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Religiosity and Function AmongCommunity-Dwelling Older AdultSurvivors of CancerLee S. Caplan a , Patricia Sawyer b , Cheryl Holt c & Richard M.Allman ba Morehouse School of Medicine , Atlanta , Georgia , USAb University of Alabama at Birmingham , Birmingham , Alabama ,USAc University of Maryland, College Park , Maryland , USAPublished online: 24 Sep 2013.
To cite this article: Lee S. Caplan , Patricia Sawyer , Cheryl Holt & Richard M. Allman (2013)Religiosity and Function Among Community-Dwelling Older Adult Survivors of Cancer, Journal ofReligion, Spirituality & Aging, 25:4, 311-325, DOI: 10.1080/15528030.2013.787575
To link to this article: http://dx.doi.org/10.1080/15528030.2013.787575
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Journal of Religion, Spirituality & Aging, 25:311–325, 2013Copyright © Taylor & Francis Group, LLCISSN: 1552-8030 print/1552-8049 onlineDOI: 10.1080/15528030.2013.787575
Religiosity and Function AmongCommunity-Dwelling Older Adult
Survivors of Cancer
LEE S. CAPLANMorehouse School of Medicine, Atlanta, Georgia, USA
PATRICIA SAWYERUniversity of Alabama at Birmingham, Birmingham, Alabama, USA
CHERYL HOLTUniversity of Maryland, College Park, Maryland, USA
RICHARD M. ALLMANUniversity of Alabama at Birmingham, Birmingham, Alabama, USA
Aspects of religiosity/spirituality are important to health andquality of life of cancer patients. The three components of religiosityof the Duke Religiosity Scale, organizational (religious affiliationand attendance); non-organizational (prayer, meditation, andprivate study); and intrinsic religiosity (identification with a higherpower and integration of spiritual belief into daily life) are used todetermine whether religiosity was associated with physical and/ormental functioning among older cancer survivors of the UAB Studyof Aging. Church attendance was independently associated withlower ADL and IADL difficulty and fewer depressive symptoms,while intrinsic religiosity was independently associated with lowerdepression scores.
KEYWORDS aging/ageing, bible study, church, religion, prayer
This research was funded in part by NIA grant numbers R01 AG15062 and3P30AG031054-06S1. The content is solely the responsibility of the authors and does notnecessarily represent the official views of the National Institute on Aging or the NationalInstitutes of Health.
Address correspondence to Lee S. Caplan, Morehouse School of Medicine, Departmentof Community Health and Preventive Medicine, 720 Westview Drive, SW, Atlanta, GA 30310,USA. E-mail: [email protected]
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The incidence rates of most non-skin cancers increase as people age (SEERCancer Statistics Review 1975–2009: www.seer.cancer.gov). Cancer is the sec-ond leading cause of death in people 65 and over. African Americans are atincreased risk of developing most cancers and usually present later in thecourse of disease than whites (American Cancer Society, 2011).
Previous research has shown that components of the spiritual context,conceptualized in terms of spirituality, religiosity, and faith are used as cop-ing mechanisms among individuals with cancer (Holt et al., 2009; Schulzet al., 2008) and are important to the health and quality of life in can-cer patients (Laubmeier, Zakowski, & Bair, 2004; Mytko & Knight, 1999).Cancer patients often draw meaning from their suffering (Kappeli, 2000) andfind prayer to be helpful, despite it sometimes being associated with reli-gious conflicts when prayers are considered unanswered (Taylor, Outlaw, &Clements, 1999). They may use religious beliefs to cope with the diagno-sis and subsequent issues (Bowie, Curbo, Laveist, Fitzgerald, & Pargament,2001; Gall, 2000; Jenkins & Pargament, 1995). Among individuals with ter-minal cancer, those reporting higher levels of faith had higher quality oflife (Swensen, 1993). Religion may be particularly important as a copingstrategy to mediate the unique burden not only of a terminal diagnosis butsurvival after a cancer diagnosis during which the threat of recurrence is everpresent.
There are multiple dimensions of spirituality and religiosity, opera-tionalized differently in research. The conceptualization of religiosity usedin this manuscript is based on the Duke Religiosity Scale, which describesan organizational component (religious affiliation and attendance), a non-organizational component (prayer, meditation, and private study), andintrinsic religiosity (identification with a higher power and integration ofspiritual belief into daily life) (Koenig & Bussing, 2010; Koenig, Parkerson, &Meador, 1997).
