J Behav Med DOI 10.1007/s10865-014-9552-y
Positive and negative religious coping, depressive symptoms, and quality of life in people with HIV Minsun Lee • Arthur M. Nezu • Christine Maguth Nezu
Received: May 16, 2013 / Accepted: January 13, 2014 Ó Springer Science+Business Media New York 2014
Abstract The present study examined the relationships of positive and negative types of religious coping with depression and quality of life, and the mediating role of benefit finding in the link between religious coping and psychological outcomes among 198 individuals with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). The results of multiple hierarchical analyses revealed that negative religious coping was significantly associated with a high level of depressive symptoms and a low level of quality of life, controlling for demographic and clinical variables. On the other hand, positive religious coping was significantly associated with positive domains of outcome measures such as positive affect and life satisfaction, but not with overall depressive symptoms or quality of life. Tests of
M. Lee (&) A. M. Nezu C. M. Nezu Department of Psychology, Drexel University, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA 19104, USA e-mail: [email protected] A. M. Nezu e-mail: [email protected] C. M. Nezu e-mail: [email protected] A. M. Nezu C. M. Nezu Department of Medicine, Drexel University, Philadelphia, PA 19102, USA A. M. Nezu Department of Community Health and Prevention, Drexel University, Philadelphia, PA, USA e-mail: [email protected] A. M. Nezu C. M. Nezu Philadelphia Veterans Administration Medical Center, Philadelphia, PA, USA
mediation analyses showed that benefit finding fully mediated the relationship between positive religious coping and the positive sub-domains of psychological outcomes. The importance of investigating both positive and negative types of religious coping in their relationships with psychological adaptation in people with HIV was discussed, as well as the significance of benefit finding in understanding the link between religious coping and psychological outcomes. Keywords Religious coping Benefit finding HIV Depression Quality of life
Introduction In spite of the great progress in reducing mortality from human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), the growing cohort of people living with HIV experience substantial stresses and challenges. Unlike other critical diseases such as cancer, many individuals living with HIV may experience discrimination due to stigma attached to the disease. The stigma may prevent people with HIV from disclosing their disease and drawing support from family or friends, which may result in social isolation and emotional distress (Paxton, 2002). Moreover, the problems people experience with disease management including numerous strict dosing schedules, consequent lifestyle modifications, and serious side effects of treatment, in addition to uncertainty and fear regarding their future, may make people with HIV vulnerable to mental problems (McIntosh & Rosselli, 2012). It is not surprising that studies have reported that the stressors and challenges associated with living with HIV profoundly affect the individual’s quality of life and lead to mental
123
J Behav Med
health problems, particularly, depression (Pence et al., 2012; Sherr et al., 2011). Therefore, identifying effective ways to cope with challenges associated with living with HIV become a topic of increasing interest. Researchers have found that religious coping is a crucial form of dealing with problems associated with the diagnosis and disease management in people with HIV. The majority of people with HIV were found to report that spirituality was ‘‘somewhat’’ or ‘‘very’’ important in their lives and that they ‘‘sometimes’’ or ‘‘often’’ rely on religious or spiritual means when making decisions or confronting problems (Lorenz et al., 2005). Religious coping is conceptualized as the utilization of religious beliefs or behaviors to deal with problems when adverse circumstances exceed the limits of resources (Koenig et al., 1998). It is distinct from dispositional dimensions of religiosity including religious belief or experience, religious commitment, and religious well-being. Literature that has explored the relationship between religious coping and psychological health has suggested that general religious coping methods, including praying, attending religious services, or taking problems to God may represent pain and struggle as well as gratitude and support (Tarakeshwar et al., 2006). The perspective that religion and spirituality can be both a source of gratitude and a source of struggle is consistent with the conceptualization of two types of religious coping methods, positive and negative religious coping. According to Pargament et al. (1998), positive religious coping is a reflection of a secure relationship with God, a belief in life’s larger meaning, and a sense of spiritual connectedness with others, whereas negative coping is an expression of a unstable relationship with God, a sense of disconnectedness with religious community, and a religious struggle in the search for meaning in life. The forms of positive religious coping strategies include benevolent religious reappraisals (e.g., ‘‘God might be trying to strengthen me in this situation’’), collaborative religious coping (e.g., ‘‘Worked together with God as partner’’), and seeking spiritual support (e.g., ‘‘Looked for God’s strength, support, and guidance’’). The set of negative religious coping methods includes punitive religious reappraisals (e.g., ‘‘God was punishing me for my sins’’), spiritual discontent (e.g., ‘‘God had abandoned me’’), and selfdirecting religious coping (e.g., ‘‘Tried to make sense of the situation without relying on God’’). The literature concerning positive and negative types of religious coping underscores that the various types of coping are not mutually exclusive and the same person may use both positive and negative religious coping methods. Although studies have indicated that general spirituality and religious behaviors are associated with psychological well-being in individuals with HIV (Amuzie & Jones,
123
2012; Tarakeshwar et al., 2006), relatively little attention has been paid to the relationship between religious coping strategies and emotional adaptation. There are even fewer studies that investigated how positive and negative religious coping strategies are related to depression and quality of life of individuals with HIV. Given that individuals with HIV may be vulnerable to experiencing spiritual struggles due to negative attitudes of religious communities toward the main risk factors for HIV infection including homosexuality and drug use (Bluthenthal et al., 2012), distinguishing positive from negative religious coping and examining their differential relationship with psychological adaptation may be particularly important for this group. Currently available research on differential relationships between positive and negative religious coping and psychological adaption in people with HIV reported that negative religious coping methods were associated with increased depressive symptoms (Hickman et al., 2013; Yi et al., 2006) and reduced quality of life (Cotton et al., 2006; Trevino et al., 2010) and that positive religious coping styles were related to greater optimism, self-esteem, life satisfaction, and spiritual well-being. Counter intuitively, however, these studies consistently reported that positive religious coping was not negatively correlated with depressive symptoms. They also did not report positive relationships between overall quality of life and positive religious coping. Lack of significant association between positive religious coping styles and depressive symptoms has also been reported in other medical populations (Ai et al., 2007; Pargament et al., 2004; Sherman et al., 2005). These studies, instead, found that positive religious coping was associated with positive psychological domains including hope (Ai et al., 2007) and stress-related growth (Pargament et al., 2004). One potential explanation of the results from the studies of individuals with HIV and other serious medical problems is that positive religious coping may be more strongly linked with positive aspects of psychological outcomes rather than negative aspects or overall psychological adjustment, whereas, negative religious coping may be associated with general decline of broad range of psychological and physical functioning, both positive and negative (Pargament et al., 1998: Sherman et al., 2005; Ai et al., 2007). If the above explanation of the differential relationship of positive and negative religious coping with psychological outcomes is correct, it is meaningful to examine the relationship between positive religious coping and sub-scales of depressive symptoms that measure positively-valenced affect and quality of life (e.g., life satisfaction), in addition to overall depressive symptom outcome scores. In fact, measures of depressive symptoms such as the Center for Epidemiologic Studies-Depression Scale (CES-D) used in many of the studies cited above include items that reflect positively valenced affect as well as those that measure negative affect
J Behav Med
and other somatic and cognitive symptoms. Thus, if only a subset of the depressive symptoms is significantly related to positive religious coping, then using an aggregate overall depressive symptom score is not likely to reveal the detailed pattern of the relationship. This perspective is supported by the literature indicating that positive and negative affect are not opposites on a single continuum but independent constructs and thus, they should be measured and analyzed separately (Russell & Barrett, 1999). For example, in a study conducted by Moskowitz (2003), the positive affect subscale of CES-D, not the overall score, was found to be a significant indicator of lower risk of AIDS mortality. Beyond the differential relationships of positive and negative religious coping with psychological adaptation, there is another important question as to whether religious coping contributes to adjustment directly or through other psychosocial pathways. Researchers have suggested a theoretical conceptualization of religious coping as meaningbased to explain the link between religious coping and psychological outcomes (Farber et al., 2010; Park, 2007). According to this framework, in the face of life challenges, individuals make efforts to understand the personal impact and significance of specific life circumstances through their personal meaning systems. Religion or spirituality may be the main resources of the meaning systems that lead people in adversity to establish purpose of life and a sense of coherence. Through this search for meaning, individuals may perceive a positive view on their stressful life experience and find benefits in their adverse situations, which is referred as benefit finding (Siegel & Schrimshaw, 2000). Benefit finding can be viewed as a result of individuals’ efforts to integrate stressful situations into their meaning systems in a positive way. Specifically, it can be defined as individuals’ perception of positive aspects and what they have learned while they are experiencing stressful events (Tennen & Affleck, 2002). There has been evidence that many individuals with HIV may find benefits in their illness experience (Siegel & Schrimshaw, 2000; Carrico et al., 2006). In addition, benefit finding was significantly associated with positive affect and decreased psychological distress after controlling for social support, locus of control, and demographic confounds in people with HIV (Siegel & Schrimshaw, 2002). A study that investigated benefit finding as a mediator in the link between spirituality and depressive symptoms among people with HIV/AIDS (Carrico et al., 2006) reported that benefit finding co-mediated the effect of spirituality on depressive symptoms and was a candidate mediator for the effects of spirituality on 24-h cortisol output. However, there is no study that investigated the mediating role of benefit finding in the connection between positive and negative religious coping and depressive symptoms or quality of life.
The aim of present study was to examine the differential relationships of positive and negative dimensions of religious coping with depressive symptoms and quality of life. Specifically, it was investigated whether positive religious coping would be associated with positive domains of outcome measures, and negative religious coping would be associated with broad domains of outcome measure both positive and negative. Another aim of this study was to investigate the mediating role of benefit finding in the link between religious coping and psychological outcomes in people with HIV. It was hypothesized that positive religious coping would be positively associated with positive domains of depressive symptoms and quality of life measures such as positive affect and life satisfaction. On the other hand, we hypothesized that negative religious coping would be positively associated with overall depressive symptoms and negatively associated with overall quality of life scores as well as positive affect and life satisfaction subscales. It was also hypothesized that the relationships between positive and negative religious coping and outcome variables would be mediated by benefit finding.
