2001; Hill, Angel, Ellison & Angel, 2005; MacKenzie, Rajagopal, Meilbohm, & Lavizzo-Mourey, 2000; Nooney & Woodrum, 2002; and Sherkat & Ellison, 1999). Furthermore, Krause, Liang, Shaw, & Sugisawa (2002) suggest that additional studies that examine the lagged response on health of religious supports and participation are needed to better understand the effect of religion on health, and this is especially applicable when examining the role of religion and spirituality throughout the life course of older adults. Attendant with the graying of American society is the growth in the costs of medical care for the elderly; escalating amounts of government and private resources are being devoted to providing for the health care and well-being of the elderly population. A more thorough understanding of the manner by which well-being may be maintained and healthy lifestyles may be fostered should be a priority for research, especially as it relates to the rapidly growing older adult population. Therefore, a better knowledge of the association between physical and mental health and religious and spiritual practices and beliefs is imperative for the medical community as well as for public and private institutions that serve the elderly. Understanding how spiritual and religious beliefs and practices shape well-being may offer medical practitioners improved techniques for approaching health by incorporating an appreciation of the influence of religion and spirituality into patient care; such knowledge may have implications for public policy, as well. More and more researchers are finding public and private religious practices to have beneficial effects on health (Benjamins & Brown, 2004; Koenig, George, & Titus, 2004; Koenig, McCullough, & Larson, 2001; Krause, 2003; and Musick, House, & Wil-

25 11 liams, 2004). However, the notion that religious involvement both directly and indirectly influences physical and mental well-being was examined as early as the work of Durkheim (1965, originally 1915; 1966, originally 1897) when he posited that religious organizations play an important role in society by promoting social affiliation and by directing believers toward positive behaviors, thus benefiting health. Durkheim (1965, originally 1915) elaborated on how religious ideas of the distinctions between the sacred and the profane were connected to notions of health and illness; specifically, he described prevalent views that when someone became ill, it was not because of poor hygiene, but, instead, was related to a breach of religious social norms. Furthermore, Durkheim recognized the role of religious institutions as agents of social control and, as a result, as instruments of social health: widely shared ideas of the body as God s earthly temple discouraged negative health practices, including sexual experimentation, and held parishioners as accountable for their lifestyles, which discouraged deviant behavior. Contemporary researchers continue to elaborate on Durkheim s theories of the power of social especially religious ties. Some principal mechanisms through which health and well-being are influenced by religiosity and spirituality have been identified (Ellison, Boardman, Williams, & Jackson, 2001; Ellison & Sherkat, 1995; Fetzer Institute, 1999; Fry, 2000; Idler, 1995; Koenig, 1998; and Sherkat & Ellison, 1999). Religiosity and spirituality appear to act upon both physical health and mental well-being through processes that directly affect health and well-being, such as through positive health behaviors that are shaped by religious ideas as well as by spiritual methods of coping. Also, religiosity and spirituality appear to impact health and well-being through indirect means, such as through the posi-

26 12 tive health effects of being involved in supportive faith-based communities. The association of religiosity and spirituality with physical health will be expanded below, followed by an elaboration on the multiple avenues through which religiosity and spirituality affect mental well-being. It is important that I acknowledge that my discussion of the relationships among spirituality, religiosity, health and well-being will be developed from a structural-functionalist perspective in that I am particularly interested in examining the function that religious and spiritual practices, habits and beliefs play in shaping life course health and illness. Relationships among Spirituality, Religiosity and Physical Health Religiosity and Health Behavior Within many religions, health is valued as an aspect of godliness or holiness itself. Taking a Durkheimian approach, Idler (1995) asserts that being associated with a religious community directly and positively effects health due to the manner by which religious tenets regulate behavior, such as by proscribing tobacco use, alcohol consumption, and even certain fatty foods. Idler (1995) also writes that religious participation positively effects health by integrating individuals within social circles that foster adherence to healthy habits, such as by encouraging individuals to remain accountable to their commitments to religious lifestyles, which often include health-promoting behaviors (p. 684). The Old Order Amish within the United States, for example, equate being physically healthy with being spiritually healthy due to the centrality of religion to their daily routine (Armer & Radina, 2002). Being unhealthy or ill means that one cannot perform his daily duties which are seen as extensions of one s service to the community and