Religiosity is an important part of African American culture, becomingespecially meaningful as people age, and is therefore integral to AfricanAmericans’ ability to cope with illness (Schulz et al., 2008). It is notablethat religiosity and health are closely linked in African American culture,with explanations of illness and healing being associated with G-d and faith(Stroman, 2000). It would be expected that religiosity would be of particularsalience among African Americans who have a diagnosis and/or treatmentof cancer.
RELIGIOSITY AND PHYSICAL FUNCTIONING
Although a well-established positive association has been demonstratedbetween the spiritual context and cancer coping, association of the spiritualcontext on functional ability has not been as well defined, particularly among
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those with cancer. Yet functional ability is a key factor in quality of life.In a population-based, cross-sectional, stratified, random sample survey of701 community-dwelling elders with diabetes in two rural North Carolinacounties, health and functional status were not associated with private reli-gious practice (Arcury et al., 2007) but were associated with public religiouspractice, as those with limited functional status participated less in publicreligious practice. A study using the Assets and Health Dynamics Among theOldest Old Survey data found that more frequent religious service attendancewas associated with fewer functional limitations (Benjamins, 2004).
RELIGIOSITY AND DEPRESSION
Much work has been done in the area of religiosity and depression. Onestudy examined the associations of dimensions of religiousness with thepresence and severity of depression in 476 psychiatric patients with a currentepisode of unipolar major depression and 167 non-depressed comparisonsubjects, 58 and above (Hayward, Owen, Koenig, Steffens, & Payne, 2012).The presence of depression was related to less frequent worship attendance,more frequent private religious practice, and moderate subjective religiosity.Among the depressed, less severe depression was related to more frequentworship attendance, less subjective religiousness, and having had a born-again experience. The results were only partially explained by effects ofsocial support and stress buffering.
A large study of medical inpatients over age 50 at Duke UniversityMedical Center and three community hospitals was done to compare reli-giosity between patients with major depression, minor depression, and nodepression (Koenig, 2007). Religious involvement among both depressedgroups was widespread, but not frequent as in the nondepressed patients.Depressed patients were more likely to indicate no religious affiliation, lesslikely to affiliate with neofundamentalist denominations, more likely to indi-cate “spiritual but not religious,” less likely to pray or read scripture, andscored lower on intrinsic religiosity, after controlling for demographic andphysical health factors. Among the depressed, there was no relationshipbetween religion and depression type, but depression severity was associ-ated with a lower religious attendance, prayer, scripture reading, and lowerintrinsic religiosity. These relationships were only partially explained bysocial factors.
A systematic review of articles dealing with religion and mental healthfound that religious beliefs and practices were consistently associatedwith greater life satisfaction and psychological well-being, increased hopeand optimism, less anxiety and fear, and decreased depression (Sternthal,Williams, Musick, & Buck, 2010). One study examined several potentialmechanisms linking religious involvement to depressive symptoms, major
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depression, and anxiety. It found attending services once a week to be asso-ciated with fewer depression and anxiety symptoms than attending servicesless than once a month or never. The study tested five sets of hypothesizedreligion mediators and found that several, including meaning, interper-sonal and self-forgiveness, congregational criticism, social attendance beliefs,and negative coping were independently associated with one or moremental health outcomes. A study examined the relationship between depres-sion symptomatology and functional impairment among elderly whites andAfrican Americans and investigated the effect of race, religiosity, and socialsupport on this relationship (Cummings, Neff, & Husaini, 2003). AfricanAmerican elderly people were more impaired in performance of activitiesof daily living (ADL) and instrumental activities of daily living (IADL) thanwhite elderly people, and they also reported significantly higher levels ofreligiosity and social support.