Methods Participants Participants were recruited from the Partnership Care Practice that serves individuals with HIV located in urban Philadelphia metropolitan area. Individuals were eligible to participate in the study if they presented with the diagnosis of HIV+; were at least 18 years of age; were able to read English at the 5th grade level; were capable of providing informed consent. Under the permission of a physician, participants were approached at the recruiting site by the investigator while they were waiting for their appointments. Each participant was given the research study recruitment letter and asked to return it to the investigator or clinic staff after signing it if they wanted to participate in the study. When they stated their interest, the investigator proceeded with obtaining informed consent and gave them a packet of questionnaires. As part of the consent to participate in the study, permission was requested to obtain diagnosis, CD4+ count and viral load, and medication information from the medical chart. Approximately 270 individuals were given the research study recruitment letter and 203 of them expressed their interest in the study and completed the consent form. Of those who consented, five participants withdrew from the study due to time constraint. Thus, 198 participants were included in the final analysis.
123
J Behav Med
Measures Demographic and clinical variables Demographic and clinical data were collected both from chart reviews and patients’ report. Demographic data included age, sex, ethnicity, sexual orientation, marital status, education level, employment status, religious affiliation, and mental treatment status. Clinical data included year diagnosed with HIV/AIDS, CD4+ cell count, viral load, methods of transmission of HIV, and other medical problems. Religious coping Religious coping styles were measured with the 63-item Religious Coping Scale (RCOPE) (Pargament et al., 1998). The RCOPE consists of 21 subscales, with 3 items for each subscale. The subscales represent two higher-order factors of positive and negative religious coping. The RCOPE assesses how much individuals utilize various religious coping strategies with their current problems. Individuals are asked how often they use each aspect of coping to deal with problems in their lives with HIV on a four-point Likert-type scale, ranging from 1 = not at all to 4 = a great deal. Internal consistency coefficients for the current sample were .93 for the positive religious coping subscale and .72 for the negative religious coping subscale.
a = .87), Health worries (4 items, a = .81), Financial worries (3 items, a = .86), Medication worries (5 items, a = .81), HIV mastery (2 items, a = .83), Disclosure worries (5 items, a = .83), Provider trust (3 items, a = .81), and Sexual functioning (2 items, a = .85). Each subscale is scored so that final dimension score is transformed to a 0–100 scale using formulas (e.g., Final overall function score = [100/(30 - 6)] 9 [value score-6)]. Zero indicates the worst functioning and 100 indicates the best functioning. Benefit finding A 17-item measure of benefit finding, which was originally used with breast cancer patients (Antoni et al., 2001) and adapted for use with HIV-positive populations (Carrico et al., 2006), was selected to measure benefit finding. The benefit-finding scale assesses the degree to which individuals feel that having HIV has made positive contributions to their lives. Participants rate their responses on Likerttype scales ranging from 1 = not at all to 5 = extremely. These items assess potential benefits across a variety of domains, including a newfound sense of purpose, enhanced feelings of closeness with others, and acceptance of life’s imperfections. In the current sample, Cronbach’s a was .88.
Results
Depressive symptoms
Demographic characteristics
Depressive symptoms were measured with the 20-item CES-D (Radloff, 1977). The CES-D is a self-report symptom rating scale to assess frequency of depressive symptom and consists of four subscales: Negative affect, Somatic symptoms, Positive affect, and Interpersonal issues. The scale uses a 4-point Likert-type scale, ranging from 0 = rarely or none of the time to 3 = all of the time, with higher scores representing greater depressive symptoms. In the present study, Cronbach’s a was .84.
The mean age of participants was 44.89 years (range 20–73) and 60.5 % of participants were male. The majority of the sample was Black (74 %) and the rest was comprised of White (15.1 %), Hispanic (9.4 %), or Other (1.5 %). Approximately three-fourths reported a high school education or less and incomes \$20,000. Eighty-two percent of participants were unemployed (26.3 %) or on disability (55.9 %). On average, participants had been living with HIV/ AIDS for 13.31 years and had CD4 cell count of 487.75. About 10 % of participants reported CD4 cell count \200. The majority reported contracting HIV through unprotected sex (67 %) or injection drug use (15.9 %). Slightly more than one-third were homosexual (25.7 %) or bisexual (11.8 %). The sample tended to be religious (84.3 %) and the religious affiliation included Protestant (53.9 %), Catholic (13.6 %), Islam (7.9 %), or Other (7.3 %).
Quality of life The HIV/AIDS-targeted quality of life (HAT-QoL) instrument was used to measure quality of life of people with HIV. The 34-item HAT-QoL assesses functions in nine domains on a five-point scale ranging from 0 = all of the time to 5 = none of the time. Higher scores indicate better quality of life (Holmes & Shea, 1998). The nine domains and the internal consistency reliability for each domain in the present study are: Overall functioning (6 items, Cronbach’s a = .84), Life satisfaction (4 items,
123
Descriptive statistics for study variables Participants used positive religious coping significantly more than negative religious coping (z = -12.8, p \ .001).
J Behav Med
The mean CES-D score was 24.7 (SD = 12.4). Significant depressive symptoms (CES-D score C16) were reported by 152 (76.8 %) of the respondents. Prior to the main analyses, the relationships between demographic variables and the main outcome variables of the study were examined by conducting ANOVA analyses. The analyses indicated that different levels of education were found to be significantly associated with both depressive symptoms [F(3,183) = 7.40, p = .000]and quality of life [F(3,183) = 3.19, p = .034]. Participants who received a college or higher level of education reported significantly lower levels of depressive symptoms (M = 11.10, SD = 6.17) and better quality of life (M = 600.96, SD = 113.91) than those who received less than college level of education (depressive symptoms M = 25.11, SD = 11.81; quality of life M = 488.28, SD = 133.71). Participants who were receiving treatment for psychiatric problems had significantly higher levels of depressive symptoms [M = 27.41, SD = 13.57; F(1,179) = 9.42, p = .002], and worse quality of life [M = 468.09, SD = 136.83; F(1,179) = 5.32, p = .022] than those who were not receiving treatment (depressive symptoms M = 21.93, SD = 10.47; quality of life M = 514.68, SD = 133.97). Education and mental health treatment were controlled in regression analyses predicting depression and quality of life in addition to HIV variables such as CD4, viral load and time since diagnosis. Zero-order correlations were conducted to examine the relationships among main study variables. Pearson correlations between positive and negative forms of religious coping and subscales of depressive symptoms and quality of life measures are presented in Table 1. Table 2 provides the correlations between each subscale of positive and negative religious coping and main outcome variables. Table 1 shows that positive religious coping was not significantly correlated with overall depressive symptoms and quality of life, whereas negative religious coping was significantly correlated with overall depressive symptoms and quality of life. However, positive religious coping was positively correlated with negative affect and somatic symptoms as well as positive affect subscales of depressive symptoms measure. Positive religious coping was also positively correlated with health worries and financial worries in addition to life satisfaction and provider trust subscales of quality of life measure. Negative religious coping was significantly correlated with all the subscales of depressive symptoms and quality of life measures except for positive affect subscale. The magnitude of the correlations of the subscales with negative religious coping was much stronger than for positive. As Table 2 shows, among positive religious coping methods, religious purification (r = .28, p \ .01) and seeking religious direction (r = .15, p \ .05) subscales were significantly positively correlated with depressive
Table 1 Pearson correlations between positive and negative forms of religious coping and subscales of outcome variables Measures CESD total
PRC .08
NRC .45***
CESD-negative affect
.14*
.46***
CESD-somatic
.15*
.39***
CESD-positive affect
.14*
CESD-interpersonal
.08
.47***
QoL total
-.13
-.39***
QoL-overall function
-.10
-.28***
-.13
QoL-life satisfaction
.16*
QoL-health worries
.21**
.36***
QoL-financial worries
.20**
.21**
QoL-medication worries QoL-HIV mastery
.11 -.11
-.19**
.32*** -.27***
QoL-disclosure worries
.03
QoL-provider trust
.16*
-.19**
.21**
Benefit finding
.61***
-.01
PRC positive religious coping, NRC negative religious coping, QoL quality of life, CESD Center for Epidemiologic Studies-Depression Scale * p \ .05; ** p \ .01; *** p \ .001
symptoms. These two subscales also revealed significant negative correlations (r = -.20, p \ .01; r = -.23, p \ .01, respectively) with quality of life along with religious focus subscale (r = -.17, p \ .05). All the subscales of negative religious coping methods except for selfdirecting religious coping subscale were significantly correlated with depressive symptoms and quality of life. Benefit finding was significantly correlated with all the subscales of positive religious coping methods. However, among the subscales of negative religious coping methods, pleading for direct intercession (r = .28, p \ .001) and marking religious boundaries (r = .16, p \ .05) subscales were positively correlated with benefit finding, while selfdirecting religious coping (r = -.16, p \ .05) and spiritual discontent (r = -.18, p \ .05) subscales were negatively correlated with the measure. Relationships between positive and negative religious coping and overall outcome measures Hierarchical regression analyses were conducted to examine the hypothesis that positive religious coping would be associated with positive domains of depressive symptoms and quality of life, whereas negative religious coping would be associated with overall depressive symptoms and quality of life controlling for demographics and HIV specific variables. Education, mental treatment, CD4, viral load, and time since diagnosis were entered in Step 1 as covariates, and positive and negative religious coping in
123
J Behav Med Table 2 Pearson correlation between subscales of positive and negative religious coping and outcome variables
Quality of life
Depressive symptoms
Benefit finding
Benevolent religious reappraisal
-.04
-.02
.46***
Collaborative religious coping Active religious surrender
-.10 .05
.06 .05
.37*** .49***
Seeking spiritual support
-.02
-.01
.43***
Religious focus
-.17*
.13
.50***
Religious purification
-.20**
.28***
.39***
Spiritual connection
-.09
.05
.47***
Seeking support from clergy/church members
-.09
.11
.45***
Religious helping
-.01
.05
.49***
Seeking religious direction
-.23**
.15*
.45***
Religious conversion
-.14
.07
.53***
Religious forgiving
-.14
.03
.47***
Punishing God reappraisal
-.32***
.36***
Demonic reappraisal
-.28***
.25***
Reappraisal of God’s power
-.12
.21**
Passive religious deferral
-.25**
.26***
Pleading for direct intercession Self-directing religious coping
-.35*** -.05
.27*** .14
.28*** -.16*
Spiritual discontent
-.35***
.44***
-.18*
Marking religious boundaries
-.23**
.25***
Interpersonal religious discontent
-.23**
.17*
Positive religious coping
Negative religious coping
* p \ .05; ** p \ .01; *** p \ .001
Table 3 Hierarchical multiple regression for religious coping predicting overall depressive symptoms and quality of life
Depression B Step 1
RC religious coping * p \ .05; ** p \ .01; *** p \ .001
123
.08 -.03 .13
.16* -.03
Quality of life 2
2
R
DR
.13
.13*
b
Education
-.26*
.09
Mental treatment Viral load
-.22* .02
.19 -.01
CD 4
-.01
Time since diag.
