Modeling the Effects of Spirituality/Religion on Patients' Perceptions of Living with HIV/
AIDS
M a g d a l e n a Szaflarski, PhD, 1,2 p. Neal Ritchey, PhD, 3 Anthony C. Leonard, PhD, 1,4
Joseph M. Mrus, MD, MSc, 4"5. A m y H. Peterman, t h D , 6 Christopher G. Ellison, t h D , 7
Michael E. McCullough, thD, 8"9 Joel Tsevat, MD, MPH, 1,4,5
~lnstitute for the Study of Health, University of Cincinnati, Cincinnati, OH, USA; 2Department of Family Medicine, University of Cincinnati
Medical Center, Cincinnati, OH, USA; 3Department of Sociology, University of Cincinnati, Cincinnati, OH, USA;4Veterans Healthcare
System of Ohio (VISN 10), Cincinnati, OH, USA; 5Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH,
USA; 6Department of Psychology, University of North Carolina at Charlotte, NC, USA; 7Department of Sociology, University of Texas at
Austin, Austin, TX, USA;8Department of Psychology, University of Miami, Coral Gables, FL, USA; 9Department of Religious Studies, University
of Miami, Coral Gables, FL, USA.
BACKGROUND: S p i r i t u a l i t y / r e l i g i o n is a n i m p o r t a n t
factor i n h e a l t h a n d i l l n e s s , b u t more work is n e e d e d
to d e t e r m i n e its l i n k to q u a l i t y of life i n p a t i e n t s w i t h
HIV/AIDS.
GBJECTIVE: To e s t i m a t e t h e direct a n d i n d i r e c t effects
of s p i r i t u a l i t y / r e l i g i o n o n p a t i e n t s ' p e r c e p t i o n s of living
w i t h H1V/AIDS.
DESIGN: I n 2 0 0 2 a n d 2 0 0 3 , as p a r t of a m u l t i c e n t e r
l o n g i t u d i n a l s t u d y of p a t i e n t s with HIV/AIDS, we collected extensive d e m o g r a p h i c , clinical, a n d b e h a v i o r a l
d a t a from c h a r t review a n d p a t i e n t interviews. We u s e d
logistic r e g r e s s i o n a n d p a t h a n a l y s i s c o m b i n i n g logistic
a n d o r d i n a r y l e a s t s q u a r e s regression.
SUBJECTS: F o u r h u n d r e d a n d fifty o u t p a t i e n t s with
HIV/AIDS from 4 sites i n 3 cities.
MEASURES: The d e p e n d e n t v a r i a b l e w a s w h e t h e r p a t i e n t s felt t h a t life h a d i m p r o v e d s i n c e b e i n g d i a g n o s e d
with HIV/AIDS. S p i r i t u a l i t y / r e l i g i o n w a s a s s e s s e d b y
u s i n g t h e D u k e Religion Index, F u n c t i o n a l A s s e s s m e n t
of C h r o n i c Illness T h e r a p y - - S p i r i t u a l W e l l - B e i n g - - E x p a n d e d , a n d Brief RCOPE m e a s u r e s . M e d i a t i n g factors
i n c l u d e d social s u p p o r t , self-esteem, h e a l t h y beliefs,
and health status/health concerns.
RESULTS: A p p r o x i m a t e l y o n e - t h i r d of t h e p a t i e n t s felt
t h a t t h e i r life w a s b e t t e r n o w t h a n it w a s before b e i n g
d i a g n o s e d with HIV/AIDS. A 1-SD i n c r e a s e i n s p i r i t u a l i t y / r e l i g i o n w a s a s s o c i a t e d with a 6 8 . 5 0 % i n c r e a s e i n
o d d s of feeling t h a t life h a s i m p r o v e d - - 2 9 . 9 7 % d u e to a
direct effect, a n d 3 8 . 5 4 % d u e to i n d i r e c t effects t h r o u g h
h e a l t h y beliefs (29.15%) a n d h e a l t h s t a t u s / h e a l t h conc e r n s (9.39%). H e a l t h y beliefs h a d the largest effect o n
The authors have no conflicts of interest to report.
An earlier version of this paper was presented at the 2005 Annual
Meeting of the American Sociological Association in Philadelphia, PA,
USA.
Address for correspondence and requests for reprints to Dr. Magdalena Szaflarski: Institute for the Study of Health, PO Box 670840.
Cincinnati, OH 45267-0840 (e-mail: [email protected]).
*Current address: North American HIV Collaborative Studies,
Infectious Diseases Medicine Development Center, GlaxoSmithKline,
Research Triangle Park, NC, USA.
S18
feeling t h a t life h a d improved; a 1-SD i n c r e a s e i n
h e a l t h y beliefs r e s u l t e d i n a 109.75% i m p r o v e m e n t i n
feeling t h a t life c h a n g e d .