27 13 to God, and, as a result, health maintenance activities, such as proper nutrition and exercise, are valued among the Amish. Religiosity shapes physical health outcomes because people are social beings, and those who are actively involved in their religious communities develop social identities that reflect the values and attitudes of their religion (Krause, Liang, Shaw, & Sugisawa, 2002). Individuals who are embedded in strong social support systems within religious communities tend to exhibit better health behaviors, such as eschewing illicit drug use and avoiding risky sexual relationships, than do individuals who are isolated from such social support networks (Idler, 1999c). Individuals who are involved in religious communities tend to internalize strong norms about how to conduct themselves, and, thus, religious individuals are more likely to follow such tenets to avoid being considered deviant by their similarly religious friends and acquaintances (Ellison & Sherkat, 1995). Matthews et al. (1998) assert that religiously affiliated individuals are inclined to develop intense friendships with others within their congregations, and coupled with the tendency for religious individuals to practice good health habits, there is a greater likelihood that religious persons will be a part of a social circle in which positive health behaviors are practiced. Additionally, active involvement in religious organizations may limit the opportunities of churchgoers to participate in activities considered deviant as well as reduce exposure to negative social pressure from those outside the religious community to participate in such unhealthy behaviors, like engaging in dangerous sexual practices or drug use (Ellison & Sherkat, 1995). Strong religiously-based social support systems may foster healthy habits in ways that may be qualitatively different than other forms of social support because relation-

28 14 ships within religious communities may encourage believers to not only practice selfdiscipline in food and drink, but also may promote the virtues of having good health, and, thus, encourage exercise and other proactive measures of good stewardship of the body (Hummer, Rogers, Nam, & Ellison, 1999). For example, the habit of attending religious services regularly and interacting with fellow parishioners may actually act as motivation for older adults to maintain their functional health so that they may remain involved within their religious social networks (Kelley-Moore & Ferraro, 2001). Writing of Black churches in the South, Blank, Mahmood, Fox, and Guterbock (2002) assert that because churches are often the strongholds of community and cultural identity, church leaders and organizations may effectively promote healthy behavior and attitudes, such as by promoting healthy diets and exercise and by encouraging mental health counseling. Furthermore, they describe such churches as being in a unique position to offer guidance on physical and mental health in a non-stigmatizing manner; such positive, health-promoting counseling may not be available or attractive to parishioners from any other source. In numerous studies, religiosity has been found to be associated with indicators of good physical health, including positive global health (Ellison et al., 2001; and Matthews et al., 1998), positive subjective health (Drevenstedt, 1998; and Musick, 1996), and protection from functional disability (Idler & Kasl, 1992, 1997), as well as to be protective against mortality (Ellison, 2000; and Hummer et al., 1999). The health-promoting habits and behaviors often associated with religious values and attitudes may be most beneficial to long-term health. Idler (1995) found that the relationship between religious practices and better health was stronger across time than in the short term. Findings such as this give support to the notion that religious participation is associated with increased physical

29 15 health over time as those who actively participate in their religion also practice associated health-promoting behaviors across the life course. However, the association between church or synagogue attendance and positive physical health among older adults has been questioned as a spurious one (Benjamins, Musick & Gold, 2003; and Ferraro & Albrecht-Jensen, 1991): Are the older adults who do not attend religious services already more frail or sick than other older adults, making religious participation more likely a measure of functional ability rather than a means toward improved functioning? Kelley-Moore and Ferraro (2001) found that mobility and lower body functional limitations were associated with less frequent religious service attendance among elderly adults, but that older adults with modest functional limitations continued to attend religious functions. Because older adults tend to attend religious services at high rates, older adults whose frequency of religious service attendance declines due to health still may remain relatively active in religious events. In a large longitudinal study of elderly adults, Idler, Kasl, and Hays (2001) found that religious older adults tend to maintain regular religious participation throughout older age and despite illness, even up to the time of their death. In summary, it appears that religious affiliation and participation in religious services influence physical health by encouraging health-promoting behaviors, by serving as a reference point by which believers may make positive lifestyle decisions, and by supporting social norms that further endorse long-term adherence to healthy ways of life. Furthermore, it appears that religious service attendance is positively associated with physical health as religious individuals are motivated to maintain their physical health in order that they might remain involved within their religious social communities.

