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Religious Struggle as a Predictor of Mortality Among Medically Ill Elderly Patients
A 2-Year Longitudinal Study
Kenneth I. Pargament, PhD;
Harold G. Koenig, MD;
Nalini Tarakeshwar, MA;
June Hahn, PhD
Arch Intern Med. 2001;161:1881-1885.
ABSTRACT
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Background Although church attendance has been associated with a reduced risk of
mortality, no study has examined the impact of religious struggle with an
illness on mortality.
Objective To investigate longitudinally the relationship between religious struggle
with an illness and mortality.
Methods A longitudinal cohort study from 1996 to 1997 was conducted to assess
positive religious coping and religious struggle, and demographic, physical
health, and mental health measures at baseline as control variables. Mortality
during the 2-year period was the main outcome measure. Participants were 596
patients aged 55 years or older on the medical inpatient services of Duke
University Medical Center or the Durham Veterans Affairs Medical Center, Durham,
NC.
Results After controlling for the demographic, physical health, and mental health
variables, higher religious struggle scores at baseline were predictive of
greater risk of mortality (risk ratio [RR] for death, 1.06; 95% confidence
interval [CI], 1.01-1.11;  2 = 5.89; P = .02). Two spiritual discontent items and 1 demonic reappraisal item from
the religious coping measure were predictive of increased risk for mortality:
"Wondered whether God had abandoned me" (RR for death, 1.28; 95% CI, 1.07-1.50; 2 = 5.22; P = .02), "Questioned God's love
for me" (RR for death, 1.22; 95% CI, 1.02-1.43; 2 = 3.69; P = .05), and "Decided the devil made this happen" (RR
for death, 1.19; 95% CI, 1.05-1.33; 2 = 5.84; P = .02).
Conclusions Certain forms of religiousness may increase the risk of death. Elderly
ill men and women who experience a religious struggle with their illness appear
to be at increased risk of death, even after controlling for baseline health,
mental health status, and demographic factors.
INTRODUCTION
A NUMBER OF studies have documented a positive and robust relationship
between religiousness and reduced risk of mortality. More frequent church
attendance, in particular, has been predictive of lower risk of mortality,
after controlling for other confounding effects.1-5
Private forms of religiousness (eg, personal religiousness, frequency of prayer,
comfort from faith) have been less consistently and less strongly associated
with mortality.6 Studies in this area have
generally relied on global benign measures of religiousness (eg, frequency
of church attendance, self-rated religiousness). The form of these measures
does not allow for the possibility that specific negative religious beliefs
and behaviors may increase the risks of mortality.
A few empirical studies indicate that certain negative forms of religiousness,
while less common than positive religious expressions, may impact negatively
on health status.7 In a study of medically
ill hospitalized older adults, poorer health (eg, number of medical diagnoses,
impairments in activities of daily life, self-rated health) was associated
with indicators of religious struggle, including reports of anger at God,
feeling punished by God, and believing that the devil was at work in the illness.8 In another study of medical rehabilitation patients,
the patients' anger at God was predictive of poorer physical recovery 4 months
later.9
No study as yet, to our knowledge, has examined whether certain negative
forms of religiousness may increase the risk of mortality among those suffering
from a medical illness. Conceivably, religious distress and struggle associated
with an illness may exacerbate the effects of the illness and increase the
risks of mortality.
In this study, we sought to determine whether religious struggle with
an illness increases the risks of mortality in a sample of medically ill elderly
patients during a 2-year period.
SUBJECTS AND METHODS
STUDY POPULATION
The initial sample for this study consisted of 596 persons aged 55 years
or older who were hospitalized on the medical inpatient services of Duke University
Medical Center, Durham, NC, or the Durham Veterans Affairs Medical Center,
Durham, between January 1, 1996, and March 31, 1997. The older patient population
in both hospitals is almost exclusively (>95%) Christian, with a majority
of patients representing conservative (eg, Baptist) or mainline (eg, Methodist)
Protestant denominations.10-11
Detailed information about religious coping as well as physical and mental
health were collected through interviews with these patients at the baseline
hospital evaluation after their verbal informed consent was obtained, documented
by the interviewer's signature or witnessed by a third person. A research
assistant attempted to locate and contact by telephone each of the 596 patients,
beginning with those first enrolled in the study in January 1996. Of the 596
patients, 268 survivors were located, 176 were identified as deceased, and
152 were either unable to be located or unable or unwilling to respond to
the follow-up interview. Those unavailable for follow-up (25.5%) were disproportionately
represented in the Veterans Affairs Medical Center, tended to be from a lower
socioeconomic class, were more migratory, had fewer social connections, and
were, therefore, more difficult to locate. The average number of days between
baseline and follow-up was 632 (range, 381-986). The confirmation of death
and date of death occurred through direct contacts with family members (50%),
review of vital records in Raleigh, NC (25%), review of Duke University Medical
Center or Durham Veterans Affairs Medical Center records (15%), or a search
of the National Death Index (10%). This project was approved by the institutional
reviews boards at Duke University Medical Center and Bowling Green State University,
Bowling Green, Ohio.