CONCLUSIONS: I n p a t i e n t s with HIV/AIDS, the level of
s p i r i t u a l i t y / r e l i g i o n is associated, b o t h directly a n d
indirectly, w i t h feeling t h a t life is b e t t e r n o w t h a n
previously. F u t u r e r e s e a r c h s h o u l d v a l i d a t e o u r n e w
c o n c e p t u a l m o d e l u s i n g other s a m p l e s a n d l o n g i t u d i n a l
s t u d i e s . Clinical e d u c a t i o n i n t e r v e n t i o n s s h o u l d focus
o n r a i s i n g a w a r e n e s s a m o n g c l i n i c i a n s a b o u t t h e imp o r t a n c e of s p i r i t u a l i t y / r e l i g i o n i n HIV/AIDS.
spirituality; q u a l i t y of life; HIV; a c q u i r e d
immunodeficiency syndrome; path analysis.
DOI: 1 0 . 1 1 1 1 / j . 1 5 2 5 - 1 4 9 7 . 2 0 0 6 . 0 0 6 4 6 . x
J GEN INTERN MED 2006; 2 1 : $ 2 8 - 3 8 .
KEY WORDS:
p
atients with life-threatening diseases often undergo deep
personal transformation, including changes in life outlook. As a coping mechanism, many focus on the positive aspects of life, seek and use social support, or search for the
spiritual meaning of the illness. 1-3 To wit, a large body of literature supports the connection between spirituality/religion
and health. 3-w Religion is usually defined in the context of
ideological commitments and institutional membership. Religiosity, a related concept, involves the cognitive, emotional,
behavioral, interpersonal, and physiological processes linking
religion and spirituality. The term "religion" is often used as an
umbrella term for both religion and religiosity. 11,12 Meanwhile,
the term spirituality is increasingly used to represent the
personal, subjective dimension of religious experience. The
literature suggests that spirituality and religion are intertwined and can be considered as aspects of a larger construct, 11,12 sometimes referred to as spirituality/religion.
In areas of the world with ready access to highly active
antlretroviral therapy (HAART), patients with H1V/AIDS are
living longer than ever before, la and, hence, understanding
and improving their quality of life (QoL} is paramount. Spirituality/religion is a key construct for men and women affected
by HIV.t4-~6 It is associated mostly with positive feelings
(e.g., hope, peace), but also with some negative ones (e.g., feeling punishment from God or feeling ostracized by a religious
group). Spirituality/religion has also been shown to be
JGIM
Szaflarski et al., Modeling the Effects of Spirituality
positively associated with h e a l t h o u t c o m e s (e.g., long survival,
h e a l t h behaviors, less distress, a n d lower cortisol levels} 17 a s
well a s with t h e will to live 17'1s in people with HW/AIDS. Alt h o u g h spiritual a n d religious coping s e e m to play a role for
p a t i e n t s with HIV/AIDS, a d e e p e r u n d e r s t a n d i n g of specific
p a t h w a y s t h r o u g h w h i c h spirituality/religion affects p a t i e n t s
w i t h HIV/AIDS is still lacking. 14
In previous studies of p a t i e n t s with HIV/AIDS, p a t i e n t s
were a s k e d to c o m p a r e t h e i r life n o w with t h e i r life before HIV/
AIDS diagnosis, ls'19 Surprisingly, a large p r o p o ~ i o n of pat i e n t s - - o n e - t h i r d to o n e - h a l f - - s a i d t h e i r life was b e t t e r a t present, and, in one study, 18 spirituality w a s a s s o c i a t e d w i t h
feeling t h a t life h a d b e c o m e better. T h e s e 2 s t u d i e s are corrobo r a t e d b y o t h e r r e s e a r c h s h o w i n g a n alteration in t h e s p i r i t u a l
perspectives of p a t i e n t s w i t h HIV/AIDS since t h e o n s e t of t h e
d i s e a s e , s u c h a s a shift to focusing o n t h e p r e s e n t a n d
r e o r d e r i n g of priorities. 2~
To posit t h e m e c h a n i s m s b y w h i c h spirituality/religion
m a y b e related to QoL in p a t i e n t s with HIV/AIDS, we developed a c o n c e p t u a l model (Fig. 1}. The p u r p o s e of t h e p r e s e n t
s t u d y is to t e s t t h e c o n c e p t u a l model b y u s i n g d a t a from a n e w
m u l t i c e n t e r s t u d y of p a t i e n t s w i t h H1V/AIDS.
