Religion, Spirituality, and Health Status in Geriatric Outpatients

These responses illustrate the myriad of orientations, conceptualizations, and subsequently, measures, that attempt to capture and quantify a unique human dimension that is characterized as spirituality. Amid such a panoply, theologian Bernard McGinn brings clarity to the discussion by offering three contemporary approaches to the study of spirituality; the theological/normative, the historical/contextual, and the anthropological/phenomenological.1 Each approach comes with its own set of assumptions, methodologies, and ways to determine validity. For example, a theological or normative approach seeks to provide criteria for determining what may be considered “healthy” or “legitimate” spirituality. An historical/contextual perspective emphasizes that most forms of spirituality are and have been rooted within particular religious communities and traditions.1 Both Dr. King’s and Drs. Hummel and Vollman’s comments, which emphasize the importance of religiosity constructs (i.e. religious service attendance, sacredness) in discussions of spirituality, highlight this perspective.

Dr. Moberg’s longstanding work and our own contribution are firmly placed within the anthropological or social scientific realm, a perspective which views spirituality as a basic element of human nature and experience, capable of distinguishing between the social, psychological, and spiritual.1 But it is here where Moberg’s and our epistemic approach to the study of spirituality differ. Moberg implies that American religious traditions predominate a common understanding of contemporary spirituality. However in After Heaven, Spirituality in America since the 1950’s, sociologist Robert Wuthnow describes the transformation in American religious life from a spirituality structured around established religious institutions, to a spirituality of searching that is eclectic and syncretic.2 Moberg also suggests that spirituality is such a unique and irreducible individual phenomenon, any conceptualizations are artificial and suspect, but nonetheless should be interpreted and validated by expert criteria.

In contrast to Moberg’s epistemic approach of relying on expert panels, we believed that the patient voice was foundational to capturing one dimension of spirituality that impacts health and well-being. Consequently, we used qualitative research methods to describe spirituality from a patient perspective and found that patients conceptualized spirituality as a congruent, meaningful life scheme and high functional self-efficacy beliefs in a way that synergistically promoted personal agency.3 Although this depiction of spirituality is a new concept, it is comprised from established psychological constructs.

The validity of new concepts, and the instruments which are presumed to measure them, can only reasonably claim construct validity when they have been securely placed within a network of laws, rules, predictions, and expectations.4 If spirituality is a hypothetical human attribute, inferences about it must be made by observing human behaviors and individual differences, and convergent and discriminant evidence is required for construct validation.5 To date, the Spirituality Index of Well-Being (SIWB) has been used to measure a dimension of health and well- being in peer-reviewed studies across a variety of populations (N=1368) and in every study, scale scores have shown meaningful and important associations with health and well-being constructs.6 In addition, analyses of primary psychometric data from three sample populations have found that SIWB scores correlate more strongly and consistently with established measures of well-being than the Spiritual Well-Being Scale, or other recognized religiosity instruments.6

The Spirituality Index of Well-Being appears to be a valid and reliable measure of well-being in patient populations based on modern standards for psychological measurement.7 Our qualitative work directed us to placing spirituality within a psychological domain and viewing the SIWB as a health-related quality-of-life (HRQOL) measure. This instrument may be best situated in studies of chronic illness, aging, and end-of-life care that are inclusive of health-related quality-of-life. However in all of our work, we continue to recognize that no global, yet parsimonious instrument captures the complexity and depth of spirituality in any context, healthcare or otherwise.

