Applied Research in Quality of Life

, Volume 4, Issue 1, pp 77–90 | Cite as

Reliance on God’s Help as a Measure of Intrinsic Religiosity in Healthy Elderly and Patients with Chronic Diseases. Correlations with Health-Related Quality of Life?

  • Arndt Büssing
  • Julia Fischer
  • Thomas Ostermann
  • Peter F. Matthiessen
Article

Abstract

Within the context of coping, we analyze whether Reliance on God’s Help, as a measure of intrinsic religiosity, is associated specifically with SF-12’s health-related quality of life. Data of 5,248 individuals (63.1 ± 10.6 years; 14% chronic diseases, 16% cancer, 8% had experienced acute diseases, and 62% healthy elderly as a control group) were enrolled. Although about half of the individuals had a strong belief that God will help and prayed to become healthy again, Reliance on God’s Help was not generally associated with better physical or mental health-related quality of life. Just in distinct subgroups we found some marginal associations. Regression analyses confirmed that physical or mental health were not among the predictors of Reliance on God’s Help. Nevertheless, intrinsic religiosity was utilized by several individuals, particularly by patients with higher age and cancer. It should be regarded as a resource to cope (meaning-focused coping) rather than an independent contributor to health-related quality of life.

Keywords

Intrinsic religiosity Spirituality Coping Health-related quality of life Chronic diseases Patients 

Background

Patients with chronic diseases have different ways to cope with their disease, and there are different ways to regulate emotions associated with chronic diseases. Folkman and Lazarus found that both, problem-solving (i.e., do something active to avoid stressful circumstances) and emotion-focused coping strategies (i.e., try to regulate the emotional consequences of stressful or potentially stressful events) are used to face stressful situations (Folkman and Lazarus 1980). However, most patients with chronic diseases are unable to ‘solve’ their persisting conditions by themselves (in terms of recovery or repair) and to find distance from negative emotions associated with their disease. They have to adapt and find ways to maintain physical, emotional and spiritual health often in spite of a long-lasting course of disease. Thus, coping with chronic disease is an ongoing process for patients, including appraisals of stress, cognitive, behavioral, and emotional coping responses, and subsequent reappraisals of stress.

An important concept on adaptation strategies differentiates active and passive coping. Recently we have shown that most patients with chronic diseases use active adaptive coping styles which conceptually refer to external and internal loci of disease control (Fig. 1), i.e., external powerful sources (Trust in Medical Help / Search for Information and Alternative Help), and on internal powers and virtues (Conscious Way of Living / Positive Attitudes), while factors associated with a fatalistic/divine external locus of disease control (i.e. Trust in God’s Help) were rated lower. It is quite obvious that patients primarily rely on external medical sources, but especially patients confronted with fatal diseases may search for `more powerful’ external sources of help (i.e., God, Allah, JHW etc.), and ask for meaning and purpose of life (Büssing et al. 2005a, b, c, 2007a, b, d, 2008a, b; Thune-Boyle et al. 2006; Baldacchino and Draper 2001). Spirituality/religiosity (SpR) thus can be a source to rely on in such times of need, e.g., to relieve stress, retain a sense of control and maintain hope and sense of meaning and purpose in life.
Fig. 1

Adaptive coping strategies in the context of health/disease control. Individuals may rely on both, the external and the internal sources to cope with illness

Although the quest for scientific evidence is ongoing, there is mounting research showing a connection between SpR and health, i.e., several studies indicate that religious involvement is related to better mental and physical health, improved coping with illness, and improved medical outcomes (reviewed in (Koenig et al. 2001)). In patients with advanced cancer, positive religious coping (e.g., benevolent religious appraisals) was reported to be associated with better overall quality of life (QoL), but also related to more physical symptoms (Tarakeshwar et al. 2006); in contrast, greater use of negative religious coping (e.g., anger at God) was related to poorer overall QoL. In a study of Johnson and colleagues, spiritual well-being scores of patients with cancer were strongly associated with QoL domains (Johnson et al. 2007). Moreover, SpR respectively a religious involvement seems to be a protective factor that promotes health (Oman et al. 2002).