CONCEPTUAL MODEL
O u r model draws u p o n P a r g a m e n t ' s religious coping model, 6-8
Ellison a n d Levin's m e c h a n i s m s b y which spirituality a n d religious involvement m a y influence h e a l t h outcomes, 4 a n d Tsevat
et al.'s 18 work relating health-related QoL a n d spirituality with
t h e feeling t h a t life h a s improved. In o u r model, spirituality/
religion was conceptualized along 2 dimensions: distal a n d proximal. Distal m e a s u r e s of religion a n d spirituality mainly tap individual behaviors (e.g., frequency of a t t e n d a n c e a t services,
prayer, or mediation, etc.), w h e r e a s proximal m e a s u r e s gauge
the ftmctions of religion a n d spirituality for the individual [e.g.,
support, Coping, meaning, etc.); proximal m e a s u r e s t e n d to be
linked more directly with h e a l t h a n d well-being. 6 ~
$29
We h y p o t h e s i z e d in o u r s t u d y t h a t spirituality/religion
would influence t h e feeling t h a t life h a s improved either directly or via 4 m e d i a t i n g m e c h a n i s m s : h e a l t h y lifestyle, w h i c h
we c a p t u r e d t h r o u g h m e d i c a t i o n a d h e r e n c e ; social s u p p o r t :
self-pereeption, or self-esteem; and, h e a l t h y beliefs, w h i c h we
c a p t u r e d t h r o u g h optimism. 4 Strict m e d i c a t i o n a d h e r e n c e is
crucial to c o m b a t i n g HIV/AIDS a n d related o p p o r t u n i s t i c infections. Psychosocial factors, s u c h a s social s u p p o r t , avoida n c e of risky behaviors, a n d positive feelings a b o u t oneself,
h a v e b e e n l i n k e d with improved a d h e r e n c e in p a t i e n t s w i t h
HIV/AIDS. 22 T h o s e are t h e s a m e factors t h a t are believed to
m e d i a t e t h e r e l a t i o n s h i p b e t w e e n spirituality/religion a n d
health, in general. People w i t h HW/AIDS m a y benefit, in p a r ticular, from i n s t r u m e n t a l aid (e.g., t r a n s p o r t a t i o n to a medical
a p p o i n t m e n t ) a n d socioemotional a s s i s t a n c e (e.g., c o m p a n i o n ship), a s well a s from formal a s s i s t a n c e p r o g r a m s a n d p a s t o r a l
advice a n d counseling. 23
We also h y p o t h e s i z e d t h a t h e a l t h s t a t u s / h e a l t h c o n c e r n s
would b e directly related to feeling t h a t life h a s improved.
In o t h e r words, t h e b e t t e r one's h e a l t h s t a t u s or the fewer
one's h e a l t h c o n c e r n s (e.g., t h e b e t t e r o n e ' s physical
f u n c t i o n i n g or t h e fewer o n e ' s financial worries), the more likely t h e p a t i e n t is to feel t h a t life h a s improved. F u r t h e r m o r e ,
h e a l t h s t a t u s / h e a l t h c o n c e r n s were h y p o t h e s i z e d to m e d i a t e
t h e r e l a t i o n s h i p b e t w e e n spirituality/religion a n d the feeling
t h a t life h a s improved, a s spirituality/religion h a s b e e n f o u n d
to b e correlated with less emotional d i s t r e s s 24 a n d a b e t t e r
QoL. 25
We specified w h a t we t h o u g h t w a s t h e m o s t p l a u s i b l e
c a u s a l ordering of t h e variables to a c c o u n t for t h e a s s o c i a t i o n
b e t w e e n spirituality/religion a n d feeling t h a t life b e c a m e
b e t t e r after t h e HIV diagnosis. In o u r model, every p a t h (arrow
r e p r e s e n t i n g a direct effect) is a n explicitly h y p o t h e s i z e d
relationship. Of course, m a n y others, i.e., t h e myriad i n d i r e c t
effects, c a n b e logically d e d u c e d from t h e s e a n d are implicitly
hypothesized. Therefore, we s t a t e only a few h y p o t h e s e s
here to give a s e n s e of w h y we posit t h i s c a u s a l order: we
FIGURE 1. Initial c o n c e p t u a l a n d final path models of the relationship b e t w e e n spirituality/religion and perception that life is better now than
it was before being diagnosed with HIV. The trimmed, final path model excludes the relationships shown in red, Odds ratios are shown on
paths to "life is better"; all others are standardized path coefficients (ordinary least squares ~ coefficients). All coefficients are statistically
significant at P<.05. (+) signs represent hypothesized positive effects that were not corroborated; (+) signs without a c c o m p a n y i n g coefficients are not statistically significant. (+) signs a c c o m p a n i e d by a negative coefficient indicate that the relationship was in the opposite
direction from that hypothesized.