REFERENCES 1. McGinn, B. The letter and the spirit: spirituality as an academic exercise. J Soc Stud Christ Spirit 1993:1:1-10. 2. Wuthnow, R. After heaven, spirituality in America since the 1950’s. Berkeley, CA: Univ of Calif, 1998. 3. Daaleman TP, Cobb AK, Frey B. Spirituality and well-being: an exploratory study of the patient perspective. Soc Sci Med 2001;53:119-127. 4. Cronbach LJ, Meehl PE. Construct validity in psychological tests. Psychol Bull 1955;52:281-302. 5. Campbell DT, Fiske DW. Convergent and discriminant validation by the multitrait-multimethod matrix. Psychol Bull 1959;56:81-105. 6. Frey BB, Daaleman TP, Peyton V. Measuring a dimension of spirituality for health research: validity of the Spirituality Index of Well-Being. Res Aging (under review). 7. American Educational Research Association, American Psychological Association, National Council on Measurement in Education. Standards for Educational and Psychological Testing. Washington DC: American Educational Research Association, 1999.

Competing interests:   None declared

Comments on “Religion, Spirituality, and Health Status in Geriatric Outpatients” by Timothy P. Daaleman, Subashan Perera, and Stephanie A. Studenski (Annals of Family Medicine 2:49-53, Jan/Feb 2004), by David O. Moberg, Ph. D.

The surprising finding that religion is not significantly correlated with either spirituality or health status contradicts other research and the social science tendency to merge religion and spirituality, which overlap empirically and theoretically.1,2 What seems a significant breakthrough reflects conceptual problems of the epistemic relationship between the Spirituality Index of Well-Being (SIWB) and real-life spirituality.3

The twelve SIWB scale items were gathered from patients in healthcare settings that typically ignore religion. The researchers’ a priori assumptions were that spirituality is subsumed within psychology, “that patients associate spirituality with well-being largely through the provision of systems of meaning and coherence,” “that spirituality within a health context is … comprised primarily of the domains of life scheme and self-efficacy,” and that other measures of spirituality “are contaminated by the inclusion of items that assess religiosity,” so items referring to religiosity are excluded.3

By emphasizing patients’ sense of stress and lack of meaning or purpose in life, SIWB’s criterion validity is based upon subjective well- being, not spirituality. It reflects only two or three of ten key domains of religion and spirituality identified by the interdisciplinary Fetzer/NIA group.4,5 It was designed “to measure the effect of patient- reported spirituality on subjective well-being,”3 which it measures (the effect is not spirituality per se).

The issue behind this epistemological limitation is the nature of human beings.6,7,8 If the essence of every person is a living soul or spirit, as the predominant American religions’ scriptures teach, then all humans are spiritual and spirituality is somehow implicated in everything people do and say. Etymological analysis of the words health, holiness, and wholeness also implies that religion, spirituality, and health are facets of whole persons that can be separated only analytically and artificially. An obvious implication is that thousands of potential indicators reflect spirituality; each research scale selects different variables. Researchers cannot separate themselves from spirituality to get an outsider’s “objective” viewpoint as if they were beings from another planet.

Nevertheless, this study raises significant questions. If all explicitly extrinsic/religious items in each spirituality scale were separated from intrinsic/spiritual items, how would each part relate to measures of health and well-being?

Separation of the diverse domains of well-being is especially important for geriatric populations because spiritual development and growth often accompanies physical and mental decline. Indexes of the quality of spirituality are needed, although each may need to be limited to a specific religious frame of reference because the criteria for spiritual health differ so radically among the various major religions.9 As spirituality is parsed away from religion, research on persons self- described as “non-religious,” “spiritual but not religious,” or “religious but not spiritual,” plus those from Eastern, non-theistic, and other religions, will need special attention.