Although there are several studies indicating that SpR may protect against distinct diseases, Powell et al. argued that these effects are “largely mediated by the healthy lifestyle it encourages”, and that “evidence fails to support a link between depth of religiousness and physical health” (Powell et al. 2003). Much more deprecatingly were Sloan and Bagiella who concluded that “there is little empirical basis for assertions that religious involvement or activity is associated with beneficial health outcomes” (Sloan and Bagiella 2002).

On the other hand, one may wonder whether the instruments intended to measure a highly subjective and multidimensional construct such as SpR are really specific. A recent study by Ellen G. Levine and co-workers found that faith/assurance, as a unique dimension of spirituality, did not correlate with well-being, social support, social networks, mood etc, while the meaning/peace dimension of spirituality did correlate (Levine et al. 2008). One may not ignore the fact that, from a conceptual point of view, intrinsic religiosity and the spiritual quest orientation are distinct aspects of the multidimensional constructs ‘spirituality’ and ‘religiosity’. Because of this multidimensionality of concepts and instruments, one may find varying associations between SpR and health related variables. Also in German breast cancer survivors there were no relevant correlations between the scale Trust in God’s Help, as a measure of intrinsic religiosity in response to illness, and mood or fatigue (Büssing et al. 2008b); there were just some weak associations with distinct life satisfaction aspects, and a negative correlation with mental health-related QoL.

Moreover, there is evidence that SpR can be regarded as a resource to cope with illness (Thune-Boyle et al. 2006; Baldacchino and Draper 2001; Büssing et al. 2007b, d, 2008b). Therefore, within the context of coping, we intended to analyze whether intrinsic religiosity, as one of the main important facets of SpR (Büssing et al. 2007c), is indeed associated specifically with health-related QoL or rather with adaptive coping - particularly in a more secular country such as Germany. The utilization of SpR may be much higher in countries with a deep-seated and vital religious tradition, and thus of higher relevance for various life concerns. Our hypothesis was that both concepts, SpR and QoL are distinct, albeit some aspects might be associated, and that SpR is only weakly associated with health-related dimensions in individuals with low SpR, but probably stronger with coping strategies. Keeping in mind that both QoL and SpR are multidimensional constructs, the measurement of QoL is based on a person’s perspective of their overall QoL and their assessment of specific components of QoL (i.e., physical, psychological and social well-being) (Mytko and Knight 1999). Also SpR is a highly subjective and multidimensional construct (Koenig 2008a; Büssing et al. 2007c) which shares several aspects of psycho-social well-being (Sawatzky et al. 2005; Stefanek et al. 2005b). Thus, it would not be surprising that distinct aspects of SpR may correlate with unique aspects of QoL (i.e., physical well being, mood states, life attitudes, self efficacy, connectedness, social activities, living environment, economic status, needs etc.). Although the relationship between SpR and various dimensions of health and QoL has been extensively examined during the past decade, no clear conclusions can be drawn. A recent meta-analysis confirmed a moderate effect size between spirituality and QoL (Sawatzky et al. 2005). The results revealed several findings that support the conceptualization of spirituality as a distinct concept that relates to QoL (Sawatzky et al. 2005). As a consequence, we intended to rely on compact and circumscribed scales to measure health-related QoL (i.e., the Medical Outcomes Study Short-Form Health Survey’ SF-12 which differentiates physical and mental health-related QoL) and the scale Reliance on God’s Help (RGH) from the AKU questionnaire.