OUR STUDY
Although much work has been done on religiosity and depression, littlehas been done on religiosity and functionality based on self-reported dif-ficulty in basic and instrumental activities of daily living (ADL and IADL)(Lawton & Brody, 1969) among persons who have survived cancer. Thepurpose of this secondary data analysis was to examine the associationbetween religiosity and functional health and depression of study partici-pants with a non–skin cancer diagnosis using data from the University ofAlabama at Birmingham (UAB) Study of Aging. This dataset provides uswith a unique opportunity to study the role of religiosity in older cancersurvivors in a community-based setting as opposed to clinic-based sam-ples. The longitudinal data make it possible to gain insight on persons whodeveloped cancer during the study period. In addition, the study popula-tion is from the southeastern United States, an area where religion is highlyimportant to much of the population (Newport, 2006; Rogers, Krueger, &Hammer, 2010). Finally, the dataset incorporated questions from the Dukereligiosity scale, providing measures of three components of religiosity: orga-nizational; non-organizational; and intrinsic. These measures were collectedlongitudinally, at baseline and 48 months later. We hypothesized that thecomponents of religiosity would be differentially associated with physicalfunction and depression, specifically that organizational religiosity would beassociated with better functional health because a certain level of functionis required to enable people to attend church, but that non-organizationalreligiosity and intrinsic religiosity would not be associated with functionalhealth. We also hypothesized that all three components of religiosity wouldbe associated with fewer symptoms of depression. We hypothesized that per-sons with greater religiosity would have better function and fewer symptoms
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of depression at the follow-up interview. Because cancer potentially car-ries an emotional burden in addition to a physical impact, religiosity couldbe expected to have particular salience as a coping mechanism. Such find-ings would highlight the role of religion in the maintenance of physical andmental health among cancer survivors.
METHOD
The UAB Study of Aging, a study of mobility among African American andwhite community-dwelling older adults, has been described in detail previ-ously (Allman, Sawyer, & Roseman, 2006). Briefly, baseline recruitment forthe study began in December 1999 and extended to February 2001. A randomsample of Medicare beneficiaries 65 and older living in five central Alabamacounties was selected from a list of Medicare beneficiaries provided by theCenters for Medicare and Medicaid Services (CMS), stratified by county, race,and sex. Specific rural counties were selected for their proximity to UABand their proportions of African American and white residents. In 2000, theAlabama population 65 and older was 80% white, 60% female, and 9% rural(United States Census Bureau, 2003). By design, rural, African American, andmale older adults were oversampled to achieve a balanced sample (50%African American, 50% male, and 51% rural) for the study.
Potential subjects were mailed a letter from CMS (3,100 letters weremailed), followed by a phone call asking if the potential participant wouldbe willing to complete an in-home interview. Of 2,188 persons contacted bytelephone, 1,000 participants were enrolled (43.7% were African Americansand 47.9% were whites). Persons were ineligible if they reported not liv-ing in one of the five study counties, were under 65, or were unableto communicate on the telephone to arrange for the in-home assessment.Participants were invited to have another family member or friend presentwhen the trained interviewer came to their homes to conduct the face-to-faceinterview.
A medical diagnosis was considered verified if the patient was takinga medication for the condition, if a physician questionnaire was returnedindicating that the participant had the condition, or if the condition was listedon a hospital discharge summer during three years prior to enrollment in thestudy. Inclusion for this analysis included participants who had a verifieddiagnosis of cancer other than skin cancer.
Survival was ascertained by telephone follow-up interviews every sixmonths with participants or alternative contacts provided by participants,and deaths were confirmed with the Social Security Death Index. A sec-ond in-home interview and assessment was conducted four years followingthe baseline interview. This interview was similar to the one conducted atbaseline. Only community-dwelling participants were eligible for this visit.
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The study protocol was approved by the Institutional Review Board at theUniversity of Alabama at Birmingham.