REFERENCES 1. Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. New York: Oxford University Press, 2001. 2. Zinnbauer BJ, Pargament KI. Capturing the meanings of religiousness and spirituality: One way down from a definitional Tower of Babel. Research in the Social Scientific Study of Religion, 2002, 13:23-54. 3. Daaleman TP, Frey BB, Wallace D, Studenski SA. Spirituality Index of Well-Being Scale: Development and testing of a new measure. Journal of Family Practice, 2002, 51(11): 952 (JFP Online). 4. Idler EL, Musick MA, Ellison CG, George LK, Krause N, Ory MG, Pargament KI, Powell LH, Underwood LG, Williams DR. Measuring multiple dimensions of religion and spirituality for health research. Research on Aging, 2003, 25(4):327-365. 5. George LK, Larson DB, Koenig HG, McCullough ME. Spirituality and health: What we know, what we need to know. Journal of Social and Clinical Psychology, 2000, 19(1):102-116. 6. Moberg DO. The encounter of scientific and religious values pertinent to man’s [i.e., humanity’s] spiritual nature. Sociological Analysis, 1967, 28(1):22-33. 7. Moberg DO. The reality and centrality of spirituality, Chapter 1 in Moberg DO, ed., Aging and Spirituality: Spiritual Dimensions of Aging Theory, Research, Practice, and Policy. Binghamton, NY: Haworth Press, 2001. 8. Brown WS, Murphy N, Malony HN, eds. Whatever Happened to the Soul? Scientific and Theological Portraits of Human Nature. Minneapolis, MN: Fortress Press, 1998. 9. Moberg DO. Assessing and measuring spirituality: Confronting dilemmas of universal and particular evaluative criteria. Journal of Adult Development, 2002, 9(1): 47-60.

Competing interests:   None declared

In their article, “Religion, Spirituality, and Health Status in Geriatric Outpatients,” Daaleman, Perera and Studenski have added to the growing research of religion and spirituality in the health-sciences. The authors are to be commended for extending this line of inquiry into Family Practice Medicine. However, we believe that there are several significant problems in the conceptual framework of their study. First, we find problematic their equation of religiosity with religion, and their further definition of religion as “various organized, individual, and attitudinal manifestations of different faith traditions.” Instead, we propose that religiosity is that dimension of religion characterized by sets of behavioral practices (church attendance, denominational affiliation, etc.), and further propose Pargament’s (1997) definition of religion as “the search for significance in ways related to the sacred.” Furthermore, we find the authors’ definition of spirituality as “often connot[ing] and express[ing] a sense of meaning, purpose, or power either from within or from a transcendent source” to be problematic in its deviance on two points from Hill et al’s. (2002) proposal that spirituality (1) invariably includes a notion of “sacredness” and (2) may overlap conceptually with religion.

Regarding the research design, the authors are correct in stating the secondary analysis of cross-sectional data limits the ability to make causal inferences about study variables. Nevertheless, the authors’ explicit focus on perceived health status as the outcome variable in this study appears valid for this population. However, the use of religious or spiritual service attendance as an index of organizational religiosity cannot be applied equally across all age groups or populations. For example, issues related to chronicity and functional impairment often limit social integration among elderly individuals (Thompson & Heller, 1990). Thus, the lack of a statistically significant odds ratio between perceived health status and religiosity may be explained, in part, by the number of study participants above 76 years of age (N=93). Although age was treated as a continuous variable in this study, study participants were placed in categories based on age ranges. It would have been interesting to see if statistically significant differences existed among these age groups on perceived health status and other study variables. Results from these added analyses may have helped identify specific sources of variance in the religiosity and perceived health status relationship in this sample.

References

Hill et al. (2002). Conceptualizing religion and spirituality: Points of commonality, points of

departure. Journal for the Theory of Social Behavior 30, 51-77.

Pargament, K. (1997). The Psychologyof Religion and Coping: Theory, Research, Practice.

New York: Guilford Press.

Thompson, M., & Heller, K. (1990). Facets of support related to well-being: Quantitative social

isolation and perceived family support in a sample of elderly women. Psychology & Aging,

5(4), 535-544.

Competing interests:   None declared

The link to the supplemental appendix is not live in the full-text version of this article because the URL is not correct. The correct URL is http://www.AnnFamMed.org/cgi/content/full/2/1/49/DC1.

The appendix can be accessed, however, either by clicking on the [Supplemental data: Appendix] link in the electronic Table of Contents or by clicking on the "Supplemental data: Appendix" link in the navigation box across from the title at the top of the page in the full-text version of the article.

We very much regret this error and apologize for the inconvenience.

Competing interests:   None declared