Methods

Patients

We analyzed data of healthy individuals and patients from three different pools (n = 5,248): The main pool consisted of individuals from a survey among elderly German insurants (n = 4,807) (Büssing et al. 2007b) which were investigated to assess their health status, health behavior, and utilization of adaptive coping strategies. The primary sample enrolled 5,830 individuals (healthy and individuals confronted with various diseases); the data sets of 4,807 individuals provided sufficient data to analyze the intended variables (i.e., SF-12 questionnaire). However, we had a strong predominance of men (72%). From previous studies we knew that men had significantly lower interest in SpR issues. To balance the data set, we enrolled data from a survey among female cancer survivors, recruited at a breast cancer support group conference (n = 381) (Büssing et al. 2008b), and from patients with chronic pain conditions from the Orthopedic Clinic in Bad Bocklet (n = 60; 75% women). All individuals were informed of the purpose of the study, were assured of confidentiality, and consented to participate. The questionnaires were anonymous, and the pooled data could not be tracked back to individual patients.

To minimize the bias of a convenience sample, different data pools were chosen. To obtain a more naturalistic sample, we had neither inclusion nor exclusion criteria (with the exception of the clinical diagnosis and consent to participate). We categorized the enrolled individuals according to their underlying disease as ‘experienced acute symptomatic’ (‘acute’-i.e., coronary by-pass, heart attack, stroke, accidents, prolapsed intervertebral disc, etc.), chronic diseases (‘chronic’-i.e., fibromyalgia, rheumatoid arthritis, arthrosis, asthma bronchiale, hypertension, diabetes mellitus, Parkinson’s disease, depression, etc.), and ‘cancer’ (51% from the main pool, 48% from the cancer survivor pool, and 0.5% from the Orthopedic clinic; the cancer survivors were included notwithstanding, because we assume that the confrontation with a putative fatal diagnosis may have changed attitudes and health-related behavior), and contrasted these groups with healthy elderly (mean age ~ 60 years).

Measures

From a conceptual point of view, one should differentiate between spirituality in religion, which has the connotation of a more open, individual and pluralistic faith, and spirituality as opposed to religion, and thus defining it as multiple but individual ‘paths’ to the one truth. Tanyi globally defined that “spirituality involves humans' search for meaning in life, while religion involves an organized entity with rituals and practices about a higher power or God” (Tanyi 2002). In a recent attempt to measure the different expressions of spirituality, we identified a broad pattern of seven main topics, i.e., Prayer/Trust/Shelter; Insight/Awareness/Wisdom; Transcendence conviction; Compassion/Generosity; Conscious interactions; Gratitude/Reverence/Respect; and Equanimity (Büssing et al. 2007c). Apart from this, it is well established to divide ‘religiosity’ into three sub-constructs: Intrinsic, Extrinsic, and Quest Religiosity (Maltby and Day 1998; Maltby and Lewis 1996), while the construct ‘spirituality’ was divided into the following sub-constructs: Cognitive orientation towards spirituality, experiential/phenomenological dimension of spirituality, existential well-being, paranormal beliefs, and religiousness (MacDonald 2000).

The Prayer/Trust motif is an essential aspect of spirituality, particularly for the elderly (Büssing et al. 2007c). For this analysis with elderly individuals, we thus focused on the utilization of non-organized, private intrinsic religiosity in response to illness or to maintain health respectively. We chose the compact and circumscribed 5-item scale Reliance on God’s Help (RGH; Cronbach’s alpha = 0.917) from the AKU questionnaire which heads the Prayer/Trust motif (i.e., faith is a strong hold even in hard times; trust in a higher power which carries through; strong belief that God will help; live in accordance with religious convictions; pray to become healthy) (Büssing et al. 2007b, 2008a). The items were scored on a 5-point scale from disagreement to agreement (0—does not apply at all; 1—does not truly apply; 2—don’t know; 3—applies quite a bit; 4—applies very much). The sum scores were referred to a 100% level (4 “applied very much” = 100%).