Measures
Three components of religiosity were assessed using the Duke ReligiosityScale: organizational, non-organizational, and intrinsic (Koenig & Bussing,2010; Koenig et al., 1997). Organizational religiosity is based on church atten-dance, and is assessed by the question “How often do you attend church orother religious meetings?” The response categories are Never, Once a year orless, A few times a year, A few times a month, Once a week, and More thanonce a week. Non-organizational is based on private behaviors like prayer,and is assessed by the question “How often do you spend time in privatereligious activities, such as prayer, meditation, or Bible study?” The responsecategories are Rarely or never, A few times a month, Once a week, Two ormore times a week, Daily, and More than once a day. Intrinsic religiosityis based on agreement level with three attitudinal statements, one dealingwith experiencing presence of the Divine, one with religious beliefs lyingbehind one’s approach to life, and the other with carrying religion into allother dealings in life. Subjects are asked to categorize their level of agree-ment with the following statements: “In my life, I experience the presenceof the Divine (i.e., G-d),” “My religious beliefs are what really lie behind mywhole approach to life,” and “I try hard to carry my religion over into allother dealings in life.” The response categories are (1) Definitely not true,(2) Tends not to be true, (3) Unsure, (4) Tends to be true, and (5) Definitelytrue of me. A mean score with standard deviation is calculated for each ofthe three statements. Religiosity measures were recoded so that lower scoresrepresented lower religiosity in this study. Psychometric data are availablefor the Duke Religiosity Scale (Koenig & Bussing, 2010). The overall scalehas high test-retest reliability (intra-class correlation = 0.91), high internalconsistence (Cronbach’s alpha’s = 0.78–0.91), and high convergent validitywith other measures of religiosity (r’s = 0.71–0.86).
Functionality was assessed using a sum of activities for which difficultywas reported. This included self-reported difficulty in basic and instrumen-tal activities of daily living (ADL and IADL) (Lawton & Brody, 1969). Basicactivities included dressing, bathing, transferring from bed to chair, eating,toileting, walking, and getting outside (range 0–7). Instrumental activitiesincluded using the telephone, managing money, preparing meals, doing lighthousework, shopping, and doing heavy housework (range 0–6).
The presence of depressive symptoms was assessed using the 15-itemversion of the Geriatric Depression Scale (Yesavage et al., 1982–1983),designed specifically to screen for depression in the elderly. Psychometricdata are available for the Geriatric Depression Scale. The median correlation
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between the GDS items and the corrected-item total scores was 0.56 (range =0.32–0.83), which suggested that all of the items on the GDS measure acommon latent variable. The mean intercorrelation among the GDS itemswas 0.36. The Cronbach alpha coefficient was 0.94, which suggested a highdegree of internal consistency for the GDS. The split-half reliability coeffi-cient was 0.94. Finally, the test-retest reliability gave a correlation of 0.85(p < .001), which suggested that GDS scores reflected stable individualdifferences.
Covariate Measures
Demographic factors were self-reported and included age, race, and maritalstatus. Locale was defined as urban or rural based on county population(Alabama Rural Health Association, 1998). Education was categorized as 1 =completed 6th grade or less, 2 = completed 7th through 11th grade, 3 =completed high school or GED, and 4 = any higher education.
Total combined family income before taxes was reported in the follow-ing nine categories: 0 = less than $5,000; 1 = $5,000–$7,999; 2 = $8,000–$11,999; 3 = $12,000–15,999; 4 = $16,000–$19,999; 5 = $20,000–29,999; 6 =$30,000–$39,000; 7 = $40,000–$49,000; and 8 = greater than $50,000. Thefollowing question also was asked about subjects’ perceived income: “Allthings considered, would you say your income is (1) not enough to makeends meet; (2) gives you just enough to get by on; (3) keeps you comfort-able, but permits no luxuries; or (4) allows you to do more or less whatyou want.” For persons who did not report income (165 subjects), responsesindicating perceived income were used to calculate income categories basedon the correspondence of income categories and perceived income amongpersons with answers to both questions. The coding to impute income levelsfor perceived income categories was: 1 = $5000–$7999; 2 = $8000–$11,999;3 = $16,000–$19,999; 4 = $30,000–$39,999.
The Mini-Mental State Exam (MMSE) (Folstein, Folstein, & McHugh,1975) was used to evaluate cognitive function. The MMSE includes itemsrelated to orientation, registration and recall, attention, and visuospatialconstruction; scores range from 0–30.
Cancer and Comorbidity
During the baseline interview, participants were asked if a physician hadever told them they had diseases that are part of the Charlson comorbidityindex22 including congestive heart failure; previous heart attack, valvularheart disease, peripheral artery disease, hypertension, diabetes mellitus, res-piratory problems (asthma/COPD), kidney failure, liver disease, cancer other
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than skin, neurological disease, and gastrointestinal disease. A simple countof these diseases without consideration of severity was created, excludingcancer.
Time since cancer was diagnosed was determined from self-reports cat-egorized as less than 1 year, more than 1 but less than 5 years, and 5 yearsor more. If more than one type of cancer was diagnosed, the most recentdiagnosis was used.