-.14
R2
DR2
.06
.04
.14
.08*
.09 .09
Step 2
.23
Positive RC
.03
-.14
Negative RC
.32**
-.24*
Step 2 to predict overall depression and quality of life. As hypothesized, negative religious coping significantly predicted both increased depressive symptoms (b = .32, p = .001) and reduced overall quality of life (b = -.24, p = .023) after controlling for HIV relevant variables in addition to demographics. Neither depressive symptoms nor overall quality of life was significantly associated with positive religious coping (Table 3). However, as expected, greater use of positive religious coping was significantly associated with enhanced positive affect (b = .26, p = .010) and greater life satisfaction (b = .23, p = .022).
-.12
.10**
Although negative religious coping was not significantly correlated with positive affect in bivariate correlation analyses, it significantly predicted reduced positive affect (b = -.23, p = .022) and life satisfaction (b = -.29, p = .005) after controlling for demographic variables and HIV-specific characteristics (Table 4). Mediating role of benefit finding To test a potential mediating role of benefit finding in the relationship between religious coping and the outcome
J Behav Med Table 4 Hierarchical regression for religious coping predicting positive sub-domains of quality of life and depressive symptoms, life satisfaction and positive affect
Life satisfaction B
.05
b
-.01
Mental treatment Viral load
.20* -.07
.19 -.05
CD 4
-.06
-.16
.10
Step 2 * p \ .05; ** p \ .01; *** p \ .001
.05
2
.03
Time since diag. RC religious coping
DR
R
Step 1 Education
Positive affect 2
.23*
Negative RC
-.29**
variables, a series of regression analyses were conducted. Based on the suggestions made by MacKinnon et al. (2000, 2009) that mediation analyses can be conducted without the requirement of the relationship between independent and dependent variables, a mediating role of benefit finding was examined not only in the relationship between positive religious coping and positive affect and life satisfaction where there were significant associations between them, but also in the relationship between positive religious coping and overall depressive symptoms and quality of life where there were no significant associations. Mediation model for the relationship between positive religious coping and positive domains of outcome measures The results of the mediation analyses (Table 5) showed that benefit finding serves a significant mediating role concerning the associations of positive religious coping with positive affect (Sobel z = 4.72, p \ .001), and with life satisfaction (Sobel z = 4.19, p \ .001). Specifically, when benefit finding was added, the original regression coefficients of positive religious coping for positive affect (b = .21) and life satisfaction (b = .19) were reduced to negative (b = -.06, and b = -.05, respectfully), indicating a full mediation. Mediation model for the relationship between positive religious coping and overall depressive symptoms As Table 4 showed, when benefit finding was added to the model, the regression coefficient (b = .08) for positive religious coping predicting depressive symptoms increased and the relationship became significant (b = .32, p = .003), indicating a suppressive mediation (MacKinnon & Fairchild, 2009; MacKinnon et al., 2000). In other words, the greater use of religious coping was associated with the higher level of benefit finding, and the higher level of benefit finding was associated with the less depressive
DR2
.07
.07
.15
.08*
.09 .15
Positive RC
R2
.10* .26** -.23*
symptoms. Thus, the indirect effect of positive religious coping on depressive symptoms mediated by benefit finding was negative [b 1(.08) -b 2 (.32) = -.24]. However, when benefit finding was controlled for, the direct effect of positive religious coping on depressive symptoms was significantly positive. The Sobel test result (Sobel z = -3.815, p \ .001) revealed that benefit finding was a significant mediator in the connection between positive religious coping and depressive symptoms. Quality of life, the other outcome variable, was not significantly associated with benefit finding. Therefore, a mediation model for the relationship between positive religious coping and overall quality of life was not tested. Mediation model for negative religious coping and outcomes Although negative religious coping was significantly associated with depressive symptoms and quality of life, benefit finding, the potential mediating variable was not significantly associated with negative religious coping. Therefore, the mediating role of benefit finding in the relationship between negative religious coping and outcome variables was not evaluated. Further post hoc regression analyses revealed that negative religious coping was significantly associated with depressive symptoms (b = .31, R2 = .26, DR2 = .09, p = .000) and quality of life (b = -.27, R2 = .14, DR2 = .07, p = .007), even after controlling for benefit finding in addition to other control variables. In other words, negative religious coping predicted depressive symptoms and quality of life over and beyond the effects of benefit finding.
Discussion This study investigated the differential relationships of positive and negative dimensions of religious coping on depressive symptoms and quality of life in people with
123
J Behav Med Table 5 Regression analysis for mediating effects of benefit finding predicting outcomes Life satisfaction
Positive affect
Overall depression
b Entry
b Final
b Entry
b Final
Positive RC
.19*
-.05
.21*
-.06
Benefit finding
.38**
.41***
.43***
.46***
R2
.17
.22
DR2
.13
.16
Sobel z test
4.19***
4.72***
b Entry
b Final
.08
.32**
-.23*
-.43*** .23 .11 -3.82***
RC religious coping, b Entry coefficient from the model on which only one of the predictors is entered, b Final coefficient from the model in which both predictor and potential mediator are entered, Sobel z test the test of the significance of the decrease in the regression coefficient for the predictor when the mediator is included (Sobel, 1982) * p \ .05; ** p \ .01; *** p \ .001
HIV, as well as a potential mediator of these relationships. As hypothesized, negative religious coping demonstrated significant associations with both overall depressive symptoms and quality of life, as well as most sub-dimensions of the outcomes, controlling for demographic variables and HIV-related covariates. Positive religious coping, as anticipated, was significantly associated with positive outcomes such as positive affect and life satisfaction. However, it was not significantly associated with general depressive symptoms or quality of life. These results are consistent with previous studies that found positive religious coping was related to positive outcomes but not to emotional distress, while negative religious coping was a more consistent and stronger predictor of emotional distress and general psychological maladjustment among medical patients with serious illness including HIV (Cotton et al., 2006; Trevino et al., 2010; Ai, et al., 2007; Sherman et al., 2005). These findings support the view that positive religious coping may contribute to enhancing positive, meaningbased psychological outcomes, rather than preventing negative, symptom-based ones (Tix & Frazier, 1998). On the other hand, negative religious coping may facilitate crisis specific and ego-dystonic struggle and thus, promote pervasive psychological distress under extreme stress. In particular, among individuals with HIV, the consistent negative associations of negative religious coping on broad range of sub-dimensions of depressive symptoms and quality of life measures may reflect the religious burdens they may experience including rejection from religious community due to stigma attached to HIV(Bluthenthal et al., 2012). In addition, the internal shame or feelings of guilt associated with past risky behaviors or the possibility of passing the virus on to others might have facilitated negative religious coping such as punishing reappraisal, which, in turn, made the people with HIV vulnerable to psychosocial problems. Although positive and negative religious coping may be predictive of differential psycho-
123
logical outcomes, competing interpretations cannot be ruled out; it is possible that individuals who feel better psychologically and experience positive affect may use more positive religious coping and those who are distressed may reveal their religious struggle. Regarding the role of benefit finding, it was suggested that benefit finding may mediate the relationship between positive religious coping and general depressive symptoms, as well as the relationships of positive religious coping with positive affect and life satisfaction, controlling for possible important confounding variables. Consistent with the existing theoretical model of benefit finding (Hobfoll, 2002; Taylor, 1983), those who frequently used positive religious coping found more benefit from their illness, which led them to increased positive affect and greater life satisfaction. In addition, benefit finding significantly suppressed the positive association between positive religious coping and depressive symptoms. These findings provide support to the existing theoretical conceptualizations of the impact of meaning-based processes in maintaining psychological well-being. Specifically, finding benefit may be a way through which individuals restore their self-esteem, and sense of meaning and mastery after stressful events that challenge their beliefs (Taylor & Brown, 1988), which, in turn, lead them to experience enhanced positive affect and life satisfaction. As some authors suggested, restoring meaning may be a central component of psychological recovery from traumatic events (Taylor & Brown, 1988) and may be the ultimate provider of motivation to maintain one’s mental and physical health (Park & Folkman, 1997). Benefit finding, however, was not significantly associated with negative religious coping. Post-hoc regression analyses showed that negative religious coping predicted depressive symptoms and quality of life above and beyond benefit finding. These results indicate that negative religious coping may uniquely or directly predict individuals’ adjustment to stress (Pargament et al., 1998). An alternative explanation is that there may be other factors that
J Behav Med
mediate the effects of negative religious coping. In fact, Pearce et al. (2006) found that self-efficacy, optimism, and social support partially mediated the relationship between negative religious coping and quality of life and life satisfaction. Similarly, although benefit finding fully mediated the link between positive religious coping and positive affect, it does not rule out alternative explanations including the relevance of third variables. Considering that dispositional optimism has been found to be associated with positive religious coping (Cotton et al., 2006) and benefit finding (Helgeson et al., 2006) as well as positive affect (Schnall et al., 2012), it is possible that positive religious coping may be associated with positive affect through optimism or other variables that were not measured in the present study. The results of this study bear several clinical implications. Because religion is an important resource for people living with HIV, assessing their religious coping strategies as an important aspect of functioning will be beneficial in understanding their problems and providing appropriate care. In particular, given that negative religious coping may have strong and consistent negative effects on well-being, it may be important to evaluate spiritual disappointments and struggle early on and refer those who experience spiritual struggle for spiritually integrated psychotherapy to prevent further detrimental outcomes. In their preliminary assessment of a psycho-spiritual intervention which offered participants an opportunity to identify personally relevant positive religious coping strategies and express their spiritual struggle, Tarakeshwar et al. (2005) reported that participants experienced decreased religious struggle and depression over the course of the intervention. Such intervention may be an important step to re-build a relationship with God and to find meaning and direction in life. In addition, given that benefit finding mediates the relationship between positive religious coping and positive outcome, and suppresses the positive association between positive religious coping and depressive symptoms, it may be helpful to encourage spiritual practices and beliefs that are likely to promote benefit finding in coping with HIV. The study has several limitations. First, this study is cross-sectional, which precludes any conclusions of causal direction, and does not provide information about the process of religious coping over time or its long-term effects. Second, the sample was recruited from one site in a large city on the East Coast of the United States, and the majority of participants were black with primarily Christian affiliation. In addition, a majority of the participants in this study belonged to a low socio-economic status, which might have limited improvements in outcome measures induced by positive coping strategies. Therefore, generalizing the results of this study to individuals of other ethnicities and religious denominations should be done with
caution. Future studies with a larger and more diverse sample of people with HIV are warranted. Another methodological limitation of the present study is that the data presented are self-reported, which may be influenced by several factors such as social desirability, mood, and a desire to manage impressions (Tourangeau et al., 2000). This study provides some directions for future research. First, although distinguishing two broad types of religious coping, positive and negative, is certainly informative, examining the effects of more specified religious coping strategies may allow us to pinpoint which coping strategies are more beneficial or harmful for certain aspect of mental health outcomes and narrow down the target of intervention. Second, change or stability of religious coping across time and the long-term consequences of each coping method is another important research topic. Especially, investigating long-term consequences of the positive religious coping methods that were related to increased depressive symptoms and decreased quality of life will be critical due to the ultimate health implications of these coping methods. Third, more research is needed to identify variables that may moderate the impact of religious coping. An individual’s religious affiliation, level of religiousness, or ethnicity may play a moderating role in the relationship between religious coping and psychological health. Identifying a potential moderator may be helpful in determining the subgroups for whom religious coping is more effective and in providing a potential explanation regarding the inconsistent and insignificant relationship between positive religious coping and general psychological adjustment. Conflict of interest Authors Minsun Lee, Arthur M. Nezu and Christine Maguth Nezu declare that they have no conflict of interest. Informed consent All procedures followed were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.
