Synonyms

Conscious living and god; Escape from illness with god's help; FACIT-Sp; Faith in god's help; Health and connectedness with god; Illness as chance; Positive attitudes and god; Religious coping; RGH

Definition

Spirituality is not only the “experiential core” (content) of ritualized religiosity (form) but a complex construct which shares relevant topics with secular aspects of spirituality. The underlying motifs found in the various definitions are the (cognitive) “search for meaning,” the (emotional) experience of connectedness (with God, others, and nature), and the respective realization in daily life in accordance with related ethical conduct. One may presume that spirituality could be assumed as persons’ commitment to a higher principle/source which is embodied in their daily life.

Description

Patients with chronic diseases use different strategies to deal with putatively restricted functional abilities, emotional impairments, and suffering. In several cases there is no way to “solve” their affected conditions and impairment or to find distance from negative emotions associated with their illness. As a consequence, they have to adapt and find ways to maintain physical, emotional, and spiritual health – despite their symptoms. As resources to cope in terms of beneficial external and internal loci of disease control, patients may rely on external powerful sources (trust in medical help and search for information and alternative help) and internal powers and virtues (conscious way of living and positive attitudes) (Büssing et al., 2006; Büssing, Ostermann, & Matthiessen, 2008); however, several refer to “more powerful” external resources (i.e., God, Allah, JHWH, etc.), either as a reactive strategy (“give it a try”) or in terms of an unconditional trust in higher support whatever the course of life and disease may bring. Even in secular societies, spirituality/religiosity can be a source to rely on in times of need (Büssing et al., 2005; Büssing, Ostermann, & Koenig, 2007, Büssing et al., 2009a, b; Zwingmann, Müller, Körber, & Murken, 2008; Zwingmann, Wirtz, Müller, Körber, & Murken, 2006; Appel et al., 2010). In fact, spirituality/religiosity can be used to relieve stress, retain a sense of control, and maintain hope and sense of meaning and purpose in life (Thune-Boyle, Stygall, Keshtgar, & Newman, 2006).

The crucial point is that, although they are interconnected, spirituality and religiosity are different concepts. Koenig (2008) raised concerns about measuring spirituality in research: Spirituality was traditionally “a subset of deeply religious people,” while today it is “including religion but expanding beyond it.” In fact, spirituality is often understood today as a broader and also changing concept which may overlap with secular concepts such as humanism, existentialism, and probably also with specific esoteric views (Zwingmann et al., 2010).

When talking about spirituality/religiosity, one has to differentiate specific beliefs (cognition/emotion), spiritual well-being, and specific practices (action), either within a specific institutional context or highly individual approaches (Table 1).

Health-Related Quality of Life and Reliance on God’s Help, Table 1 Conceptual differentiation of the different layers of spirituality/religiosity
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If one intends to analyze connections between “spirituality” and the likewise multidimensional topic quality of life, one has to be aware that one has to deal with rather unspecific constructs which may significantly overlap (i.e., spiritual well-being). With respect to spiritual well-being, as measured with the FACIT-Sp questionnaire, the sub-construct faith did not correlate with well-being, social support, social networks, and mood, while the sub-construct meaning/peace did correlate (Levine, Aviv, Yoo, Ewing, & Au, 2009). A more specific analysis of Canada, Murphy, Fitchett, Peterman, and Schover (2008) found that particularly the peace component correlated strongly with mental health, while the associations with respect to the sub-constructs meaning or faith were just weak. This means, it is a “secular” and less-specific aspect of spirituality which can be associated with mental health but not the circumscribed “religious” aspects of spiritual well-being. Also in German patients, we have found that Reliance on God’s Help in response to illness, as a measure of intrinsic religiosity, was not associated with physical or mental health (Büssing, Fischer, Ostermann, & Matthiessen, 2008). Thus, there is evidence that specific dimensions such as faith or intrinsic religiosity are not necessarily associated with well-being or health-related quality of life, while unspecific dimensions such as peace can be associated with well-being. In fact, the underlying items of the respective peace subscale refer to circumscribed aspects of well-being (i.e., feeling peaceful, sense of harmony with oneself, etc.), and thus, significant associations can be expected.

Therefore, it was necessary to reanalyze already existing data pools with healthy individuals and patients with chronic disorders with respect to circumscribed variables of intrinsic religiosity and health-related quality of life (HrQoL).