Change in religiosity and change in the outcome measures werecalculated by subtracting 48-month scores from baseline.
Analysis
Descriptive statistics were calculated for each of the three religiosity mea-sures and the functionality measures, including frequencies, correlations,and cross-tabs. Multiple linear regression was used to evaluate the indepen-dent association of the three measures of religiosity with function, measuredby ADL and IADL difficulty and depressive symptomatology measured bythe Geriatric Depression Scale. Logistic regression was used to examine theimpact of declines in religiosity on the functional measures, and Cox regres-sion analyses were used to examine the impact of baseline religiosity onsurvival. All models controlled for age, gender, race, urban/rural residence,income, education, marital status, cognition, and comorbidity.
RESULTS
Non–skin cancer diagnoses were reported by 177 participants. As seen inTable 1, the mean age of the study population was 76.3 (SD = 6.7); 48%were African American, 57.6% were male, and 47.5% lived in rural counties.With respect to religiosity, 65% reported church attendance of at least onceper week. Private religiosity (time spent in prayer, meditation, or Bible study)was reported to be more than once a week by nearly 81% of the studypopulation. For intrinsic religiosity, 80.2% reported “definitely true” for allthree statements.
Regarding physical functionality, the mean ADL difficulty score at base-line was 1.30 (SD = 1.8) out of 6 and the mean IADL difficulty score forthe study population was 1.24 (SD = 1.5) out of 7. The mean number ofdepressive symptoms was 2.44 (SD = 2.5) out of 15.
Four-year follow-up was available on 97.2% at four years: 58 (32.8%) haddied, and five (2.8%) were in a nursing home. At four years an additional45 participants had a new diagnosis of non–skin cancer. Thus, 139 partici-pants (94 survivors from baseline and 45 with cancer diagnosed during thestudy) had baseline and follow-up data and were included in the longitudinalanalysis.
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TABLE 1 Sample Description (Baseline Values)
Baseline DiagnosesN = 177
New Diagnosesat 4 YearsN = 45
Factor Mean (SD) or N (%)Age 76.3 (6.7) 72.6 (5.6)African American 85 (48%) 24 (53.3%)Female 75 (42.4%) 19 (42.2%)Married 94 (53.1%) 26 (57.8%)Income
Less than $8,000/year 39 (22.0%) 8 (17.8%)More than $50,000/year 15 (8.5%) 6 (13.3%)
Rural 84 (47.5%) 22 (48.9%)Education
Less than 6th 36 (20.3%) 15 (15.6%)More than 12th 38 (21.5%) 17 (37.8%)
MMSE 24.9 (5.0) 25.6 (3.4)Comorbid conditions other than cancer 2.3 (1.6) 1.7 (1.3)Time since most recent diagnosisa
Less than 1 year 21 (11.9%) −1–4 years 49 (27.7%) −5 or more years 83 (46.9%) −
Church attendance once a week or more 115 (65.0%) 32 (71.1%)Private study more than once a week 143 (80.8%) 34 (75.6%)IntrinsicBelief in divine definitely true 155 (87.6%) 38.4 (84.4%)Beliefs behind approach to life definitely
true144 (81.4%) 34 (75.6%)
Religion in all dealings in life definitely true 142 (80.2%) 34 (75.6%)
aMissing 24 at baseline.
Bivariate correlations indicated that at baseline, organizational religiositywas associated with less difficulty in activities of daily living (p < .001),less difficulty in instrumental activities of daily living (p = .003), and lowernumbers of depressive symptoms (p < .001). A higher score on intrinsicreligiosity was significantly associated with fewer depressive symptoms (p =.038).
In multivariable models, controlling for sociodemographic factors, cog-nition, and comorbidity, church attendance was independently associatedwith lower ADL and IADL task difficulty and fewer depressive symptoms.Intrinsic religiosity was independently associated with lower depressionscores (see Table 2). Table 3 shows that controlling for baseline religiosity,none of the concurrent religiosity measures were independently associatedwith function or depression at four years of follow-up.