Health-related QoL can be measured either generic or disease specific, as health profiles or preference based. We were aware that several instruments tend to discriminate against older persons because of their relation to physical function which may be lower in the elderly when compared to younger individuals (Hickey et al. 2005). Nevertheless, we intended to focus on circumscribed health-related variables rather than subjective well-being in terms of emotional, cognitive or social aspects. Thus, we chose the robust ‘Medical Outcomes Study Short-Form Health Survey’ SF-12 (Resnick and Nahm 2001; Ware et al. 1996). This instrument differentiates physical and mental health, and lacks the emotional, cognitive or social aspects which conceptually may overlap with unique aspects of spirituality.

To make statements about the conceptual relationships with coping, we also enrolled the AKU questionnaire (AKU is an acronym of the German translation of “Adaptive Disease Coping”). This instrument was designed to identify active and adaptive coping styles, such as to create favorable conditions, search for information, medical support, religious support, social support, initiative spirit, and positive (re)interpretation of disease (Büssing et al. 2007b, 2008c). The 28-item questionnaire (Büssing et al. 2008a) (Cronbach’s alpha = 0.867) refers to the concept of internal and external loci of disease control (Fig. 1), and differentiates Conscious and Healthy Way of Living (intrinsic locus of control), Positive Attitudes (intrinsic locus of control), Trust in Medial Help (external locus of control), Search for Information and Alternative Help (external locus of control), Reappraisal: Illness as Chance (intrinsic; meaning focused), and holds the RGH scale (“Trust in God’s Help; external locus of control). All items were scored on a 5-point scale from disagreement to agreement (0—does not apply at all; 1—does not truly apply; 2—don’t know; 3—applies quite a bit; 4—applies very much). The sum scores were referred to a 100% level (4 “applied very much” = 100%).

The AKU bears an independent 3-item scale termed Escape from illness which is an indicator of an escape-avoidance strategy to deal with illness (i.e., fear what illness will bring; would like to run away from illness; when I wake up, I don’t know how to face the day). It was confirmed recently that this scale correlated strongly with depression, with appraisals such as ‘weakness/failure’ and ‘punishment’, and negatively with life satisfaction (Büssing et al. 2008d). The items were scored on a 5-point scale from disagreement to agreement.

Statistical Analysis

Data were presented as mean values ± standard deviations or relative proportions (%). All statistical analyses (variance, correlation, and regression analyses) were performed with SPSS for Windows 15.0 (SPSS Inc. Headquarters, Chicago, Illinois, USA). We judged p < 0.05 as significant.

Results

Socio-demographic and Psychometric Analyses

Among the 5,248 test persons (mean age 63.1 ± 10.6 years), 34% were female and 66% male; 74% were married, 5% lived with a partner with whom they were not married, 6% lived alone, 5% were divorced, and 10% widowed. 19% had a secondary education (Hauptschule), 23% a junior high school education (Realschule), 51% a high school education (Gymnasium), and 8% other. 72% were healthy (mean age 62.8 ± 10.8 years), 8% had experienced acute symptoms (66.1 ± 9.8 years), 14% had chronic diseases (63.2 ± 11.4 years), and 16% cancer (63.9 ± 9.3 years). Although all individuals were in the same age category, their mean age significantly differed (F = 12.5; p < 0.0001; ANOVA).

For 50% of the healthy elderly and 53% of the patients, faith was a strong hold even in hard times (item a37), 49% / 53% had trust in a higher power which carries them through (item a35); 48% / 52% had a strong belief that God will help (item a36), 45% / 47% stated to live in accordance with their religious convictions, and 44% / 48% prayed to become healthy (item a38).