30 16 Religiosity as a Form of Social Capital Religiosity also impacts physical health through the positive effects of being affiliated within religious organizations. Health appears to be benefited by access to healthpromoting instrumental supports provided to individuals involved within religious organizations, as exampled by parishioners who provide older church members transportation to their physicians offices, provide warm meals to those who are sick, or even cash assistance for medical treatment (Ellison et al., 2001). Lin (1999) describes social capital as the resources that individuals can access through their social networks, and he writes that such resources may vary by quantity (or, the amount available) and quality (or, the form and substance of the support). Religious institutions tend to be wellsprings of social capital within their local areas (Sherkat & Ellison, 1999). Putnam (2000) writes that [f]aith communities in which people worship together are arguably the single most important repository of social capital in America (p. 66). For example, religiously affiliated individuals tend to volunteer with service programs, not only within their own congregations, but within their neighborhoods, as well. Putnam (2000) explains that the social capital that typically may be found within religious organizations takes two forms: bridging social capital that turns the attention of church members outside of their church bodies and promotes a more global concern for others and bonding social capital that focuses on the social network within the church and encourages concern for fellow church members. For example, religious organizations that collect and distribute funds for local or world charities are exhibiting bridging social capital, whereas bonding social capital is shared within churches and synagogues whenever social networks within the religious organization are tapped. The bonding form

31 17 of social capital tends to be robustly shared within religious communities as fellow church members exchange emotional, instrumental, and financial forms of support within multiple contexts of interaction, from giving offerings during church on Sunday morning to helping with a bake sale to benefit the church library to offering to take an older member of one s church to the doctor. Specific examples of how social capital may be shared by and among church members will be further elaborated below in my discussion of the provision of diverse forms of support by religious social networks. Individuals who are affiliated with religious organizations often have access to a wide variety of resources through formal support systems based in churches or synagogues as well as through informal support networks of church friends and fellow parishioners. Mackenzie et al. (2000) emphasize that religious persons may believe that they have a religious or spiritual calling to assist others, and many believers also hold true that God ordains others to help in times of need; they found that, as well, those who are religious tend to be able to call on their fellow church members for support when in difficult situations. Highly religious individuals are likely to report that, through the social capital they have available from their church affiliations, they can access help to address existing as well as potential problems (Jang & Johnson, 2004). Furthermore, individuals who report having strong sense of religiosity and being involved in their church tend to receive more support when needed from their social networks than do individuals who are not as religiously devoted; furthermore, religious individuals are likely to evaluate such assistance favorably (Krause et al., 2001). Other researchers have noted that tangible forms of assistance are often more easily accessed by individuals within religious organizations than in other community set-

32 18 tings, and, very often, such assistance is of the type that may promote or protect health. For example, Oman and Reed (1998) discovered that religiously-affiliated adults appear to have improved access to organized nutritional programs, such as weekday hot meal programs supported by local churches, than are their non-religiously-active peers. As well, fellow churchgoers often provide instrumental assistance to older, frail, or needy members of their congregations, such as transportation to physicians offices for appointments (Koenig, McCullough & Larson, 2001). And, when individuals have others within a close social network, such as fellow church members, who are concerned about their well-being and remind them to take their medication or ask them about their treatment regimens, they tend to exhibit greater medical compliance, thus bolstering health (Daltroy & Godin, 1989). Local religious institutions, such as churches and synagogues, are often the primary social resources of a community and tend to eagerly support either their own or community-based programs to assist the poor, the elderly, and the homebound (Ellison et al., 2001). As a result, churchgoers tend to have large and developed social networks on which they may draw when in need. The religiously affiliated may have more diverse forms of support available to them from these extended social networks and may find such support, because it is the product of shared values and beliefs, more satisfying (Ellison et al., 2001). Furthermore, religious institutions have historically addressed the needs of specific groups more effectively than have other social organizations, such as special programs for older adults and overburdened mothers of small children, and have provided programs that generally work to benefit overall well-being (Sherkat & Ellison, 1999).