RELIGIOUS COPING
Positive religious coping and religious struggle with the illness at
baseline were measured with the Brief RCOPE.12
This is a 14-item questionnaire that assesses the extent to which the patient
uses specific methods of religious coping. Positive religious coping consists
of 7 items that measure seeking spiritual support, seeking a spiritual connection,
collaboration with God in problem solving, religious forgiveness, and benevolent
religious appraisals of the illness. Religious struggle was measured by the
negative religious coping subscale, which is made up of 7 items that assess
punishing God appraisals, interpersonal religious discontent, demonic appraisals,
spiritual discontent, and questioning God's powers. Patients indicate how
often they engage in each form of religious coping on a 4-point scale from
0 (not at all) to 3 (a lot). This instrument has demonstrated good construct
validity and internal consistency in medical settings and among people facing
major life crises.8, 12 With respect
to test-retest reliability, religious coping attitudes in older medical patients
are generally stable over time (eg, >0.80). Measures of coping activities,
however, are not expected to show high levels of stability because coping
presumably changes during the course of hospitalization, treatment, and discharge.
Nevertheless, among the survivors in this study, religious coping at baseline
and follow-up were significantly intercorrelated according to both positive
(r = 0.75, P<.05) and
negative (r = 0.43, P<.05)
religious coping subscales.
GLOBAL RELIGIOUSNESS
To provide a point of comparison with previous studies of religiousness
and mortality, 3 traditional indexes of global religiousness were included.8 Patients indicated how often they attended church
or other religious meetings on a 6-point scale from 6 (more than once a week)
to 1 (never). They reported how often they spent time in private religious
activities, such as prayer, meditation, or Bible study on the same 6-point
scale. Patients also indicated how important religion was to them on a 3-point
scale from 3 (very important) to 1 (not important).
COVARIATES
We gathered information on 3 sets of potential confounding variables:
demographic, physical health, and mental health. Several demographic variables
were measured: age, race, sex, education, and hospital (Duke or Durham Veterans
Affairs).
Physical health was assessed at baseline and follow-up through 5 established
measures: (1) the number of active medical diagnoses as determined by physical
examination of the patient and medical record review was counted; they were
classified into 18 categories of illness based on the International
Classification of Diseases, Ninth Revision, Clinical Modification,
and summed13; (2) the severity of medical illness
was measured by the American Society of Anesthesiologists Severity of Illness
Scale14; this scale is a single-item observer-rated
measure of global illness severity ranging from 0 (healthy) to 5 (severely
ill); (3) cognitive status was measured by means of an abbreviated version
of the Mini-Mental State Examination,15 developed
and validated in elderly medical inpatients16;
higher scores indicate better cognitive functioning; (4) functional status
was assessed by the ability to independently perform 12 instrumental and 8
physical activities of daily living17-18;
higher scores indicate more dependence and less functional ability; and (5)
subjective health was measured by a single item in the traditional manner
(poor to excellent).
Mental health was measured at baseline and follow-up by 2 instruments.
Depressive symptoms were measured with an 11-item self-rated scale that has
been validated in older medical patients against clinically determined diagnoses
of major depression19; higher scores indicate
more depressive symptoms. Quality of life was assessed by means of a 5-item
observer-rated quality-of-life index that assesses general activity, functioning,
social support, health, and psychological functioning20;
higher scores indicate better quality of life.
DATA ANALYSIS
We used t tests and 2 statistics
to compare survivors and deceased with respect to their demographic characteristics,
physical health, mental health, positive religious coping and religious struggle,
and global religiousness. These analyses did not take into account censored
observations.
To determine whether religious coping was a significant predictor of
mortality, we modeled the time until death by means of Cox regression analyses.
This robust semiparametric procedure was chosen for its flexibility in handling
censored observations, time-dependent predictors, and late entry into the
study. For these analyses, all available data were used. Time to death was
censored for surviving individuals, individuals we were unable to recontact,
and individuals who were unable or unwilling to complete the follow-up interview.
Time-dependent covariates allowed for inclusion of measures collected at both
times for individuals who completed the 2 interviews. Four models were tested
in hierarchical form: positive religious coping and religious struggle; positive
religious coping, religious struggle, and demographics; positive religious
coping, religious struggle, demographics, and physical health; and positive
religious coping, religious struggle, demographics, physical health, and mental
health. Parameter estimates for each predictor were tested via a 2 statistic. Additional information on the impact each predictor had
on mortality was obtained through computation of risk ratios (RRs). Additional
Cox regression analyses were conducted to identify the specific religious
coping items from the Brief RCOPE that were predictive of mortality. Finally,
Cox regression analyses were conducted to determine whether the global religious
indexes were significant predictors of mortality.