Measures and Persons

The combined data set (with respect to SF-12 data) comprised 5,046 individuals from different cohorts of either health individuals (Büssing, Ostermann, et al., 2008; Büssing, Ostermann, Neugebauer, & Heusser, 2010) or patients with chronic pain conditions (Büssing et al., 2009b), breast cancer (Büssing, Fischer, et al., 2008), and other chronic diseases (Büssing, Ostermann, et al., 2008; Büssing et al., 2010) (Table 2). The analysis here refers to a sample of 62 % healthy older individuals, 15 % with cancer, 14 % with other chronic diseases, 8 % who already experienced acute diseases/traumata (in most cases it is assumed that the individuals experienced their acute trauma/illness several years ago, and thus, this group should not be overestimated).

Health-Related Quality of Life and Reliance on God’s Help, Table 2 Characteristics of individuals with complete SF-12 data set
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As a measure of intrinsic religiosity in response to illness, the 5-item scale Reliance on God’s Help (RGH, Cronbach’s alpha = 0.9) deriving from the AKU questionnaire (Büssing et al., 2006; Büssing, Ostermann, & Matthiessen, 2008) was used. The items address unconditional trust (“Whatever may happen, I trust in a higher power which carries me through”), awaiting belief (“I have strong belief that God will help me”), faith as a resource (“My faith is a strong hold, even in hard times”), an actional component (“I pray to become healthy again”), and a behavioral component (“I try to live in accordance with my religious convictions”). The specific term “God” was used just one time.

To measure physical and mental HrQoL, the Medical Outcomes Study Short-Form Health Survey SF-12 (Resnick & Nahm, 2001; Ware, Kosinski, & Keller, 1996) was used. The instrument measures particularly physical and mental functioning but also mood states, pain disability, and affected social contacts.

Additional instruments were the 3-item scale Escape from Illness as an indicator of an avoidance-escape strategy to deal with illness (Büssing, Matthiessen, & Mundle, 2008) and internal adaptive coping strategies derived from the AKU questionnaire, i.e., Positive Attitudes, Conscious Living, and Reappraisal: Illness as Chance (Büssing et al., 2006; Büssing, Ostermann, & Matthiessen, 2007, 2008).

Reliance on God’s Help and Health-Related Quality of Life

The categorized disease groups differed significantly with respect to gender, age, and health status (Table 2). Particularly patients with cancer had the highest RGH. Although this cohort had a predominance of women when compared to the other individuals, their RGH scores did not differ with respect to gender (F = 0.0; p = .98).

As shown in Table 3, RGH and HrQoL were just marginally intercorrelated:

Health-Related Quality of Life and Reliance on God’s Help, Table 3 Correlation analyses between RGH, HrQoL, and internal adaptive coping strategies
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  • In healthy individuals (mean age, 62.9 ± 11.6 years), RGH correlated just marginally with SF-12’s physical health and Escape (p < .0001) but not significantly with mental health. None of the underlying items of the RGH scale correlated significantly with HrQoL.

  • In individuals experiencing acute diseases or trauma, RGH correlated neither with physical/mental health nor with Escape. None of the RGH items correlated significantly with the test variables.

  • In patients with various chronic conditions, RGH correlated just marginally with SF-12’s physical health but neither with mental health nor with Escape. Particularly the item “I pray to become healthy again” correlated weakly with physical health (r = − .137; p < 0.0001), all other items just marginally (data not shown).

  • In patients with cancer, RGH did not correlate with physical or mental health and just weakly with Escape from illness. Moreover, in women with breast cancer, RGH correlated neither with fatigue (CFS-D, r = .083; n.s.) nor with life satisfaction (BMLSS, r = .093; n.s.). In this population, the RGH items correlated negatively with mental health, i.e., “Whatever may happen, I trust in a higher power which carries me through” (r = − .132; p = .010), “My faith is a strong hold, even in hard times” (r = − .126; p = .015), “I pray to become healthy again” (r = −.113; p = .029), “I try to live in accordance with my religious convictions” (r = − .108; p = .038), and “I have strong belief that god will help me” (r = − .107; p = .038). Physical health did not correlate significantly with the items of the RGH scale (data not shown).