References Ai, A. L., Park, C. L., Huang, B., Rodgers, W., & Tice, T. N. (2007). Psychosocial mediation of religious coping styles: A study of short-term psychological distress following cardiac surgery. Personality and Social Psychology Bulletin, 33, 867–882. Amuzie, R., & Jones, M. (2012). A systematic review: the role of spirituality in reducing depression in people living with HIV/ AIDS. British Journal of General Practice, 62, 68. Antoni, M. H., Lehman, J. M., Klibourn, K. M., Boyers, A. E., Culver, J. L., Alferi, S. M., et al. (2001). Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychology, 20, 20–32. Bluthenthal, R. N., Palar, K., Mendel, P., Kanouse, D. E., Corbin, D. E., & Derose, K. P. (2012). Attitudes and beliefs related to HIV/AIDS in
123
J Behav Med urban religious congregations: barriers and opportunities for HIVrelated interventions. Social Science and Medicine, 74, 1520–1527. Carrico, A. W., Ironson, G., Antoni, M. H., Lechner, S. C., Duran, R. E., Kumar, M., et al. (2006). A path model of the effects of spirituality on depressive symptoms and 24-h urinary-free cortisol in HIV-positive persons. Journal of Psychosomatic Research, 61, 51–58. Cotton, S., Puchalski, C. M., Sherman, S. N., Mrus, J. M., Peterman, A. H., Feinberg, J., et al. (2006). Spirituality and religion in patients with HIV/AIDS. Journal of General Internal Medicine, 21, S5–S13. Farber, E. W., Bhaju, J., Campos, P. E., Hodari, K. E., Motley, V. J., Dennany, B. E., et al. (2010). Psychological well-being in persons receiving HIV-related mental health services: The role of personal meaning in a stress and coping model. General Hospital Psychiatry, 32, 73–79. Helgeson, V. S., Reynolds, K. A., & Tomich, P. L. (2006). A metaanalytic review of benefit finding and growth. Journal of Consulting and Clinical Psychology, 74, 797–816. Hickman, E. E., Glass, C. R., Arnkoff, D. B., & Fallot, R. D. (2013). Religious coping, stigma, and psychological functioning among HIV-positive African American women. Mental Health, Religion & Culture, 16, 832–851. Hobfoll, S. E. (2002). Social and psychological resources and adaptation. Review of General Psychology, 6, 307–324. Holmes, W. C., & Shea, J. A. (1998). A new HIV/AIDS-targeted quality of life (HAT-QoL) instrument: Development, reliability, and validity. Medical Care, 36, 138–154. Koenig, H. G., Pargament, K. I., & Nielsen, J. (1998). Religious coping and health status in medically ill hospitalized older adults. Journal of Nervous and Mental Disease, 186, 513–521. Lorenz, K. A., Hays, R. D., Shapiro, M. F., Cleary, P. D., Asch, S. M., & Wenger, N. S. (2005). Religiousness and spirituality among HIV-infected Americans. Journal of Palliative Medicine, 8, 774–781. MacKinnon, D. P., & Fairchild, A. J. (2009). Current directions in mediation analysis. Current Directions in Psychological Science, 18, 16. MacKinnon, D. P., Krull, J. L., & Lockwood, C. M. (2000). Equivalence of the mediation, confounding and suppression effect. Prevention Science, 1, 173–181. McIntosh, R. C., & Rosselli, M. (2012). Stress and coping in women living with HIV: A meta-analytic review. AIDS and Behavior, 16, 2144–2159. Moskowitz, J. T. (2003). Positive affect predicts lower risk of AIDS mortality. Psychosomatic Medicine, 65, 620–626. Pargament, K. I., Koenig, H. G., Tarakeshwar, N., & Hahn, J. (2004). Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: A two-year longitudinal study. Journal of Health Psychology, 9, 713–730. Pargament, K. I., Smith, B., Koenig, H., & Perez, L. (1998). Patterns of positive and negative religious coping with major life stressors. Journal for the Scientific Study of Religion, 37, 710–724. Park, C. L. (2007). Religiousness/spirituality and health: a meaning systems perspective. Journal of Behavioral Medicine, 30, 319–328. Park, C. L., & Folkman, S. (1997). Meaning in the context of stress and coping. General Review of Psychology, 1, 115–144. Paxton, S. (2002). The paradox of public HIV disclosure. AIDS Care, 14, 559–567. Pearce, M. J., Singer, J. L., & Prigerson, H. G. (2006). Religious coping among caregivers of terminally ill cancer patients: Main effects and psychosocial mediators. Journal of Health Psychology, 11, 743–759.
123
Pence, B. W., Shirey, K., Whetten, K., Agala, B., Itemba, D., Adams, J., et al. (2012). Prevalence of psychological trauma and association with current health and functioning in a sample of HIV-infected and HIV-uninfected Tanzanian adults. PLoS One, 7, e36304. Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. Russell, J. A., & Barrett, L. F. (1999). Core affect, prototypical emotional episodes, and other things called emotion: dissecting the elephant. Journal of Personality and Social Psychology, 76, 805–819. Schnall, E., Kalkstein, S., Fitchett, G., Salmoirago-Blotcher, E., Ockene, J., Tindle, H. A., et al. (2012). Psychological and social characteristics associated with religiosity in women’s health initiative participants. Journal of Religion and Health, 51, 20–31. Sherman, A. C., Simonton, S., Latif, U., Spohn, R., & Tricot, G. (2005). Religious struggle and religious comfort in response to illness: Health outcomes among stem cell transplant patients. Journal of Behavioral Medicine, 28, 359–367. Sherr, L., Clucas, C., Harding, R., Sibley, E., & Catalan, J. (2011). HIV and depression—A systematic review of interventions. Psychology, Health & Medicine, 16, 493–527. Siegel, K., & Schrimshaw, E. W. (2000). Perceiving benefits in adversity: Stress-related growth in women living with HIV/ AIDS. Social Science and Medicine, 51, 1543–1554. Siegel, K., & Schrimshaw, E. W. (2002). The perceived benefits of religious and spiritual coping among older adults living with HIV/ AIDS. Journal for the Scientific Study of Religion, 41, 91–102. Sobel, M. E. (1982). Asymptotic confidence intervals for indirect effects in structural equation models. Sociology Methodology, 13, 290–312. Tarakeshwar, N., Khan, N., & Sikkema, K. J. (2006). A relationshipbased framework of spirituality for individuals with HIV. AIDS and Behavior, 10, 59–70. Tarakeshwar, N., Pearce, M. J., & Sikkema, K. J. (2005). Development and implementation of a spiritual coping group intervention for adults living with HIV/AIDS: A pilot study. Mental Health, Religion & Culture, 8, 179–190. Taylor, S. E. (1983). Adjustment to threatening events: A theory of cognitive adaptation. American Psychologist, 38, 1161–1173. Taylor, S. E., & Brown, J. D. (1988). Illusion and well-being: A social psychological perspective on mental health. Psychological Bulletin, 103, 193–210. Tennen, H., & Affleck, G. (2002). Benefit-finding and benefitreminding. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 584–597). New York, NY: Oxford University Press. Tix, A. P., & Frazier, P. A. (1998). The use of religious coping during stressful life events: Main effects, moderation, and mediation. Journal of Consulting and Clinical Psychology, 66, 411–422. Tourangeau, R., Rips, L. J., & Rasinski, K. (2000). The psychology of survey response. Cambridge: Cambridge University Press. Trevino, K. M., Pargament, K. I., Cotton, S., Leonard, A. C., Hahn, J., Caprini-Faigin, C. A., et al. (2010). Religious coping and physiological, psychological, social, and spiritual outcomes in patients with HIV/AIDS: Cross-sectional and longitudinal findings. AIDS and Behavior, 14, 379–389. Yi, M. S., Mrus, J. M., Wade, T. J., Ho, M. L., Hornung, R. W., Cotton, S., et al. (2006). Religion, spirituality, and depressive symptoms in patients with HIV/AIDS. Journal of General Internal Medicine, 21, S21–S27.