$30
Szaflarski et al., Modeling the Effects of Spirituality
h y p o t h e s i z e d t h a t as a p a t i e n t ' s level of spirituality/religion
i n c r e a s e s , s / h e i n t e r a c t s m o r e with o t h e r s a n d s e e k s a n d
receives more social s u p p o r t . As social s u p p o r t i n c r e a s e s ,
t h e p a t i e n t is less isolated a n d h e r / h i s self-esteem grows. A
g r e a t e r self-esteem leads to m o r e h e a l t h y beliefs. AS h e a l t h y
beliefs increase, t h e p a t i e n t ' s m e d i c a t i o n a d h e r e n c e improves.
W i t h improved a d h e r e n c e to m e d i c a t i o n (healthy lifestyles),
t h e p a t i e n t ' s h e a l t h s t a t u s improves a n d h e a l t h c o n c e r n s
decrease. And, finally, as h e a l t h s t a t u s i m p r o v e s / h e a l t h conc e m s decrease, t h e p a t i e n t is more likely to believe t h a t life is
b e t t e r n o w t h a n in t h e past.
METHODS
Subjects
B e t w e e n F e b r u a r y 2 0 0 2 a n d F e b r u a r y 2003, 4 5 0 o u t p a t i e n t s
w i t h v a r i o u s stages of HIV/AIDS were recruited from 4 sites in
3 cities: t h e University of C i n c i n n a t i Medical C e n t e r a n d t h e
C i n c i n n a t i V e t e r a n s Affairs (VA) Medical Center, b o t h in Cincinnati, OH; George W a s h i n g t o n University Medical C e n t e r in
W a s h i n g t o n , DC; a n d t h e VA P i t t s b u r g h H e a l t h c a r e S y s t e m in
P i t t s b u r g h , PA. To o b t a i n a s a m p l e t h a t w a s d e m o g r a p h i c a l l y
r e p r e s e n t a t i v e of p a t i e n t s s e e k i n g care a t e a c h site, we enrolled
m i n o r i t y a n d female p a t i e n t s in approximately t h e s a m e
p r o p o r t i o n a s t h e i r p r o p o r t i o n s a t e a c h s t u d y site's HIV
clinic. Informed c o n s e n t w a s o b t a i n e d from e a c h subject.
S u b j e c t s were paid $30 p e r interview. The i n s t i t u t i o n a l review
b o a r d s a t e a c h site a p p r o v e d t h e study.
Measures
We collected d a t a from c h a r t review a n d p a t i e n t interviews.
Clinical d a t a i n c l u d e d CD4 c o u n t s , viral loads (dichotomized
a s detectable v s u n d e t e c t a b l e ) , a n d time since HIV diagnosis.
I n f o r m a t i o n regarding c u r r e n t antiretroviral t h e r a p y w a s asc e r t a i n e d b o t h b y c h a r t review a n d p a t i e n t interview, with
n a m e s a n d p i c t u r e s of all a p p r o v e d antiretroviral m e d i c a t i o n s
p r e s e n t e d to t h e p a t i e n t for e a s e of identification. H e a l t h stat u s / h e a l t h concerns, spirituality/religion, a n d o t h e r b e h a v ioral d a t a were collected t h r o u g h p a t i e n t interviews u s i n g
standardized instruments.
O u r o u t c o m e m e a s u r e , w h e t h e r life is better, is w a s a bina r y variable a n d c o n t r a s t e d p a t i e n t s for w h o m life w a s "better
now" with t h o s e w h o r e s p o n d e d "worse now," " a b o u t t h e
s a m e , " or "don't know." We u s e d t h i s variable for c o n s i s t e n c y
a n d comparability with a n earlier study, is as o u r goal w a s to
replicate a n d e x t e n d t h e p r e v i o u s s t u d y u s i n g a larger, more
representative, a n d c o n t e m p o r a n e o u s s a m p l e of p a t i e n t s . We
m e a s u r e d spirituality/religion b y u s i n g 3 i n s t r u m e n t s : the
D u k e Religion Index (DUREL), 26 t h e F u n c t i o n a l A s s e s s m e n t
of Chronic Illness T h e r a p y - - S p i r i t u a l W e l l - B e i n g - - E x p a n d e d
(FACIT-Sp-Ex) scale, 27 a n d a religious coping scale, t h e Brief
RCOPE. 28 The DUREL a s s e s s e s t h e distal v a r i a b l e s of organized religious activity (DUREL-ORA; frequency of a t t e n d i n g
services), n o n o r g a n i z e d religious activity (DUREL-NORA;
f r e q u e n c y of praying, meditating, s t u d y i n g Bible, etc.), a n d
i n t r i n s i c religiosity (DUREL-IR). The FACIT-Sp-Ex is a 2 3 - i t e m
m e a s u r e of proximal s p i r i t u a l well-being a d d r e s s i n g faith,
m e a n i n g , a n d peace. T h e Brief RCOPE a d d r e s s e s b o t h
positive religious coping (RCOPE-Positive; spiritual c o n n e c tion, spiritual s u p p o r t seeking, religious forgiveness, collab-
JGIM
orative religious coping, b e n e v o l e n t religious reappraisals,
religious purification, a n d religious focus) a n d negative religious coping (RCOPE-Negative; spiritual discontent, p u n i s h ing God r e a p p r a i s a l s , i n t e r p e r s o n a l religious discontent,
d e m o n i c r e a p p r a i s a l s , a n d r e a p p r a i s a l s of God's powers).