Adaptive Coping and Health-related QoL in Different Disease Groups

There were significant differences between the disease groups with respect to adaptive coping strategies and health-related QoL (Table 1). RGH was the highest in patients with cancer, and the lowest in patients with other chronic diseases and healthy elderly. Moreover, cancer patients had the highest scores for Search for Information and Alternative Help, Positive Attitudes and Reappraisal: Illness as Chance, and the lowest mental health-related QoL. In contrast, physical health was the lowest in patients with chronic disease, while Escape from illness was the highest in patients with cancer and chronic diseases (Table 1). Conscious and Healthy Living, which addresses active cognitive behavioral styles to cope (in terms of internal powers and virtues), was utilized by all individuals (Table 1).
Table 1

Adaptive coping styles, Escape from illness, and health-related quality of life

 

Adaptive coping styles (AKU)

Health-related quality of life (SF-12)

 

Reliance on God’s help

Trust in medical help

Search for information / alternative help

Positive attitudes

Conscious and healthy living

Reappraisal: Illness as chance

Physical health

Mental health

Escape from illness

Healthy elderly

Mean

53.27

74.38

57.11

72.24

81.09

34.67

49.58

53.56

27.22

SD

34.61

21.67

28.01

15.95

15.00

26.68

8.01

7.59

21.75

Acute

Mean

55.40

84.15

67.45

72.45

82.13

44.19

42.08

52.93

29.85

SD

33.44

14.60

21.55

15.20

16.97

24.51

9.95

8.11

21.83

Chronic

Mean

53.14

83.00

69.87

72.16

80.46

39.50

41.02

50.41

33.86

SD

33.64

15.65

19.75

15.85

14.68

25.61

11.25

10.94

26.44

Cancer

Mean

58.57

81.45

71.59

75.80

82.35

54.70

43.17

49.95

33.71

SD

34.28

20.65

19.04

15.62

13.07

26.99

10.07

9.90

23.31

All

Mean

54.25

77.51

62.12

72.80

81.28

39.37

46.77

52.49

29.41

SD

34.37

20.64

25.96

15.87

14.84

27.39

9.75

8.71

22.93

F-value

5.329

65.828

104.681

11.106

2.664

122.704

276.653

53.881

27.903

p-value

0.001

<0.001

<0.001

<0.001

0.046

<0.001

<0.001

<0.001

<0.001

Cancer women

Mean

58.54

78.90

72.66

77.44

81.40

60.55

42.90

47.81

36.42

SD

34.57

22.94

19.56

15.67

13.13

25.70

10.13

10.17

23.71

Cancer men

Mean

58.60

85.91

69.71

72.98

84.02

44.54

43.64

53.63

28.90

SD

33.81

14.97

18.02

15.13

12.87

26.29

9.95

8.22

21.88

F-value

0.000

21.301

4.330

14.920

7.263

68.577

0.963

68.093

19.080

p-value

n.s.

<0.001

0.038

<0.001

0.007

<0.001

n.s.

<0.001

<0.001

Results are mean values ± standard deviation (SD)

Because cancer patients remarkably differed from the other patients with respect to RGH and adaptive coping strategies (and to account for the fact that the cancer patients are from two different samples with different proportions of women and men), we analyzed gender-specific effects within this sub-subset (Table 1). RGH and physical health did not differ between female and male cancer patients. Particularly Reappraisal and Positive attitudes were significantly higher in women (and exceeded the mean vales of all other disease groups), while mental health was significantly lower as compared to male cancer patients. Thus, in cancer patients, the higher Reliance on God’s Help and Reappraisal seemed to be associated with the disease rather than gender. Although analyses of variance (GLM univariate, between subject effects) revealed a significant impact of age and gender on RGH (Table 2), age was of significance particularly in healthy individuals, while in patients with chronic diseases both gender and age were of relevance.
Table 2

Impact of socio-demographic variables on Reliance on God’s Help (GLM univariate; between-subject effects)

Dependent variable: Reliance on God’s Help

Variables *

F-value

Significance *

Healthy

Gender

2.512

n.s.

Age group

5.826

<0.001

Family status

0.988

n.s.

Educational level

0.944

n.s.

Acute diseases

Gender

4.617

0.032

Age group

1.025

n.s.

Family status

0.711

n.s.