33 19 Another avenue by which religion indirectly affects health is through social support often made available to those who share beliefs (Krause, Ellison, Shaw, Marcum, & Boardman, 2001; and Nooney & Woodrum, 2002). Examples of religion-based social support include informal care networks to comfort those who are dealing with death of loved ones or personal illness (Blank, Mahmood, Fox, & Guterbock, 2002) as well as religious organizations social gatherings that engender perceptions of solidarity, belonging and cohesiveness among fellow believers (Krause et al., 2001), which appear to improve physiological functioning (Koenig, McCullough, & Larson, 2001). Blank et al. (2002) state that, within African American communities, churches have historically provided many informal services to their members and, as a result, have maintained a dominant role as centers of social support within African American neighborhoods. They argue that the support offered by fellow members within such churches may supplant the services of formal providers outside of the church community because help obtained within the church may be received without the stigmatization associated with receiving assistance from public or charitable organizations. Yet, overall, the informal services provided by religious institutions do not appear to negatively impact health behavior as highly religious individuals are more likely to make use of formal preventative health services, as well (Benjamins & Brown, 2004). Ebaugh and Chafetz (1999) describe the role of churches and synagogues as purveyors of culture and stress the importance of religious institutions as providers of health information as well as tangible support that ultimately benefits health. They point to the church as a hub of instrumental and knowledge resources for its members, especially women, who develop relationships with each other that, when necessary, they may lean

34 20 on for help. Matthews et al. (1998) assert that members of clergy are typically available to provide spiritual and emotional forms of support for ill or disabled individuals and may also help them tap into extra community support such as sources of instrumental support (p. 123). Furthermore, very religious individuals tend to be less distressed than their nonreligious or less religious counterparts when experiencing difficult situations, such as dealing with illness, because they have a greater sense that resources from their churchbased social support network will be available when needed (Jang & Johnson, 2004). In summary, religious participation and affiliation appear to positively affect health by placing religious individuals into a context of like-minded persons who together provide social networks that can be called on when in need. Furthermore, various forms of instrumental support provided by fellow churchgoers indirectly promote health by meeting needs within religious communities, especially among the ill and the elderly. Relationships among Religiosity, Spirituality and Mental Well-Being Religious Coping Religiosity and spirituality appear to bolster mental well-being by operating as a coping mechanism for believers. Ellison et al. (2001) assert that the salutary effects of religious participation on well-being result from factors other than just the social affiliation that religious involvement provides, and that other dimensions of religiosity contribute to positive well-being, such as religious coping. Unlike the benefits of religiosity to health that are tied strongly to the social aspects of religion, religiosity and spirituality as utilized as a coping resource are not necessarily yoked to public religious practices and religious social affiliation. The role of religiosity and spirituality in coping appears to

35 21 work primarily as a function of private religious and spiritual practices, such as prayer or meditation on scripture readings and spiritual beliefs, which may serve to alleviate stress and preserve mental well-being. Pearlin and Schooler (1978) define coping as the things that people do to avoid being harmed by life-strains (p. 2). Religious coping will be the term used in this study to refer to the use of spiritual or religious beliefs and behaviors to counterbalance an individual s life strains. Studies focusing on the relationship of religious coping and illness have typically found that individuals, when faced with seemingly overwhelming problems such as life-threatening or debilitating illness, tend to rely on positive religious coping methods, such as seeking God s will through prayer and expressing positive prayer expectancies (Ellison, Boardman, Williams, & Jackson, 2001; Fry, 2000; Harrison, Koenig, Hays, Eme-Akwari, & Pargament, 2001; Koenig, 1998; Krause, 2003; Maton, 1989; Pargament, Smith, Koenig, & Perez, 1998; Strawbridge, Shema, Cohen, Roberts, & Kaplan, 1998; and Tix & Frazier, 1998). And, it seems that such religious coping is a widely-used strategy to deal with formidable life strains. Among a group of adults 65- years-old or older who were admitted to a Veterans Administration medical center, 21% reported that religiosity was the single most important factor enabling them to cope, and, on a scale ranging from 0 to10 (with 10 being highest), 56% of the patients rated the utilization of religiosity or spirituality as a coping mechanism a score of 7.5 or higher (Koenig, Cohen, Blazer, Peiper, Meador, Shelp, Goli, & DiPasquale, 1992). Koenig, Georgy and Siegler (1988), in a longitudinal study of aging, asked community-dwelling older adults how they coped with the worst event or situation during different points in their lives, and religius coping was cited as the most common response. Among hospital-