T h e DUREL a n d RCOPE h a v e previously b e e n t e s t e d in
national, c o m m u n i t y , or clinical p o p u l a t i o n s , w h e r e a s the
FACIT-Sp-Ex h a s also b e e n u s e d specifically in p a t i e n t s
with H1V/AIDS. The m e a s u r e s showed good i n t e r n a l consistency reliability i n o u r s a m p l e ( C r o n b a c h ' s ~ of 0.88, 0.92, 0.82,
a n d 0.95 for t h e DUREL, RCOPE-Positive, RCOPE-Negative,
a n d FACIT-Sp-Ex, respectively). We confirmed a h i g h e r
ordered c o n s t r u c t of spirituality/religion b a s e d on t h e s e
3 m e a s u r e s b y u s i n g confirmatory factor a n a l y s i s 29 (Appendix
A). As o u r i n t e r e s t w a s in t h e b r o a d c o n c e p t of s p i r i t u a l i t y /
religion, we i n c l u d e d a composite (e.g., l a t e n t variable) t h a t
r e p r e s e n t e d t h i s complex c o n s t r u c t ( C r o n b a c h ' s ~ = 0 . 8 3 ;
A p p e n d i x A).
We a s s e s s e d h e a l t h s t a t u s / h e a l t h c o n c e r n s by u s i n g 3
m e a s u r e s : t h e HIV/AIDS-Targeted (HAT)-QoL, a~ t h e H1V
S y m p t o m I n d e x (HSI), 31 a n d the 10-item v e r s i o n of the C e n t e r
for Epidemiologic S t u d i e s - D e p r e s s i o n (CESD-10) scale. 32 The
HAT-QoL is a 3 4 - i t e m scale a d d r e s s i n g 9 d o m a i n s identified
previously b y p a t i e n t s w i t h HIV/AIDS a s b e i n g i m p o r t a n t :
overall functioning; s e x u a l functioning; disclosure worries;
m e d i c a t i o n worries; h e a l t h worries; f i n a n c i a l worries; HIV
mastery, or level of comfort with h o w t h e p a t i e n t c o n t r a c t e d
HIV; life satisfaction; a n d provider trust. T h e HSI a s s e s s e s the
p r e s e n c e a n d degree of b o t h e r of 20 s y m p t o m s , i n c l u d i n g fatigue, fever, p a i n or n u m b n e s s , difficulty w i t h memory, r a s h ,
h e a d a c h e , s t o m a c h p a i n or g a s / b l o a t i n g , c h a n g e s in b o d y app e a r a n c e s u c h a s fat deposits, a n d c h a n g e s in weight over the
p a s t 4 weeks. For e a c h s y m p t o m t h a t t h e p a t i e n t c h e c k e d off
a s having, s / h e r a t e d its degree of b o t h e r o n a 4-point scale
("it d o e s n ' t b o t h e r me"; "it b o t h e r s m e a little"; "it b o t h e r s me";
or "it b o t h e r s m e a lot"). For t h e HSI, we c o u n t e d the n u m b e r of
s y m p t o m s t h a t t h e p a t i e n t reported a s b o t h e r i n g t h e m or b o t h ering t h e m a lot. T h e CESD- 10 is a 10-item m e a s u r e a s s e s s i n g
depressive symptomatology. 33 B e c a u s e several q u e s t i o n s on
t h e HSI p e r t a i n i n g to d e p r e s s i o n have s i m i l a r c o u n t e r p a r t s on
t h e CESD- 10, we scored only t h e 15 q u e s t i o n s o n the HSI with
n o CESD-10 c o u n t e r p a r t s , a s advocated b y Kilbourne et al. 33
O u r 3 m e a s u r e s of h e a l t h s t a t u s / h e a l t h c o n c e r n s s h o w e d
good reliability in o u r s a m p l e ( C r o n b a c h ' s ct of 0.91, 0.87,
a n d 0.86 for t h e HSI, CESD-10, a n d HAT-QoL, respectively).
We identified a composite of h e a l t h s t a t u s / h e a l t h c o n c e r n s
t h r o u g h a confirmatory factor a n a l y s i s r e p r e s e n t e d b y the
3 c o n s t r u c t s ( C r o n b a c h ' s ct=0.81) a n d u s e d t h e composite in
o u r p a t h a n a l y s i s (Appendix A).