Educational level

1.154

n.s.

Gender * age * education

2.326

0.043

Chronic diseases

Gender

0.009

n.s.

Age group

2.335

0.031

Family status

1.372

n.s.

Educational level

0.711

0.013

Gender * age

3.411

0.005

Cancer

Gender

0.268

n.s.

Age group

2.368

0.038

Family status

0.602

n.s.

Educational level

1.867

n.s.

* Levene’s test for equality of variances was significant in all cases and thus the level of significance should be p < 0.01

Associations Between Reliance on God’s Help, Adaptive Coping and Health-related Variables

Although individuals with high RGH scores had a somewhat lower physical health-related QoL as compared to those with no or indifferent RGH (F = 17.0, p < 0.001), these differences were just marginal (Fig. 2). Their mental health scores were marginally different in trend (F = 2.6; p = 0.058). However, individuals with high RGH had significantly (p < 0.001) higher Positive Attitudes (F = 91.8) and Conscious Living (F = 184.3).
Fig. 2

Reliance on God’s Help (RGH), health-related QoL (SF-12) and internal adaptive coping strategies (AKU). Results are mean values and standard deviations. RGH scores >60% indicate high reliance, scores <40% indicate no interest / rejection, while scores 40–60% are indifferent states. ** p < 0.001 (ANOVA)

Correlation analyses confirmed that physical health correlated marginally with RGH, while mental health did not (Table 3). With respect to the adaptive coping strategies, RGH was moderately associated with Reappraisal: Illness as Chance (Table 3), indicating that this cognitive appraisal dimension has a spiritual connotation; moreover, RGH correlated to a weak extend also with Search for Information and Alternative Help and Escape from Illness (Table 3). Subgroup analyses approved that RGH correlated marginally with physical help only in healthy individuals and patient with chronic diseases, but not in patients with acute diseases or cancer (Table 4). Escape from illness was weakly associated with RGH in patients with cancer (Table 4), and to a minor extend in healthy elderly.
Table 3

Correlation between adaptive coping and health-related QoL

 

Reliance on God’s help

Trust in medical help

Search for information / alternative help

Positive attitudes

Conscious living

Reappraisal: Illness as chance

Reliance on God’s Help

1.000

.183*

.201*

.180*

.252*

.417*

Trust in Medical Help

 

1.000

.342*

.220*

.262*

.139*

Search for Information / Alternative Help

  

1.000

.303*

.279*

.393*

Positive Attitudes

   

1.000

.480*

.213*

Conscious / healthy living

    

1.000

.126*

Reappraisal: Illness as Chance

     

1.000

Escape from illness

.083*

.066*

.191*

−.027

−.087*

.232*

SF-12 physical health

−.087*

−.223*

−.207*

.016

.049*

−.149*

SF-12 mental health

−.025

.070*

−.086*

.113*

.163*

−.162*

*p < 0.001 (Spearman rho; 2-tailed)

Table 4

Correlation between RGH, health-related QoL and escape

Variable: Reliance on God’s Help

Healthy (n = 3,075)

Acute (n = 389)

Chronic (n = 718)

Cancer (n = 776)

SF-12 physical health

−.089*

.038

−.100*

−.058

SF-12 mental health

−.018

−.036

.021

−.038

Escape from illness

.068*

.077

.077

.115*

*p < 0.001 (Spearman rho; 2-tailed)

Stepwise regression analyses revealed complex predictor pattern for RGH (R2 = 0.233). As shown in Table 5, the Reappraisal strategy and age were the strongest predictors, while particularly health-related QoL, positive attitudes, and also chronic and acute conditions were excluded variables. If one would ignore Reappraisal (because of its SpR connotation), a much weaker prediction model (R2 = 0.114) would include at least mental health (Beta = −0.040, p = 0.009). Thus, RGH is not a matter of health-related QoL but an intrinsic attitude within the context of meaning-focused (adaptive) coping. Even if one asks for the predictors of physical or mental health, RGH is not a significant predicator of health (but Escape for mental health, Beta = −0.370, p < 0.0001).
Table 5