Positive and negative religious coping, depressive symptoms, and quality of life in people with HIV Minsun Lee • Arthur M. Nezu • Christine Maguth Nezu
Received: May 16, 2013 / Accepted: January 13, 2014 Ó Springer Science+Business Media New York 2014
Abstract The present study examined the relationships of positive and negative types of religious coping with depression and quality of life, and the mediating role of benefit finding in the link between religious coping and psychological outcomes among 198 individuals with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). The results of multiple hierarchical analyses revealed that negative religious coping was significantly associated with a high level of depressive symptoms and a low level of quality of life, controlling for demographic and clinical variables. On the other hand, positive religious coping was significantly associated with positive domains of outcome measures such as positive affect and life satisfaction, but not with overall depressive symptoms or quality of life. Tests of
M. Lee (&) A. M. Nezu C. M. Nezu Department of Psychology, Drexel University, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA 19104, USA e-mail: [email protected] A. M. Nezu e-mail: [email protected] C. M. Nezu e-mail: [email protected] A. M. Nezu C. M. Nezu Department of Medicine, Drexel University, Philadelphia, PA 19102, USA A. M. Nezu Department of Community Health and Prevention, Drexel University, Philadelphia, PA, USA e-mail: [email protected] A. M. Nezu C. M. Nezu Philadelphia Veterans Administration Medical Center, Philadelphia, PA, USA
mediation analyses showed that benefit finding fully mediated the relationship between positive religious coping and the positive sub-domains of psychological outcomes. The importance of investigating both positive and negative types of religious coping in their relationships with psychological adaptation in people with HIV was discussed, as well as the significance of benefit finding in understanding the link between religious coping and psychological outcomes. Keywords Religious coping Benefit finding HIV Depression Quality of life
Introduction In spite of the great progress in reducing mortality from human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), the growing cohort of people living with HIV experience substantial stresses and challenges. Unlike other critical diseases such as cancer, many individuals living with HIV may experience discrimination due to stigma attached to the disease. The stigma may prevent people with HIV from disclosing their disease and drawing support from family or friends, which may result in social isolation and emotional distress (Paxton, 2002). Moreover, the problems people experience with disease management including numerous strict dosing schedules, consequent lifestyle modifications, and serious side effects of treatment, in addition to uncertainty and fear regarding their future, may make people with HIV vulnerable to mental problems (McIntosh & Rosselli, 2012). It is not surprising that studies have reported that the stressors and challenges associated with living with HIV profoundly affect the individual’s quality of life and lead to mental
123
J Behav Med
health problems, particularly, depression (Pence et al., 2012; Sherr et al., 2011). Therefore, identifying effective ways to cope with challenges associated with living with HIV become a topic of increasing interest. Researchers have found that religious coping is a crucial form of dealing with problems associated with the diagnosis and disease management in people with HIV. The majority of people with HIV were found to report that spirituality was ‘‘somewhat’’ or ‘‘very’’ important in their lives and that they ‘‘sometimes’’ or ‘‘often’’ rely on religious or spiritual means when making decisions or confronting problems (Lorenz et al., 2005). Religious coping is conceptualized as the utilization of religious beliefs or behaviors to deal with problems when adverse circumstances exceed the limits of resources (Koenig et al., 1998). It is distinct from dispositional dimensions of religiosity including religious belief or experience, religious commitment, and religious well-being. Literature that has explored the relationship between religious coping and psychological health has suggested that general religious coping methods, including praying, attending religious services, or taking problems to God may represent pain and struggle as well as gratitude and support (Tarakeshwar et al., 2006). The perspective that religion and spirituality can be both a source of gratitude and a source of struggle is consistent with the conceptualization of two types of religious coping methods, positive and negative religious coping. According to Pargament et al. (1998), positive religious coping is a reflection of a secure relationship with God, a belief in life’s larger meaning, and a sense of spiritual connectedness with others, whereas negative coping is an expression of a unstable relationship with God, a sense of disconnectedness with religious community, and a religious struggle in the search for meaning in life. The forms of positive religious coping strategies include benevolent religious reappraisals (e.g., ‘‘God might be trying to strengthen me in this situation’’), collaborative religious coping (e.g., ‘‘Worked together with God as partner’’), and seeking spiritual support (e.g., ‘‘Looked for God’s strength, support, and guidance’’). The set of negative religious coping methods includes punitive religious reappraisals (e.g., ‘‘God was punishing me for my sins’’), spiritual discontent (e.g., ‘‘God had abandoned me’’), and selfdirecting religious coping (e.g., ‘‘Tried to make sense of the situation without relying on God’’). The literature concerning positive and negative types of religious coping underscores that the various types of coping are not mutually exclusive and the same person may use both positive and negative religious coping methods. Although studies have indicated that general spirituality and religious behaviors are associated with psychological well-being in individuals with HIV (Amuzie & Jones,
123
2012; Tarakeshwar et al., 2006), relatively little attention has been paid to the relationship between religious coping strategies and emotional adaptation. There are even fewer studies that investigated how positive and negative religious coping strategies are related to depression and quality of life of individuals with HIV. Given that individuals with HIV may be vulnerable to experiencing spiritual struggles due to negative attitudes of religious communities toward the main risk factors for HIV infection including homosexuality and drug use (Bluthenthal et al., 2012), distinguishing positive from negative religious coping and examining their differential relationship with psychological adaptation may be particularly important for this group. Currently available research on differential relationships between positive and negative religious coping and psychological adaption in people with HIV reported that negative religious coping methods were associated with increased depressive symptoms (Hickman et al., 2013; Yi et al., 2006) and reduced quality of life (Cotton et al., 2006; Trevino et al., 2010) and that positive religious coping styles were related to greater optimism, self-esteem, life satisfaction, and spiritual well-being. Counter intuitively, however, these studies consistently reported that positive religious coping was not negatively correlated with depressive symptoms. They also did not report positive relationships between overall quality of life and positive religious coping. Lack of significant association between positive religious coping styles and depressive symptoms has also been reported in other medical populations (Ai et al., 2007; Pargament et al., 2004; Sherman et al., 2005). These studies, instead, found that positive religious coping was associated with positive psychological domains including hope (Ai et al., 2007) and stress-related growth (Pargament et al., 2004). One potential explanation of the results from the studies of individuals with HIV and other serious medical problems is that positive religious coping may be more strongly linked with positive aspects of psychological outcomes rather than negative aspects or overall psychological adjustment, whereas, negative religious coping may be associated with general decline of broad range of psychological and physical functioning, both positive and negative (Pargament et al., 1998: Sherman et al., 2005; Ai et al., 2007). If the above explanation of the differential relationship of positive and negative religious coping with psychological outcomes is correct, it is meaningful to examine the relationship between positive religious coping and sub-scales of depressive symptoms that measure positively-valenced affect and quality of life (e.g., life satisfaction), in addition to overall depressive symptom outcome scores. In fact, measures of depressive symptoms such as the Center for Epidemiologic Studies-Depression Scale (CES-D) used in many of the studies cited above include items that reflect positively valenced affect as well as those that measure negative affect
J Behav Med
and other somatic and cognitive symptoms. Thus, if only a subset of the depressive symptoms is significantly related to positive religious coping, then using an aggregate overall depressive symptom score is not likely to reveal the detailed pattern of the relationship. This perspective is supported by the literature indicating that positive and negative affect are not opposites on a single continuum but independent constructs and thus, they should be measured and analyzed separately (Russell & Barrett, 1999). For example, in a study conducted by Moskowitz (2003), the positive affect subscale of CES-D, not the overall score, was found to be a significant indicator of lower risk of AIDS mortality. Beyond the differential relationships of positive and negative religious coping with psychological adaptation, there is another important question as to whether religious coping contributes to adjustment directly or through other psychosocial pathways. Researchers have suggested a theoretical conceptualization of religious coping as meaningbased to explain the link between religious coping and psychological outcomes (Farber et al., 2010; Park, 2007). According to this framework, in the face of life challenges, individuals make efforts to understand the personal impact and significance of specific life circumstances through their personal meaning systems. Religion or spirituality may be the main resources of the meaning systems that lead people in adversity to establish purpose of life and a sense of coherence. Through this search for meaning, individuals may perceive a positive view on their stressful life experience and find benefits in their adverse situations, which is referred as benefit finding (Siegel & Schrimshaw, 2000). Benefit finding can be viewed as a result of individuals’ efforts to integrate stressful situations into their meaning systems in a positive way. Specifically, it can be defined as individuals’ perception of positive aspects and what they have learned while they are experiencing stressful events (Tennen & Affleck, 2002). There has been evidence that many individuals with HIV may find benefits in their illness experience (Siegel & Schrimshaw, 2000; Carrico et al., 2006). In addition, benefit finding was significantly associated with positive affect and decreased psychological distress after controlling for social support, locus of control, and demographic confounds in people with HIV (Siegel & Schrimshaw, 2002). A study that investigated benefit finding as a mediator in the link between spirituality and depressive symptoms among people with HIV/AIDS (Carrico et al., 2006) reported that benefit finding co-mediated the effect of spirituality on depressive symptoms and was a candidate mediator for the effects of spirituality on 24-h cortisol output. However, there is no study that investigated the mediating role of benefit finding in the connection between positive and negative religious coping and depressive symptoms or quality of life.
The aim of present study was to examine the differential relationships of positive and negative dimensions of religious coping with depressive symptoms and quality of life. Specifically, it was investigated whether positive religious coping would be associated with positive domains of outcome measures, and negative religious coping would be associated with broad domains of outcome measure both positive and negative. Another aim of this study was to investigate the mediating role of benefit finding in the link between religious coping and psychological outcomes in people with HIV. It was hypothesized that positive religious coping would be positively associated with positive domains of depressive symptoms and quality of life measures such as positive affect and life satisfaction. On the other hand, we hypothesized that negative religious coping would be positively associated with overall depressive symptoms and negatively associated with overall quality of life scores as well as positive affect and life satisfaction subscales. It was also hypothesized that the relationships between positive and negative religious coping and outcome variables would be mediated by benefit finding.