To examine the impact of religiosity on decreased physical functionand increased depression, logistic regression models were used. Modelscontrolled for the baseline religiosity measures as well as declines in the reli-giosity measures (see Table 4). Church attendance had declined for 25.9% ofthe sample, in contrast to declines in private religiosity of 8.6% and declines
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TABLE 2 Multivariable Linear Regression Models Predicting Baseline Associations ofReligiosity Measures With Measures of Physical Functioning and Depression
ADL Difficulty IADL Difficulty Depression
Factor Beta Significance Beta Significance Beta Significance
Age .017 .825 .085 .274 −.056 .482African American .011 .905 .033 .733 −.501 .307Female .118 .141 .182 .029 .093 .268Married −.102 .213 −.061 .471 .059 .498Rural .055 .466 −.017 .827 .042 .608Education .139 .164 .083 .423 .251 .018Income −.183 .087 −.117 .293 −.387 .001MMSE −.125 .205 −.249 .016 −.132 .205Comorbidity (Non-cancer) .213 .002 .112 .121 .074 .315Organizational Religiosity −.315 <.001 −.170 .032 −.226 .006Non-organizational
Religiosity.146 .059 .034 .667 .155 .058
Intrinsic Religiosity −.027 .730 −.008 .921 −.185 .029
TABLE 3 Multivariable Linear Regression Models Predicting Physical Function andDepression at 48 Months
ADL Difficulty IADL Difficulty Depression
Factor Beta Significance Beta Significance Beta Significance
Age .293 <.001 .186 .033 .002 .985African American −.093 .341 −.104 .314 −.219 .048Female .141 .116 .117 .218 −.041 .684Married .153 .118 .116 .252 −.024 .831Rural .119 .138 .175 .040 −.014 .873Education −.037 .737 .087 .458 .163 .202Income −.152 .202 −.137 .276 −.387 .011MMSE .042 .701 −.098 .402 −.168 .179Comorbidity (Non-cancer) −.059 .418 .049 .520 .030 .731Organizational Religiosity −.104 .205 −.123 .154 .095 .296Non-organizational
Religiosity.018 .816 .119 .143 .016 .858
Intrinsic Religiosity −.066 .413 −.136 .112 −.132 .149Baseline ADL difficulty .466 <.001Baseline IADL difficulty .410 <.001Baseline depressive
symptoms.535 <.001
in intrinsic religiosity of 13.7%. Organizational and non-organizational reli-giosity at baseline were both associated with decreased ADL difficulty at fouryears, while intrinsic religiosity at baseline was not. Baseline organizationalreligiosity was also associated a decrease in depressive symptoms. Whenlength of time since diagnosis was included in the models, organizationaland non-organizational religiosity remained significant in predicting lowerADL difficulty. Only organizational religiosity was significantly associated
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TABLE 4 Logistic Regression Showing the Association of Decreased Religiosity on PhysicalFunction and Depression at Four Years
Increased ADL Increased IADLMore Depressive
Symptoms
FactorOddsRatio Significance
OddsRatio Significance Odds Significance
OrganizationalReligiosityBaseline .614 .015 1.193 .788 .762 .042Decreased 1.299 .735 1.112 .612 1.83 .196
Non-organizationalReligiosityBaseline .438 .025 1.8∗108 .996 .916 .706Decreased .331 .256 .000 .999 1.208 .797
Intrinsic ReligiosityBaseline .837 .236 1.205 .421 .811 .066Decreased .516 .477 .292 .284 .963 .949
Note. Models controlled for age, race, gender, marital status, rural residence, education, income, MMSE,comorbidity, and baseline functional difficulty (ADL, IADL, and GDS respectively).
with decreased IADL difficulty and no measure of religiosity was associatedwith depression.
Cox regression models were run to examine baseline measures of reli-giosity in predicting mortality. In models controlling for sociodemographicfactors, non-cancer comorbidity, physical measures of function, and depres-sion, only intrinsic religiosity was associated with longer survival (p =.051 when time since diagnosis was not included in the model and p =.045 when time since diagnosis was included).