Predictors of intrinsic religiosity (stepwise regression analysis)

Dependent variable

Predictors a

R2a

Beta

T test

Sign. T

Reliance on God’s Help

(Constant)

0.232

 

−9.061

.000

Reappraisal: Illness as Chance

 

.398

27.288

.000

Age group

 

.180

13.040

.000

Conscious Living

 

.128

9.283

.000

Healthy elderly

 

.045

2.830

.005

Trust in Medical Help

 

.053

3.658

.000

Men

 

−.045

−3.194

.001

Search for Information / Alternative Help

 

−.038

−2.416

.016

Cancer

 

−.032

−2.043

.041

Escape from Illness

 

.027

1.997

.046

aOnly the strongest prediction model was presented (excluded variables: SF-12’s physical health; SF-12’s mental health; Positive attitudes, and also chronic and acute disease conditions)

Other external adaptive coping strategies (i.e. Trust in Medical Help and Search for Information and Alternative Help) correlated weakly and inversely with physical health (Table 3), while internal adaptive coping strategies (i.e., Conscious Living and Positive Attitudes) correlated weakly with mental health. In contrast, the Reappraisal attitude correlated negatively (yet weak) with both physical and mental health.

Discussion

Reliance on God’s Help in response to disease, as a measure of private, non-institutional intrinsic religiosity, was utilized particularly by patients with higher age, women, and patients suffering from cancer (Büssing et al. 2007b). This is, in part, congruent with findings of others (Maltby et al. 1999). Previous research has shown that religiosity is not related to disease stages (Gall et al. 2000), and thus one may assume that SpR is a resource which was vital in the patients prior to the onset of disease. Indeed, patients with chronic diseases and also healthy individuals (who were of similar age) exhibited the same RGH level, while patients with cancer had the highest scores. This Reliance seems to be a ‘pre-existing’ intrinsic attitude, a resource to cope in times of existential need. One may suggest that particularly in patients with cancer this Reliance was associated with higher expectancies of hope to manage a fatal disease. In fact, RGH correlated well with Reappraisal: Illness as Chance which is an active cognitive behavioral (meaning-focused) coping style. However, RGH correlated just marginally with physical health-related QoL, but not with mental health which in turn was weakly associated with internal adaptive coping strategies. In cancer patients, RGH was moreover associated with a passive escape-avoidance strategy (i.e., Escape from illness). The findings of this study are in contrast to several reports which indicate that religious involvement is related to better mental and physical health, improved coping with illness, and improved medical outcomes (reviewed in (Koenig et al. 2001)).

However, the associations between health-related QoL, coping strategies and SpR issues are complex. RGH seems to play a minor role for physical or mental health - at least in German patients or healthy elderly. Griffin et al. reported that heart failure patients had significantly lower physical QoL (SF-12) but more spiritual well-being than the non-heart failure patients, albeit there were no significant differences in daily spiritual experiences, mental component of health-related QoL, and depressive symptoms between the two groups (Griffin et al. 2007). As already addressed, both QoL and SpR are multidimensional concepts which may share several aspects of psycho-social well-being (Sawatzky et al. 2005; Stefanek et al. 2005a). Tsuang and coworkers investigated whether associations with health variables are primarily attributable to explicitly religious aspects of spiritual well-being or to ‘existential’ aspects that primarily reflect a sense of satisfaction or purpose in life (Tsuang et al. 2007). They found associations between spiritual well-being and health outcomes which were uniquely explained by existential well-being, with much less of a unique explanatory contribution from religious well-being or ‘spiritual involvement’ (Tsuang et al. 2007). The group concluded that studies of spiritual well-being and health should continue to distinguish between explicitly religious variables and others that more closely approximate the psychological construct of personal well-being (Tsuang et al. 2007). In fact, the results of Levine et al. shed an interesting light of the discussion because the religious dimension faith/assurance of the FACIT-Sp questionnaire did not correlate with health-related variables, but the meaning/peace dimension of spirituality (Levine et al. 2008). Our findings indicate that internal adaptive coping strategies (i.e., Conscious way of living and Positive attitudes) rather than intrinsic religiosity are related to mental health. In fact, individuals with high RGH had significantly higher internal adaptive coping strategies than patients with no or indifferent RGH scores. A much stronger predictor for mental health was an escape-avoidance strategy (i.e., Escape from illness).