We m e a s u r e d h e a l t h y lifestyle t h r o u g h m e d i c a t i o n a d h e r ence b y u s i n g a modified version of a q u e s t i o n n a i r e developed
b y t h e AIDS Clinical Trials G r o u p 34 a s s e s s i n g the n u m b e r of
antiretroviral m e d i c a t i o n d o s e s m i s s e d in t h e l a s t 4 days. We
a s s e s s e d social s u p p o r t b y u s i n g t h e Brief I n t e r p e r s o n a l Support E v a l u a t i o n List, w h i c h c a p t u r e s a p p r a i s a l , belonging, a n d
tangible s u p p o r t (score range: 12 to 48) 35 a n d self-esteem by
u s i n g t h e 6 - i t e m R o s e n b e r g Global Self-Esteem M e a s u r e (score
range: 6 to 24). 36 Finally, we a s s e s s e d h e a l t h y beliefs, or
optimism, b y u s i n g the 12-item Life O r i e n t a t i o n Test (score
range: 0 to 48). 37 The respective C r o n b a c h ' s a's for t h e social
s u p p o r t , self-esteem, a n d h e a l t h y beliefs scales were 0.90,
0.81, a n d 0.83.
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Szaflarski et al., Modeling the Effects of Spirituality
Procedure of Analysis
First, we a s s e s s e d the multivariable relationship b e t w e e n the
o u t c o m e "life is better" a n d o u r i n d e p e n d e n t variables by cons t r u c t i n g a logistic r e g r e s s i o n model. I n d e p e n d e n t variables
were divided into the following blocks: demographics, h e a l t h
s t a t u s and clinical variables, spirituality/religion variables,
a n d variables r e p r e s e n t i n g h e a l t h y lifestyle, social s u p p o r t ,
self-perception, a n d h e a l t h y beliefs. Candidate i n d e p e n d e n t
variables were t h o s e t h a t exhibited simple bivariate relations h i p s with the outcome at P < . 10. Variables in the first block
(demographics) were e n t e r e d in unison, a n d b a c k w a r d selection w a s u s e d until all variables remaining were a s s o c i a t e d
with the outcome at P < .05 in t h e p r e s e n c e of the o t h e r predictors. Candidate variables from the n e x t block were added,
a n d all variables in the model were again subjected to b a c k w a r d elimination. We r e p e a t e d the p r o c e s s sequentially until
variables h a d b e e n a d d e d from all blocks. As a final step, to
d e t e r m i n e w h e t h e r spirituality/religion h a s a greater i m p a c t
on t h e feeling t h a t life h a s improved a m o n g p a t i e n t s with poor
h e a l t h s t a t u s t h a n it does a m o n g p a t i e n t s with excellent h e a l t h
s t a t u s , we a d d e d the possible interaction b e t w e e n HAT-QoL
overall functioning a n d spirituality (FACIT-SpEx), a n d again
p e r f o r m e d b a c k w a r d elimination of nonsignificant predictors.
At all stages of the variable selection process, previously rem o v e d variables were tested for re-insertion into t h e m o d e l
w h e n e v e r it a p p e a r e d t h a t colinearity a m o n g the p r e d i c t o r s
m i g h t have led to the removal of a potentially valuable predictor. T h e s e a n a l y s e s were p e r f o r m e d u s i n g SAS, version 8.02
(SAS Institute, Cary, NC).
Next, we u s e d p a t h analysis, a simple s t r u c t u r a l e q u a t i o n
modeling technique, 38'a9 to t e s t our conceptual model. As emp h a s i z e d by Pedhazur, p a t h a n a l y s i s is "a m e t h o d for s t u d y i n g
direct a n d indirect effects of variables hypothesized a s c a u s e s
of variables treated a s effects" a n d "is i n t e n d e d not to discover
c a u s e s b u t to s h e d light on t h e tenability of the c a u s a l m o d e l s
a r e s e a r c h e r formulates b a s e d on knowledge a n d theoretical
c o n s i d e r a t i o n s " (pp. 769-70). 39 The "causal" effects d e s c r i b e d
in t h i s p a p e r are b a s e d on correlational matrices, and, t h u s ,
r e p r e s e n t associations. Although s t r u c t u r a l equation modeling (SEM) is often advocated for testing p a t h models, p a t h
a n a l y s i s is sufficient for m o d e l s without a m e a s u r e m e n t comp o n e n t , which, a s we explain below, was our case.