RESULTS
Table 1 reports the comparison
between survivors and deceased on demographic, physical health, mental health,
positive religious coping, religious struggle, and global religious variables
at baseline. Compared with the deceased, survivors were significantly younger
and more educated at baseline. In addition, a larger proportion of survivors
were white. With respect to physical health, in comparison with the deceased,
survivors manifested significantly fewer active medical diagnoses, less severe
ratings of illness, better subjective health, more independent functional
status, and better cognitive functioning at baseline. In terms of mental health,
survivors also reported better mood and better quality of life at baseline
than participants who died before follow-up. With respect to positive religious
coping and religious struggle, both groups reported low levels of religious
struggle. However, in comparison with the deceased, survivors reported lower
levels of religious struggle at baseline. In terms of the global religious
indexes, survivors indicated that they attended church more frequently than
participants who died before follow-up.
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Table 1. Comparison Between Survivors and Deceased on Baseline Variables*
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Cox regression analyses that took into account censored observations
confirmed the results of the t tests. Religious struggle
was a significant predictor of increased risk for mortality in the initial
model (RR, 1.06; 95% confidence interval [CI], 1.02-1.11; 2
= 9.04; P = .01). The effects of religious struggle
remained significant after controlling for the demographic variables (RR,
1.07; 95% CI, 1.02-1.11; 2 = 9.07; P
= .01), the demographic and physical health variables (RR, 1.05; 95% CI, 1.00-1.10; 2 = 4.37; P = .04), and the demographic, physical
health, and mental health variables (RR, 1.06; 95% CI, 1.01-1.11; 2 = 5.89; P = .02). The complete model is presented
in Table 2. Age, illness severity,
and poorer self-rated overall health were also associated with greater risk
of mortality.
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Table 2. Cox Regression Estimates of Demographic, Mental Health, Physical
Health, Positive Religious Coping, and Religious Struggle Variables on Mortality*
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Additional Cox regression analyses were conducted to identify the specific
religious struggle items on the negative religious coping subscale of the
Brief RCOPE that were predictive of mortality. In these analyses, the religious
struggle items from the Brief RCOPE were entered into the equations in hierarchical
form in the same manner as above. Two spiritual discontent and 1 demonic reappraisal
item were identified as predictors of increased risk for mortality after controlling
for demographic, physical health, and mental health variables: "Wondered whether
God had abandoned me" (RR, 1.28; 95% CI, 1.07-1.50; 2 = 5.22; P = .02), "Questioned God's love for me" (RR, 1.22; 95%
CI, 1.02-1.43; 2 = 3.69; P = .05),
and "Decided the devil made this happen" (RR, 1.19; 95% CI, 1.05-1.33; 2 = 5.84; P = .02). One punishing God reappraisal
item ("Felt punished by God for my lack of devotion") was marginally predictive
of mortality after controlling for demographic variables (RR, 1.16; 95% CI,
1.00-1.32; 2 = 3.57; P<.06) but
not after controlling for physical health and mental health.
Additional Cox regression analyses were conducted on the effects of
the global religious variables on mortality after controlling for demographic,
physical health, and mental health variables. Consistent with previous studies,
more frequent church attendance was associated with a lower risk of mortality
(RR, 0.87; 95% CI, 0.75-0.97; 2 = 5.67; P = .02). When church attendance was entered into a Cox regression
analysis with positive religious coping and religious struggle as well as
the control variables, religious struggle continued to predict mortality significantly
(RR, 1.05; 95% CI, 1.00-1.10; 2 = 4.37; P = .04) and church attendance was only marginally significant (RR,
0.88; 95% CI, 0.77-1.00; 2 = 3.49; P<.06).
COMMENT
Several empirical studies have shown that religious involvement is predictive
of lower mortality.1-5
To our knowledge, this is the first empirical study to identify religious
variables that increase the risk of mortality. Religious struggle was associated
with greater risk of mortality. Although the magnitude of the effects associated
with religious struggle was relatively small (from 6% to 10% increased risk
of mortality), the effects remained significant even after controlling for
a number of possible confounding variables, including demographic, physical
health, and mental health variables. Furthermore, we were able to identify
specific forms of religious struggle that were more predictive of mortality.
Patients' reports that they felt alienated from or unloved by God and attributed
their illness to the devil were associated with a 19% to 28% increase in risk
of dying during the approximately 2-year follow-up period. It should also
be noted that religious struggle was predictive of mortality, while other
variables that have been implicated in longevity were not. For instance, mortality
was not predicted by race, diagnosis, cognitive functioning, independence
in daily activities, depressed mood, or quality of life.