Methods Participants Participants were recruited from the Partnership Care Practice that serves individuals with HIV located in urban Philadelphia metropolitan area. Individuals were eligible to participate in the study if they presented with the diagnosis of HIV+; were at least 18 years of age; were able to read English at the 5th grade level; were capable of providing informed consent. Under the permission of a physician, participants were approached at the recruiting site by the investigator while they were waiting for their appointments. Each participant was given the research study recruitment letter and asked to return it to the investigator or clinic staff after signing it if they wanted to participate in the study. When they stated their interest, the investigator proceeded with obtaining informed consent and gave them a packet of questionnaires. As part of the consent to participate in the study, permission was requested to obtain diagnosis, CD4+ count and viral load, and medication information from the medical chart. Approximately 270 individuals were given the research study recruitment letter and 203 of them expressed their interest in the study and completed the consent form. Of those who consented, five participants withdrew from the study due to time constraint. Thus, 198 participants were included in the final analysis.
123
J Behav Med
Measures Demographic and clinical variables Demographic and clinical data were collected both from chart reviews and patients’ report. Demographic data included age, sex, ethnicity, sexual orientation, marital status, education level, employment status, religious affiliation, and mental treatment status. Clinical data included year diagnosed with HIV/AIDS, CD4+ cell count, viral load, methods of transmission of HIV, and other medical problems. Religious coping Religious coping styles were measured with the 63-item Religious Coping Scale (RCOPE) (Pargament et al., 1998). The RCOPE consists of 21 subscales, with 3 items for each subscale. The subscales represent two higher-order factors of positive and negative religious coping. The RCOPE assesses how much individuals utilize various religious coping strategies with their current problems. Individuals are asked how often they use each aspect of coping to deal with problems in their lives with HIV on a four-point Likert-type scale, ranging from 1 = not at all to 4 = a great deal. Internal consistency coefficients for the current sample were .93 for the positive religious coping subscale and .72 for the negative religious coping subscale.
a = .87), Health worries (4 items, a = .81), Financial worries (3 items, a = .86), Medication worries (5 items, a = .81), HIV mastery (2 items, a = .83), Disclosure worries (5 items, a = .83), Provider trust (3 items, a = .81), and Sexual functioning (2 items, a = .85). Each subscale is scored so that final dimension score is transformed to a 0–100 scale using formulas (e.g., Final overall function score = [100/(30 - 6)] 9 [value score-6)]. Zero indicates the worst functioning and 100 indicates the best functioning. Benefit finding A 17-item measure of benefit finding, which was originally used with breast cancer patients (Antoni et al., 2001) and adapted for use with HIV-positive populations (Carrico et al., 2006), was selected to measure benefit finding. The benefit-finding scale assesses the degree to which individuals feel that having HIV has made positive contributions to their lives. Participants rate their responses on Likerttype scales ranging from 1 = not at all to 5 = extremely. These items assess potential benefits across a variety of domains, including a newfound sense of purpose, enhanced feelings of closeness with others, and acceptance of life’s imperfections. In the current sample, Cronbach’s a was .88.
Results
Depressive symptoms
Demographic characteristics
Depressive symptoms were measured with the 20-item CES-D (Radloff, 1977). The CES-D is a self-report symptom rating scale to assess frequency of depressive symptom and consists of four subscales: Negative affect, Somatic symptoms, Positive affect, and Interpersonal issues. The scale uses a 4-point Likert-type scale, ranging from 0 = rarely or none of the time to 3 = all of the time, with higher scores representing greater depressive symptoms. In the present study, Cronbach’s a was .84.
The mean age of participants was 44.89 years (range 20–73) and 60.5 % of participants were male. The majority of the sample was Black (74 %) and the rest was comprised of White (15.1 %), Hispanic (9.4 %), or Other (1.5 %). Approximately three-fourths reported a high school education or less and incomes \$20,000. Eighty-two percent of participants were unemployed (26.3 %) or on disability (55.9 %). On average, participants had been living with HIV/ AIDS for 13.31 years and had CD4 cell count of 487.75. About 10 % of participants reported CD4 cell count \200. The majority reported contracting HIV through unprotected sex (67 %) or injection drug use (15.9 %). Slightly more than one-third were homosexual (25.7 %) or bisexual (11.8 %). The sample tended to be religious (84.3 %) and the religious affiliation included Protestant (53.9 %), Catholic (13.6 %), Islam (7.9 %), or Other (7.3 %).
Quality of life The HIV/AIDS-targeted quality of life (HAT-QoL) instrument was used to measure quality of life of people with HIV. The 34-item HAT-QoL assesses functions in nine domains on a five-point scale ranging from 0 = all of the time to 5 = none of the time. Higher scores indicate better quality of life (Holmes & Shea, 1998). The nine domains and the internal consistency reliability for each domain in the present study are: Overall functioning (6 items, Cronbach’s a = .84), Life satisfaction (4 items,
123
Descriptive statistics for study variables Participants used positive religious coping significantly more than negative religious coping (z = -12.8, p \ .001).
J Behav Med
The mean CES-D score was 24.7 (SD = 12.4). Significant depressive symptoms (CES-D score C16) were reported by 152 (76.8 %) of the respondents. Prior to the main analyses, the relationships between demographic variables and the main outcome variables of the study were examined by conducting ANOVA analyses. The analyses indicated that different levels of education were found to be significantly associated with both depressive symptoms [F(3,183) = 7.40, p = .000]and quality of life [F(3,183) = 3.19, p = .034]. Participants who received a college or higher level of education reported significantly lower levels of depressive symptoms (M = 11.10, SD = 6.17) and better quality of life (M = 600.96, SD = 113.91) than those who received less than college level of education (depressive symptoms M = 25.11, SD = 11.81; quality of life M = 488.28, SD = 133.71). Participants who were receiving treatment for psychiatric problems had significantly higher levels of depressive symptoms [M = 27.41, SD = 13.57; F(1,179) = 9.42, p = .002], and worse quality of life [M = 468.09, SD = 136.83; F(1,179) = 5.32, p = .022] than those who were not receiving treatment (depressive symptoms M = 21.93, SD = 10.47; quality of life M = 514.68, SD = 133.97). Education and mental health treatment were controlled in regression analyses predicting depression and quality of life in addition to HIV variables such as CD4, viral load and time since diagnosis. Zero-order correlations were conducted to examine the relationships among main study variables. Pearson correlations between positive and negative forms of religious coping and subscales of depressive symptoms and quality of life measures are presented in Table 1. Table 2 provides the correlations between each subscale of positive and negative religious coping and main outcome variables. Table 1 shows that positive religious coping was not significantly correlated with overall depressive symptoms and quality of life, whereas negative religious coping was significantly correlated with overall depressive symptoms and quality of life. However, positive religious coping was positively correlated with negative affect and somatic symptoms as well as positive affect subscales of depressive symptoms measure. Positive religious coping was also positively correlated with health worries and financial worries in addition to life satisfaction and provider trust subscales of quality of life measure. Negative religious coping was significantly correlated with all the subscales of depressive symptoms and quality of life measures except for positive affect subscale. The magnitude of the correlations of the subscales with negative religious coping was much stronger than for positive. As Table 2 shows, among positive religious coping methods, religious purification (r = .28, p \ .01) and seeking religious direction (r = .15, p \ .05) subscales were significantly positively correlated with depressive
Table 1 Pearson correlations between positive and negative forms of religious coping and subscales of outcome variables Measures CESD total
PRC .08
NRC .45***
CESD-negative affect
.14*
.46***
CESD-somatic
.15*
.39***
CESD-positive affect
.14*
CESD-interpersonal
.08
.47***
QoL total
-.13
-.39***
QoL-overall function
-.10
-.28***
-.13
QoL-life satisfaction
.16*
QoL-health worries
.21**
.36***
QoL-financial worries
.20**
.21**
QoL-medication worries QoL-HIV mastery
.11 -.11
-.19**
.32*** -.27***
QoL-disclosure worries
.03
QoL-provider trust
.16*
-.19**
.21**
Benefit finding
.61***
-.01
PRC positive religious coping, NRC negative religious coping, QoL quality of life, CESD Center for Epidemiologic Studies-Depression Scale * p \ .05; ** p \ .01; *** p \ .001
symptoms. These two subscales also revealed significant negative correlations (r = -.20, p \ .01; r = -.23, p \ .01, respectively) with quality of life along with religious focus subscale (r = -.17, p \ .05). All the subscales of negative religious coping methods except for selfdirecting religious coping subscale were significantly correlated with depressive symptoms and quality of life. Benefit finding was significantly correlated with all the subscales of positive religious coping methods. However, among the subscales of negative religious coping methods, pleading for direct intercession (r = .28, p \ .001) and marking religious boundaries (r = .16, p \ .05) subscales were positively correlated with benefit finding, while selfdirecting religious coping (r = -.16, p \ .05) and spiritual discontent (r = -.18, p \ .05) subscales were negatively correlated with the measure. Relationships between positive and negative religious coping and overall outcome measures Hierarchical regression analyses were conducted to examine the hypothesis that positive religious coping would be associated with positive domains of depressive symptoms and quality of life, whereas negative religious coping would be associated with overall depressive symptoms and quality of life controlling for demographics and HIV specific variables. Education, mental treatment, CD4, viral load, and time since diagnosis were entered in Step 1 as covariates, and positive and negative religious coping in
123
J Behav Med Table 2 Pearson correlation between subscales of positive and negative religious coping and outcome variables
Quality of life
Depressive symptoms
Benefit finding
Benevolent religious reappraisal
-.04
-.02
.46***
Collaborative religious coping Active religious surrender
-.10 .05
.06 .05
.37*** .49***
Seeking spiritual support
-.02
-.01
.43***
Religious focus
-.17*
.13
.50***
Religious purification
-.20**
.28***
.39***
Spiritual connection
-.09
.05
.47***
Seeking support from clergy/church members
-.09
.11
.45***
Religious helping
-.01
.05
.49***
Seeking religious direction
-.23**
.15*
.45***
Religious conversion
-.14
.07
.53***
Religious forgiving
-.14
.03
.47***
Punishing God reappraisal
-.32***
.36***
Demonic reappraisal
-.28***
.25***
Reappraisal of God’s power
-.12
.21**
Passive religious deferral
-.25**
.26***
Pleading for direct intercession Self-directing religious coping
-.35*** -.05
.27*** .14
.28*** -.16*
Spiritual discontent
-.35***
.44***
-.18*
Marking religious boundaries
-.23**
.25***
Interpersonal religious discontent
-.23**
.17*
Positive religious coping
Negative religious coping
* p \ .05; ** p \ .01; *** p \ .001
Table 3 Hierarchical multiple regression for religious coping predicting overall depressive symptoms and quality of life
Depression B Step 1
RC religious coping * p \ .05; ** p \ .01; *** p \ .001
123
.08 -.03 .13
.16* -.03
Quality of life 2
2
R
DR
.13
.13*
b
Education
-.26*
.09
Mental treatment Viral load
-.22* .02
.19 -.01
CD 4
-.01
Time since diag.