The p a t h analysis u s e d in t h i s s t u d y is u n i q u e a s it comb i n e s ordinary least s q u a r e s a n d logistic regression. While we
u s e d ordinary least s q u a r e s r e g r e s s i o n to e s t i m a t e t h e effects
of s o m e of the model's variables, our ultimate d e p e n d e n t
variable, "life is better," w a s b i n a r y a n d would typically be
e s t i m a t e d by u s i n g logistic regression. We c o m b i n e d t h e inform a t i o n from b o t h estimation p r o c e d u r e s by developing semis t a n d a r d i z e d p a t h coefficients to p a r s e the direct a n d various
indirect influences on "life is better" (Appendices 2 a n d 3). We
are u n a w a r e of a n y other s t u d i e s u s i n g this approach; it w a s
developed specifically for this study.
In the findings, the direct, indirect, a n d total (causal)
effects are p r e s e n t e d in 2 f o r m s (Table 2). For "life is better,"
we r e p o r t the effects u s i n g a n e w measure---the percent change
in the odds (%Aodds) of feeling t h a t life is b e t t e r per standard
deviation increase (SDI) in a predictor (%Aodds/SDI). For a
p a r t i c u l a r path, % A o d d s / S D I is calculated u s i n g u n s t a n d a r d ized p a t h coefficients a n d the m o s t distal variable's SD. The
p a t h coefficients for the s t e p s b e t w e e n the variables of i n t e r e s t
$31
are multiplied, t h u s yielding the c h a n g e in log-odds resulting
from a 1-unit i n c r e a s e in the distal variable. This value is t h e n
multiplied by t h e distal variable SD to p r o d u c e the c h a n g e in
log-odds r e s u l t i n g from a 1-SD i n c r e a s e in t h e distal variable.
The e x p o n e n t of the value yields the o d d s ratio (OR); multiplying the OR by 100 a n d s u b t r a c t i n g 100 yields the %Aodds/SDI
in the distal variable. T h e s e p a t h coefficients, %Aodds/SDl,
are s e m i - s t a n d a r d i z e d - - t h e predictors c a n be viewed as s t a n d ardized, while t h e d e p e n d e n t variable is not. As t h e d e p e n d e n t
variable is the s a m e for e a c h predictor, the p a t h coefficients
are comparable. For the other e n d o g e n o u s variables, the
effects of their predictors are s h o w n a s ]3 coefficients.
In p r e s e n t i n g our results, we refer to effects with adjectives s u c h as "small," "moderate," a n d "strong." These reflect
our j u d g m e n t s of the s t r e n g t h of effects b e c a u s e there is no
gold s t a n d a r d ; however, we do p r e s e n t t h e coefficients for r e a d ers to m a k e t h e i r own j u d g m e n t s . The p a t h analysis w a s cond u c t e d u s i n g SPSS, version 12.0.2 (SPSS, Inc., Chicago, IL).
RESULTS
A total of 449 p a t i e n t s a n s w e r e d the q u e s t i o n t h a t a s k e d t h e m
to compare life before having HIV/AIDS with life now. The m e a n
(SD) age w a s 43.3 (8.4) years. A total of 386 (86.0%) p a t i e n t s
were male; 225 (50.1%) were African American, 203 (45.2%)
were C a u c a s i a n , a n d 10 (2.2%) were Hispanic (Table 1). The
majority of t h e p a t i e n t s (342 [76.5%]) were treated with
mul;HAART.
Preliminary Model Testing
Comparing life n o w with their life before t h e y k n e w they h a d
HIV/AIDS, 145 (32.3%; 95% CI: 28.1 to 36.8%) p a t i e n t s said
life w a s b e t t e r now, 130 (29.0%) said it w a s worse, 116 (25.8%)
said it w a s a b o u t the same, a n d 58 (12.9%) did not know. In
bivariate analyses, believing t h a t life w a s b e t t e r now was associated with c e r t a i n demographic, h e a l t h s t a t u s , spirituality/
religion, a n d o t h e r p e r s o n a l c h a r a c t e r i s t i c s (online A p p e n d i x
2, Table S 1). A m o n g the d e m o g r a p h i c variables, p a t i e n t s who
h a d a t t e n d e d college, p a t i e n t s who were currently employed,
a n d p a t i e n t s who identified t h e m s e l v e s a s having a religion
were significantly (P< .05) more likely to say t h a t their life is
b e t t e r now t h a n before they k n e w t h e y c o n t r a c t e d HlV. All of
the HAT-QoL d o m a i n s were significantly a s s o c i a t e d with feeling t h a t life is better, s u c h t h a t higher HAT-QoL scores were
a s s o c i a t e d with a greater probability of feeling t h a t life is better. P a t i e n t s believing life h a d improved h a d significantly fewer
b o t h e r s o m e HIV-related s y m p t o m s , fewer depressive s y m p toms, a n d greater levels of optimism, self-esteem, and social
support. Feeling t h a t life is b e t t e r n o w w a s also associated with
level of participation in nonorganized religious activity, with
intrinsic religiosity, with b o t h positive a n d negative religious
coping, a n d with greater spiritual well-being. Believing t h a t life
is b e t t e r n o w w a s not significantly a s s o c i a t e d with length of
time since diagnosis, receipt or a d h e r e n c e to HAART, detectable v e r s u s u n d e t e c t a b l e viral loads, h i s t o r y of injection d r u g
use, or alcohol use.