DISCUSSION
The UAB Study of Aging provided the opportunity to study the associationof religiosity among a sample of highly religious community-dwelling olderadults. A contribution of this secondary data analysis is that three aspectsof religiosity were examined separately. Consistent with the hypotheses, theresults did differ between the three dimensions of religious involvement.Nearly two-thirds of the sample reported regular religious service attendance,and at baseline organizational religiosity was significantly associated withbetter mental and physical functioning, reflecting that the people who wentto religious services had better health. This is consistent with previous studiesthat have shown associations between religiosity and physical functioning(Arcury et al., 2007; Benjamins, 2004), perhaps reflecting on the ability ofpersons to travel to church. At 48 months, concurrent service attendancewas not significantly associated with better functional and/or mental health,
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indicating that the protective effect from baseline was robust. A decrease inreligious service attendance was not associated with functional decline overfour years. Baseline organizational religiosity predicted baseline depression,which affected four-year depression, but baseline religiosity did not affectfour-year depression directly. Again, this confirms previous findings of theassociation of religiosity and mental functioning (Sternthal et al., 2010), buthighlights the sustained salience of religiosity over time.
Our second hypothesis, that all measures of religiosity would be asso-ciated with improved or maintained health outcomes, was not supported.The lack of a baseline association of non-organizational religiosity with anymeasure of function and the association of increased ADL difficulty at follow-up is perhaps an indication that personal patterns of prayer and meditationremain stable over time, even in the context of a diagnosis of cancer.
In this sample of persons who had or who developed cancer, baselineorganizational and non-organization religiosity appeared to be stable andthe association was maintained even when persons were diagnosed withcancer, suggesting that both church attendance (more social) and prayer(more cognitive) aspects of religion are important correlates of functionalhealth. This is particularly salient in the highly loaded emotional impact of acancer diagnosis. The measure of intrinsic religiosity, feelings that religiousbeliefs lie behind one’s approach to life not only was associated with fewerdepressive symptoms at baseline but predicted survival. This makes someintuitive sense since it implies that having religious feelings offering hopewould make you want to stay alive.
A potential limitation of this analysis is that the sample includescommunity-dwelling, relatively healthy older adults, based on the thoughtthat those who were not feeling well would not have participated. This sam-ple thus follows persons who may have “come to terms” with their cancerdiagnosis. However, we were able to assess a subset of individuals beforethey had a diagnosis. Both a strength and limitation were the high levelsof organizational and non-organizational religiosity of participants. Althoughthis allowed the exploration of the impact of religiosity on outcomes, the lackof variation may explain why there were no associations between decreasedreligiosity and physical and mental functioning at four years. The people whowere already religious had little room to increase but merely to decrease lev-els of religious activity. However, although it has been suggested that religionbecomes more important with the development of age associated losses anddifficulty, access to religious support may decline (Ebersole & Hess, 1998).One might expect that non-organizational religiosity might become moreimportant and organizational religiosity declines but that was not found inthese analyses. Although there was some decrease in the measures of reli-giosity, the decreases did not significantly track with decreased function asmeasured here. Another limitation was the relatively small sample size, whichmay have been responsible for the lack of statistical significance in some of
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the analyses. Another limitation of the small sample size was the inability toexamine differences by cancer type, except that it was not skin cancer.
In conclusion, this study found that organizational religiosity was asso-ciated with lower levels of ADL and IADL and lower numbers of depressivesymptoms. These results were in agreement with the results from a numberof other studies (Arcury et al, 2007; Benjamins, 2004; Hayward et al., 2012;Koenig, 2007; Koenig & Bussing, 2010; and Sternthal et al., 2010). However,what was particularly important was that this study examined these relation-ships over time, while most of the others have been done in a cross-sectionalmanner. This analysis confirms the importance of organizational religios-ity on health in a sample of African Americans and Caucasian older adultcancer survivors living in the southeastern United States. The result that non-organizational and intrinsic religiosity were not associated with outcomeshighlights the importance of discovering the aspects of religion that promotebetter health. Church attendance was the most often cited activity of the UABStudy of Aging participants (Sawyer & Allman, 2010) which may be a conse-quence of the geographic location of the study. Future work might focus ondisentangling the benefits of church attendance in contrast to other forms ofsocial participation.
Despite the limitations, the study had a number of strengths. First, thestudy sample was selected from the community, as opposed to selecting can-cer survivors from clinics. This makes our results more generalizable thanthey otherwise would have been. In addition, the dataset was racially bal-anced. In all, this study adds to the evidence that increased religiosity isprotective against functional and mental impairment, but it does so in aunique population.
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