-.14
R2
DR2
.06
.04
.14
.08*
.09 .09
Step 2
.23
Positive RC
.03
-.14
Negative RC
.32**
-.24*
Step 2 to predict overall depression and quality of life. As hypothesized, negative religious coping significantly predicted both increased depressive symptoms (b = .32, p = .001) and reduced overall quality of life (b = -.24, p = .023) after controlling for HIV relevant variables in addition to demographics. Neither depressive symptoms nor overall quality of life was significantly associated with positive religious coping (Table 3). However, as expected, greater use of positive religious coping was significantly associated with enhanced positive affect (b = .26, p = .010) and greater life satisfaction (b = .23, p = .022).
-.12
.10**
Although negative religious coping was not significantly correlated with positive affect in bivariate correlation analyses, it significantly predicted reduced positive affect (b = -.23, p = .022) and life satisfaction (b = -.29, p = .005) after controlling for demographic variables and HIV-specific characteristics (Table 4). Mediating role of benefit finding To test a potential mediating role of benefit finding in the relationship between religious coping and the outcome
J Behav Med Table 4 Hierarchical regression for religious coping predicting positive sub-domains of quality of life and depressive symptoms, life satisfaction and positive affect
Life satisfaction B
.05
b
-.01
Mental treatment Viral load
.20* -.07
.19 -.05
CD 4
-.06
-.16
.10
Step 2 * p \ .05; ** p \ .01; *** p \ .001
.05
2
.03
Time since diag. RC religious coping
DR
R
Step 1 Education
Positive affect 2
.23*
Negative RC
-.29**
variables, a series of regression analyses were conducted. Based on the suggestions made by MacKinnon et al. (2000, 2009) that mediation analyses can be conducted without the requirement of the relationship between independent and dependent variables, a mediating role of benefit finding was examined not only in the relationship between positive religious coping and positive affect and life satisfaction where there were significant associations between them, but also in the relationship between positive religious coping and overall depressive symptoms and quality of life where there were no significant associations. Mediation model for the relationship between positive religious coping and positive domains of outcome measures The results of the mediation analyses (Table 5) showed that benefit finding serves a significant mediating role concerning the associations of positive religious coping with positive affect (Sobel z = 4.72, p \ .001), and with life satisfaction (Sobel z = 4.19, p \ .001). Specifically, when benefit finding was added, the original regression coefficients of positive religious coping for positive affect (b = .21) and life satisfaction (b = .19) were reduced to negative (b = -.06, and b = -.05, respectfully), indicating a full mediation. Mediation model for the relationship between positive religious coping and overall depressive symptoms As Table 4 showed, when benefit finding was added to the model, the regression coefficient (b = .08) for positive religious coping predicting depressive symptoms increased and the relationship became significant (b = .32, p = .003), indicating a suppressive mediation (MacKinnon & Fairchild, 2009; MacKinnon et al., 2000). In other words, the greater use of religious coping was associated with the higher level of benefit finding, and the higher level of benefit finding was associated with the less depressive
DR2
.07
.07
.15
.08*
.09 .15
Positive RC
R2
.10* .26** -.23*
symptoms. Thus, the indirect effect of positive religious coping on depressive symptoms mediated by benefit finding was negative [b 1(.08) -b 2 (.32) = -.24]. However, when benefit finding was controlled for, the direct effect of positive religious coping on depressive symptoms was significantly positive. The Sobel test result (Sobel z = -3.815, p \ .001) revealed that benefit finding was a significant mediator in the connection between positive religious coping and depressive symptoms. Quality of life, the other outcome variable, was not significantly associated with benefit finding. Therefore, a mediation model for the relationship between positive religious coping and overall quality of life was not tested. Mediation model for negative religious coping and outcomes Although negative religious coping was significantly associated with depressive symptoms and quality of life, benefit finding, the potential mediating variable was not significantly associated with negative religious coping. Therefore, the mediating role of benefit finding in the relationship between negative religious coping and outcome variables was not evaluated. Further post hoc regression analyses revealed that negative religious coping was significantly associated with depressive symptoms (b = .31, R2 = .26, DR2 = .09, p = .000) and quality of life (b = -.27, R2 = .14, DR2 = .07, p = .007), even after controlling for benefit finding in addition to other control variables. In other words, negative religious coping predicted depressive symptoms and quality of life over and beyond the effects of benefit finding.
Discussion This study investigated the differential relationships of positive and negative dimensions of religious coping on depressive symptoms and quality of life in people with
123
J Behav Med Table 5 Regression analysis for mediating effects of benefit finding predicting outcomes Life satisfaction
Positive affect
Overall depression
b Entry
b Final
b Entry
b Final
Positive RC
.19*
-.05
.21*
-.06
Benefit finding
.38**
.41***
.43***
.46***
R2
.17
.22
DR2
.13
.16
Sobel z test
4.19***
4.72***
b Entry
b Final
.08
.32**
-.23*
-.43*** .23 .11 -3.82***
RC religious coping, b Entry coefficient from the model on which only one of the predictors is entered, b Final coefficient from the model in which both predictor and potential mediator are entered, Sobel z test the test of the significance of the decrease in the regression coefficient for the predictor when the mediator is included (Sobel, 1982) * p \ .05; ** p \ .01; *** p \ .001
HIV, as well as a potential mediator of these relationships. As hypothesized, negative religious coping demonstrated significant associations with both overall depressive symptoms and quality of life, as well as most sub-dimensions of the outcomes, controlling for demographic variables and HIV-related covariates. Positive religious coping, as anticipated, was significantly associated with positive outcomes such as positive affect and life satisfaction. However, it was not significantly associated with general depressive symptoms or quality of life. These results are consistent with previous studies that found positive religious coping was related to positive outcomes but not to emotional distress, while negative religious coping was a more consistent and stronger predictor of emotional distress and general psychological maladjustment among medical patients with serious illness including HIV (Cotton et al., 2006; Trevino et al., 2010; Ai, et al., 2007; Sherman et al., 2005). These findings support the view that positive religious coping may contribute to enhancing positive, meaningbased psychological outcomes, rather than preventing negative, symptom-based ones (Tix & Frazier, 1998). On the other hand, negative religious coping may facilitate crisis specific and ego-dystonic struggle and thus, promote pervasive psychological distress under extreme stress. In particular, among individuals with HIV, the consistent negative associations of negative religious coping on broad range of sub-dimensions of depressive symptoms and quality of life measures may reflect the religious burdens they may experience including rejection from religious community due to stigma attached to HIV(Bluthenthal et al., 2012). In addition, the internal shame or feelings of guilt associated with past risky behaviors or the possibility of passing the virus on to others might have facilitated negative religious coping such as punishing reappraisal, which, in turn, made the people with HIV vulnerable to psychosocial problems. Although positive and negative religious coping may be predictive of differential psycho-
123
logical outcomes, competing interpretations cannot be ruled out; it is possible that individuals who feel better psychologically and experience positive affect may use more positive religious coping and those who are distressed may reveal their religious struggle. Regarding the role of benefit finding, it was suggested that benefit finding may mediate the relationship between positive religious coping and general depressive symptoms, as well as the relationships of positive religious coping with positive affect and life satisfaction, controlling for possible important confounding variables. Consistent with the existing theoretical model of benefit finding (Hobfoll, 2002; Taylor, 1983), those who frequently used positive religious coping found more benefit from their illness, which led them to increased positive affect and greater life satisfaction. In addition, benefit finding significantly suppressed the positive association between positive religious coping and depressive symptoms. These findings provide support to the existing theoretical conceptualizations of the impact of meaning-based processes in maintaining psychological well-being. Specifically, finding benefit may be a way through which individuals restore their self-esteem, and sense of meaning and mastery after stressful events that challenge their beliefs (Taylor & Brown, 1988), which, in turn, lead them to experience enhanced positive affect and life satisfaction. As some authors suggested, restoring meaning may be a central component of psychological recovery from traumatic events (Taylor & Brown, 1988) and may be the ultimate provider of motivation to maintain one’s mental and physical health (Park & Folkman, 1997). Benefit finding, however, was not significantly associated with negative religious coping. Post-hoc regression analyses showed that negative religious coping predicted depressive symptoms and quality of life above and beyond benefit finding. These results indicate that negative religious coping may uniquely or directly predict individuals’ adjustment to stress (Pargament et al., 1998). An alternative explanation is that there may be other factors that
J Behav Med
mediate the effects of negative religious coping. In fact, Pearce et al. (2006) found that self-efficacy, optimism, and social support partially mediated the relationship between negative religious coping and quality of life and life satisfaction. Similarly, although benefit finding fully mediated the link between positive religious coping and positive affect, it does not rule out alternative explanations including the relevance of third variables. Considering that dispositional optimism has been found to be associated with positive religious coping (Cotton et al., 2006) and benefit finding (Helgeson et al., 2006) as well as positive affect (Schnall et al., 2012), it is possible that positive religious coping may be associated with positive affect through optimism or other variables that were not measured in the present study. The results of this study bear several clinical implications. Because religion is an important resource for people living with HIV, assessing their religious coping strategies as an important aspect of functioning will be beneficial in understanding their problems and providing appropriate care. In particular, given that negative religious coping may have strong and consistent negative effects on well-being, it may be important to evaluate spiritual disappointments and struggle early on and refer those who experience spiritual struggle for spiritually integrated psychotherapy to prevent further detrimental outcomes. In their preliminary assessment of a psycho-spiritual intervention which offered participants an opportunity to identify personally relevant positive religious coping strategies and express their spiritual struggle, Tarakeshwar et al. (2005) reported that participants experienced decreased religious struggle and depression over the course of the intervention. Such intervention may be an important step to re-build a relationship with God and to find meaning and direction in life. In addition, given that benefit finding mediates the relationship between positive religious coping and positive outcome, and suppresses the positive association between positive religious coping and depressive symptoms, it may be helpful to encourage spiritual practices and beliefs that are likely to promote benefit finding in coping with HIV. The study has several limitations. First, this study is cross-sectional, which precludes any conclusions of causal direction, and does not provide information about the process of religious coping over time or its long-term effects. Second, the sample was recruited from one site in a large city on the East Coast of the United States, and the majority of participants were black with primarily Christian affiliation. In addition, a majority of the participants in this study belonged to a low socio-economic status, which might have limited improvements in outcome measures induced by positive coping strategies. Therefore, generalizing the results of this study to individuals of other ethnicities and religious denominations should be done with
caution. Future studies with a larger and more diverse sample of people with HIV are warranted. Another methodological limitation of the present study is that the data presented are self-reported, which may be influenced by several factors such as social desirability, mood, and a desire to manage impressions (Tourangeau et al., 2000). This study provides some directions for future research. First, although distinguishing two broad types of religious coping, positive and negative, is certainly informative, examining the effects of more specified religious coping strategies may allow us to pinpoint which coping strategies are more beneficial or harmful for certain aspect of mental health outcomes and narrow down the target of intervention. Second, change or stability of religious coping across time and the long-term consequences of each coping method is another important research topic. Especially, investigating long-term consequences of the positive religious coping methods that were related to increased depressive symptoms and decreased quality of life will be critical due to the ultimate health implications of these coping methods. Third, more research is needed to identify variables that may moderate the impact of religious coping. An individual’s religious affiliation, level of religiousness, or ethnicity may play a moderating role in the relationship between religious coping and psychological health. Identifying a potential moderator may be helpful in determining the subgroups for whom religious coping is more effective and in providing a potential explanation regarding the inconsistent and insignificant relationship between positive religious coping and general psychological adjustment. Conflict of interest Authors Minsun Lee, Arthur M. Nezu and Christine Maguth Nezu declare that they have no conflict of interest. Informed consent All procedures followed were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.