Harold G. Koenig correctly pointed to the fact that several instruments used to measure spirituality are heavily contaminated with questions assessing positive character traits or mental health, i.e., optimism, forgiveness, gratitude, meaning and purpose in life, peacefulness, harmony, and general well-being (Koenig 2008b). Therefore, spirituality, as measured by indicators of good mental health, can correlate with good mental health, and thus one may explain the positive correlations between SpR and QoL (Koenig 2008b). In the light of Koenig’s arguments, a person with a vivid intrinsic religiosity should be per definition a spiritual person, while a person with a strong extrinsic religiosity is not necessarily a spiritual person.

To rely on these arguments and to account for the fact that the QoL instruments may share too many overlapping constructs, we used a compact and circumscribed measure of intrinsic religiosity and a bi-dimensional and specific scale to measure health-related (physical/mental) QoL. Although we were unable to confirm significant associations between health and RGH, there are some week correlations between mental health and internal adaptive coping styles. But one should not over-interpret these associations, because health status was predicted by a complex pattern of variables. We cannot exclude the possibility that existentialistic spirituality could be a better measure than intrinsic religiosity to correlate with health status. One may also argue that concrete engagement in a spiritual practice could be of higher relevance than their spiritual attitude. To attenuate this objection, one has to state that half of the patients investigated herein prayed to become healthy again; but even this concrete engagement correlated only to a minor extent with physical (r = −0.109; p < 0.0001) or mental health (r = −0.056; p < 0.0001), but somewhat better with Escape from illness (r = 0.152; p < 0.0001).

Taken together, it is evident that patients confronted with illness rely on external sources of disease/health control, i.e., medical doctors, and in case of severe and chronic diseases also on ‘more powerful’ external sources than medical sources (i.e., God). Although we have confirmed that intrinsic religiosity is a relevant resource particularly for patients with cancer, one has to state that health-related QoL and intrinsic religiosity are independent dimensions. Reliance on God’s Help should be regarded as a resource to cope, which is utilized particularly when confronted with a fatal diagnosis, but also as an intrinsic source of faith and trust to deal with life concerns. In fact, in long-term adjustment to chronic disease, SpR can be a relevant resource to maintain self-esteem, to give emotional comfort, and to provide a sense of meaning, purpose and hope (Thune-Boyle et al. 2006).

Notes

Acknowledgements

We are grateful to Die Continentale Versicherung for their support, to Ralf-Achim Grünther (Orthopaedic Clinic in Bad Bocklet) for encouraging his patients to fill the questionnaires, and to Judith M. Fouladbakhsh (Wayne State University, Detroit) for her comments and advises. The authors disclose any potential conflicts of interest.

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Copyright information

© Springer Science+Business Media B.V./The International Society for Quality-of-Life Studies (ISQOLS) 2009

Authors and Affiliations

  • Arndt Büssing
    • 1
    • 2
  • Julia Fischer
    • 1
  • Thomas Ostermann
    • 1
    • 2
  • Peter F. Matthiessen
    • 1
  1. 1.Chair of Medical Theory and Complementary Medicine, Faculty of MedicineUniversity Witten/HerdeckeHerdeckeGermany
  2. 2.Interdisciplinary Center of Health Care ResearchUniversity Witten/HerdeckeHerdeckeGermany

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