It could be argued that these results are idiosyncratic to a distinctive
sample. Contrary to this interpretation, however, frequency of church attendance
was associated with reduced risk of mortality in this study, as has been reported
by several other researchers.1-5
In addition, as would be expected, in this sample, risk of mortality was related
to age, ratings of illness severity, and subjective ratings of poorer health.
Nevertheless, additional research is needed to determine whether these findings,
based on a predominantly conservative and mainline Christian sample, are generalizable
to other religious groups, including those in which religious struggles may
be more normative or take other forms. In this vein, theologians from different
religious traditions have suggested that at least some forms of religious
struggle (eg, questions about God, practice, doctrine) are prerequisites to
spiritual maturity.21
Questions could also be raised about the percentage of patients (25.5%)
who were unavailable for follow-up. This rate of attrition is higher than
we would have preferred and represents a weakness of the study. Nevertheless,
follow-up rates of 70% to 80% are commonplace in longitudinal studies and
are usually deemed acceptable. Furthermore, religious struggle was predictive
of greater risk of dying even after statistical adjustments for potential
biases in patient attrition.
Why should religious struggle increase the risk of dying? One possibility
is that religious struggle causes poorer physical health. In support of this
explanation, further analyses showed that religious struggle was predictive
of declines in independence in daily activities among the survivors in this
sample. Similarly, Fitchett et al9 found that
the negative religious coping scale from the Brief RCOPE was predictive of
significant declines over time in the same measure (activities of daily living)
among a sample of medical rehabilitation patients. On the other hand, religious
struggle was not generally predictive of declines in other measures of physical
health among survivors in our sample, including subjective health, severity
of illness ratings, and cognitive functioning. Nevertheless, religious struggle
may go hand in hand with declines in immunologic functioning22
or other health indexes that were not examined in this study.
Another possible explanation is that religious struggle is associated
with emotional or personality differences that relate directly or indirectly
to mortality. Other cross-sectional studies have shown that religious struggle
is related to higher levels of emotional distress23
and symptoms of posttraumatic stress among survivors of the Oklahoma City
bombing.12 Similarly, Exline and colleagues24 found that 2 dimensions closely related to religious
struggle, difficulty forgiving God and alienation from God, were associated
with higher levels of depression and anxiety. However, it is important to
remember that religious struggle was predictive of mortality in this study,
even after controlling for depressed mood and quality of life, 2 variables
that tap into dimensions of emotionality and personality. Nevertheless, the
critical emotions here may have more to do with fear, anxiety, guilt, and
anger and less to do with sadness and loss. The specific RCOPE items that
were most predictive of mortality (wondered whether God had abandoned me;
questioned God's love for me; decided the devil made this happen; felt punished
by God for my lack of devotion) do seem to reflect the former rather than
the latter cluster of emotions.
Yet another possible explanation for the religious struggle–mortality
connection is that religious struggle may result in social alienation. Expressions
of dissatisfaction, confusion, and discontent with God and religion are not
normative in the United States. Levels of religious struggle are, on the average,
quite low. Thus, individuals who voice religious dissatisfaction and discontent
in the midst of their illnesses may alienate themselves from the support and
caring of family, friends, clergy, and health professionals, which may, in
turn, result in a loss of social, emotional, and tangible support. In this
vein, greater religious struggle at baseline was slightly but significantly
correlated with less frequent church attendance (r
= -0.12; P<.05).
Of course, these 3 explanations are not mutually exclusive. Several
factors may account for the connection between religious struggle and mortality.
Clearly, additional research is needed to examine these and other potential
mediating variables. These studies should move beyond a reliance on global
religious measures to a focus on more specific aspects of religiousness, positive
and negative, that have the potential to enhance or diminish health and longevity.
Physicians are now being asked to take a spiritual history,25-26 and more than 70 of the 126 medical
schools in the United States now have courses that train students to take
such a history. Our findings suggest that patients who indicate religious
struggle during a spiritual history may be at particularly high risk for poor
medical outcomes. Referral of these patients to clergy to help them work through
these issues may ultimately improve clinical outcomes; further research is
needed to determine whether interventions that reduce religious struggles
might also improve medical prognosis.
AUTHOR INFORMATION
Accepted for publication January 11, 2001.
This study was supported by a grant from the Retirement Research Foundation,
Chicago, Ill.
Corresponding author and reprints: Kenneth I. Pargament, PhD, Department
of Psychology, Bowling Green State University, Bowling Green, OH 43403 (e-mail: kpargam{at}bgnet.bgsu.edu).
From the Department of Psychology, Bowling Green State University,
Bowling Green, Ohio (Dr Pargament and Ms Tarakeshwar); Departments of Psychiatry
and Medicine, Duke University Medical Center, Durham, NC (Dr Koenig); and
The Procter & Gamble Company, Cincinnati, Ohio (Dr Hahn).
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