Additional analyses revealed that patients with chronic conditions, either with high, intermediate, or low RGH (scores > 60, between 40 and 60, and < 40, respectively), showed no significant differences with respect to physical and mental health scores (Table 4), while individuals with high RGH had higher internal coping strategies (i.e., illness as chance, conscious living, and positive attitudes).

Health-Related Quality of Life and Reliance on God’s Help, Table 4 HrQoL and internal adaptive coping strategies of patients with chronic disease
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Regression analyses with the relevant variables indicated that RGH can be predicted best by illness as chance, age, conscious living, healthy situation, and female gender, while neither SF-12’s physical/mental health components nor Escape was of significant relevance (Table 5).

Health-Related Quality of Life and Reliance on God’s Help, Table 5 Predictors of intrinsic religiosity (regression analysis)
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Thus, also in German individuals, either healthy or with chronic diseases, RGH was associated negatively with physical HrQoL, albeit to a marginal or weak extent. This could indicate that intrinsic religiosity was used by a fraction of individuals in response to physical health problems. In fact, in patients with chronic diseases, “praying to become healthy again” was associated with reduced physical health, and thus, it is a reactive strategy. In contrast, a significant association between RGH and mental health was observed only in women with breast cancer (r = − .125; p = .015; mean age, 59.7 ± 7.2 years), not in the cohort of women with cancer in general (r = − .064; n.s.; mean age, 64.2 ± 11.0 years). Of importance was the fact that RGH was moderately or even strongly associated the reappraisal strategy to view illness as a chance and weakly also with the internal adaptive coping strategies conscious living and positive attitudes (Tables 3 and 4). This means, for a group of patients with chronic diseases, intrinsic religiosity can be regarded as a resource to cope, to behave differently, and to change the perspectives in life (i.e., “reflect on what is essential in life,” “regard illness as a chance for development,” “live consciously each and every day,” “change life to get well,” etc.).

These findings are apparently in contrast to those of Tarakeshwar and coworkers (2006) who reported that in patients with advanced cancer, positive religious coping (R-COPE) was associated with better overall QoL (McGill QOL Questionnaire). However, looking at the underlying dimensions, it became clear that neither the physical nor the psychological aspects of QoL correlated with religious coping but the existential and support dimensions (Tarakeshwar et al., 2006). Moreover, religious coping was associated with reports of greater physical symptoms. This indicates that religious coping strategies were used because of an affected physical health situation – and therefore, patients were in search of support. Similarly Tarakeshwar et al. mentioned that “patients who experienced greater physical symptoms turned to religion more often for strength, comfort, and guidance.”

To address these issues in future analyses, specific multidimensional measures (rather than aggregated scales or indices) and longitudinal data are needed. For this analysis, a short and circumscribed scale to measure intrinsic religiosity as a strategy to deal with illness was used. This 5-item scale addresses unconditional trust, awaiting belief, faith as a resource, an actional, and a behavioral component. Patients may use specific facets of spirituality acutely as a resource in times of need (i.e., praying, church attendance, meditation, etc.) but not necessarily all the time during long-term courses of chronic illness. In case their expectations are “fulfilled,” patients may feel affirmed in their faith and specific beliefs and attitudes, and thus, their spiritual well-being might be high, while in other cases, they may quit their specific religious activities, and thus, their spiritual well-being may decrease.

But what about the secular forms of spirituality – could we expect strong associations with HrQoL? There are at least several hints that the existential aspects of spirituality are in fact associated with health and well-being (Canada et al., 2008; Davison & Jhangri, 2010; Levine et al., 2009; Tarakeshwar et al., 2006; Tsuang, Simpson, Koenen, Kremen, & Lyons, 2007). In patients with chronic kidney diseases, religious issues were either not or just weakly associated with SF-36’s QoL dimensions, while particularly existential well-being was moderately associated with several domains, particularly mental health (Davidson & Jhangri, 2010). Relying on the fact that the associations between spiritual well-being and health outcomes could be uniquely explained by existential well-being, Tsuang et al. (2007) specifically suggested “to distinguish between explicitly religious variables and others that more closely approximate the psychological construct of personal well-being” (Tsunag et al.). In fact, further research is needed, particularly in secular societies.

Cross-References

Assessment of Spirituality and Religious Sentiments (ASPIRES) Scale

Coping with Diagnosis

Meaning in Life

Peace of Mind

Ways of Coping Checklist