References Ai, A. L., Park, C. L., Huang, B., Rodgers, W., & Tice, T. N. (2007). Psychosocial mediation of religious coping styles: A study of short-term psychological distress following cardiac surgery. Personality and Social Psychology Bulletin, 33, 867–882. Amuzie, R., & Jones, M. (2012). A systematic review: the role of spirituality in reducing depression in people living with HIV/ AIDS. British Journal of General Practice, 62, 68. Antoni, M. H., Lehman, J. M., Klibourn, K. M., Boyers, A. E., Culver, J. L., Alferi, S. M., et al. (2001). Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychology, 20, 20–32. Bluthenthal, R. N., Palar, K., Mendel, P., Kanouse, D. E., Corbin, D. E., & Derose, K. P. (2012). Attitudes and beliefs related to HIV/AIDS in
123
J Behav Med urban religious congregations: barriers and opportunities for HIVrelated interventions. Social Science and Medicine, 74, 1520–1527. Carrico, A. W., Ironson, G., Antoni, M. H., Lechner, S. C., Duran, R. E., Kumar, M., et al. (2006). A path model of the effects of spirituality on depressive symptoms and 24-h urinary-free cortisol in HIV-positive persons. Journal of Psychosomatic Research, 61, 51–58. Cotton, S., Puchalski, C. M., Sherman, S. N., Mrus, J. M., Peterman, A. H., Feinberg, J., et al. (2006). Spirituality and religion in patients with HIV/AIDS. Journal of General Internal Medicine, 21, S5–S13. Farber, E. W., Bhaju, J., Campos, P. E., Hodari, K. E., Motley, V. J., Dennany, B. E., et al. (2010). Psychological well-being in persons receiving HIV-related mental health services: The role of personal meaning in a stress and coping model. General Hospital Psychiatry, 32, 73–79. Helgeson, V. S., Reynolds, K. A., & Tomich, P. L. (2006). A metaanalytic review of benefit finding and growth. Journal of Consulting and Clinical Psychology, 74, 797–816. Hickman, E. E., Glass, C. R., Arnkoff, D. B., & Fallot, R. D. (2013). Religious coping, stigma, and psychological functioning among HIV-positive African American women. Mental Health, Religion & Culture, 16, 832–851. Hobfoll, S. E. (2002). Social and psychological resources and adaptation. Review of General Psychology, 6, 307–324. Holmes, W. C., & Shea, J. A. (1998). A new HIV/AIDS-targeted quality of life (HAT-QoL) instrument: Development, reliability, and validity. Medical Care, 36, 138–154. Koenig, H. G., Pargament, K. I., & Nielsen, J. (1998). Religious coping and health status in medically ill hospitalized older adults. Journal of Nervous and Mental Disease, 186, 513–521. Lorenz, K. A., Hays, R. D., Shapiro, M. F., Cleary, P. D., Asch, S. M., & Wenger, N. S. (2005). Religiousness and spirituality among HIV-infected Americans. Journal of Palliative Medicine, 8, 774–781. MacKinnon, D. P., & Fairchild, A. J. (2009). Current directions in mediation analysis. Current Directions in Psychological Science, 18, 16. MacKinnon, D. P., Krull, J. L., & Lockwood, C. M. (2000). Equivalence of the mediation, confounding and suppression effect. Prevention Science, 1, 173–181. McIntosh, R. C., & Rosselli, M. (2012). Stress and coping in women living with HIV: A meta-analytic review. AIDS and Behavior, 16, 2144–2159. Moskowitz, J. T. (2003). Positive affect predicts lower risk of AIDS mortality. Psychosomatic Medicine, 65, 620–626. Pargament, K. I., Koenig, H. G., Tarakeshwar, N., & Hahn, J. (2004). Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: A two-year longitudinal study. Journal of Health Psychology, 9, 713–730. Pargament, K. I., Smith, B., Koenig, H., & Perez, L. (1998). Patterns of positive and negative religious coping with major life stressors. Journal for the Scientific Study of Religion, 37, 710–724. Park, C. L. (2007). Religiousness/spirituality and health: a meaning systems perspective. Journal of Behavioral Medicine, 30, 319–328. Park, C. L., & Folkman, S. (1997). Meaning in the context of stress and coping. General Review of Psychology, 1, 115–144. Paxton, S. (2002). The paradox of public HIV disclosure. AIDS Care, 14, 559–567. Pearce, M. J., Singer, J. L., & Prigerson, H. G. (2006). Religious coping among caregivers of terminally ill cancer patients: Main effects and psychosocial mediators. Journal of Health Psychology, 11, 743–759.
123
Pence, B. W., Shirey, K., Whetten, K., Agala, B., Itemba, D., Adams, J., et al. (2012). Prevalence of psychological trauma and association with current health and functioning in a sample of HIV-infected and HIV-uninfected Tanzanian adults. PLoS One, 7, e36304. Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. Russell, J. A., & Barrett, L. F. (1999). Core affect, prototypical emotional episodes, and other things called emotion: dissecting the elephant. Journal of Personality and Social Psychology, 76, 805–819. Schnall, E., Kalkstein, S., Fitchett, G., Salmoirago-Blotcher, E., Ockene, J., Tindle, H. A., et al. (2012). Psychological and social characteristics associated with religiosity in women’s health initiative participants. Journal of Religion and Health, 51, 20–31. Sherman, A. C., Simonton, S., Latif, U., Spohn, R., & Tricot, G. (2005). Religious struggle and religious comfort in response to illness: Health outcomes among stem cell transplant patients. Journal of Behavioral Medicine, 28, 359–367. Sherr, L., Clucas, C., Harding, R., Sibley, E., & Catalan, J. (2011). HIV and depression—A systematic review of interventions. Psychology, Health & Medicine, 16, 493–527. Siegel, K., & Schrimshaw, E. W. (2000). Perceiving benefits in adversity: Stress-related growth in women living with HIV/ AIDS. Social Science and Medicine, 51, 1543–1554. Siegel, K., & Schrimshaw, E. W. (2002). The perceived benefits of religious and spiritual coping among older adults living with HIV/ AIDS. Journal for the Scientific Study of Religion, 41, 91–102. Sobel, M. E. (1982). Asymptotic confidence intervals for indirect effects in structural equation models. Sociology Methodology, 13, 290–312. Tarakeshwar, N., Khan, N., & Sikkema, K. J. (2006). A relationshipbased framework of spirituality for individuals with HIV. AIDS and Behavior, 10, 59–70. Tarakeshwar, N., Pearce, M. J., & Sikkema, K. J. (2005). Development and implementation of a spiritual coping group intervention for adults living with HIV/AIDS: A pilot study. Mental Health, Religion & Culture, 8, 179–190. Taylor, S. E. (1983). Adjustment to threatening events: A theory of cognitive adaptation. American Psychologist, 38, 1161–1173. Taylor, S. E., & Brown, J. D. (1988). Illusion and well-being: A social psychological perspective on mental health. Psychological Bulletin, 103, 193–210. Tennen, H., & Affleck, G. (2002). Benefit-finding and benefitreminding. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 584–597). New York, NY: Oxford University Press. Tix, A. P., & Frazier, P. A. (1998). The use of religious coping during stressful life events: Main effects, moderation, and mediation. Journal of Consulting and Clinical Psychology, 66, 411–422. Tourangeau, R., Rips, L. J., & Rasinski, K. (2000). The psychology of survey response. Cambridge: Cambridge University Press. Trevino, K. M., Pargament, K. I., Cotton, S., Leonard, A. C., Hahn, J., Caprini-Faigin, C. A., et al. (2010). Religious coping and physiological, psychological, social, and spiritual outcomes in patients with HIV/AIDS: Cross-sectional and longitudinal findings. AIDS and Behavior, 14, 379–389. Yi, M. S., Mrus, J. M., Wade, T. J., Ho, M. L., Hornung, R. W., Cotton, S., et al. (2006). Religion, spirituality, and depressive symptoms in patients with HIV/AIDS. Journal of General Internal Medicine, 21, S21–S27.