In our final multivariable logistic r e g r e s s i o n model,
p a t i e n t s saying t h a t life h a d improved h a d significantly
(P< .05) b e t t e r overall functioning; fewer worries a b o u t finances a n d HW disclosure; poorer HIV mastery; a n d greater levels
of spirituality (FACIT-SpEx scores) a n d o p t i m i s m (online
Szaflarski et al., Modeling the Effects of Spirituality
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Table I. Patient Characteristics
Mean (SD) age. y
Mean (SD; median [25th, 75th
percentiles]) time since diagnosis, y
Male. N (%)
Race
Caucasian, N (%)
African American, N (%)
Hispanic. N (%)
Other, N{%)
Sexual orientation
Heterosexual, N (%)
Gay or lesbian, N (%)
Bisexual, N (%)
Asexual, N {%1
Refused to answer, N (%)
Injection drug u s e history
Never used, N (%)
Past use, N (%)
Current use, N {%)
Refused to answer, N (%)
Number of alcoholic drinks per month,
Mean (SD; median [25th, 75th
percentiles])
Education level
Did not graduate from high school, N
43.3 (8.4)
8.4 (5.3; 8 [4, 12]}
386 (86.0)
203
225
10
11
(45.21
(50. II
(2.2)
(2.5)
148
226
54
2
19
(33.0)
(50.3)
(12,0)
(0.5)
(4.2)
370
61
12
6
12.5
(82.4)
(13.6)
(2.7)
(1.3}
(30.2; 1.5 [0.0, 9.0])
60 (13.4}
{%)
Graduated from high school b u t did
122 (27.2)
not attend college, N (%)
Attended college, N (%)
267 (59.5)
Employment s t a t u s
Working full-time, N {%)
180 (40.1)
Working part-time, N (%)
51 (11.4)
Not working. N (%)
218 (48.5)
Married or living with significant other,
121 (27.01
N (%}
Has one or more children, N (%)
139 (31.0)
Has a religion, N (%)
357 (79.5)
Taking highly active antiretroviral
342 (76.5)
therapy, N (%)
Mean (SD; median [25th, 75th
420.0 (301.0; 351 [192. 610])
percentiles]) CD4 count, cells/gL
Viral load < 400 copies/mL, N (%)
232 (52.7)
A p p e n d i x 2, T a b l e $2). A s h y p o t h e s i z e d , t h e i n t e r a c t i o n of
overall functioning and spirituality was negative and statistically s i g n i f i c a n t , i n d i c a t i n g t h a t s p i r i t u a l i t y w a s m o r e s t r o n g l y
r e l a t e d to feeling t h a t life is b e t t e r a m o n g p e r s o n s w i t h l o w e r
levels o f overall f u n c t i o n i n g t h a n a m o n g p e r s o n s w i t h h i g h e r
levels o f f u n c t i o n i n g . T h e a r e a u n d e r t h e r e c e i v e r o p e r a t i n g
c h a r a c t e r i s t i c (ROC) c u r v e for t h e final logistic r e g r e s s i o n m o d el w a s 0 . 7 9 .
Path Analysis
O w i n g to a s m a l l n u m b e r o f m i s s i n g v a l u e s o n t h e i n d e p e n d e n t
v a r i a b l e s ( O n l i n e A p p e n d i x 1), o u r p a t h a n a l y s i s is b a s e d o n
N = 4 4 7 . T h e p r e l i m i n a r y m o d e l t e s t i n g s h o w e d t h a t a g e , sex,
r a c e , l e n g t h of t i m e s i n c e d i a g n o s i s , a n d m e d i c a t i o n a d h e r e n c e
w e r e n o t a s s o c i a t e d w i t h f e e l i n g t h a t life is better. T h e r e f o r e ,
t h e s e v a r i a b l e s w e r e n o t i n c l u d e d in t h e p a t h a n a l y s i s .
I n o u r p a t h m o d e l , all b i v a r i a t e c o r r e l a t i o n s ( P e a r s o n ' s r)
w e r e p o s i t i v e a n d s i g n i f i c a n t ( r = . 19 to .62; P < . 0 0 1 } . W e o b s e r v e d t h a t a 1-factor m o d e l b a s e d o n t h e D U R E L , F A C I T - S p Ex, a n d R C O P E - P o s i t i v e y i e l d e d a p l a u s i b l e c o m p o s i t e (App e n d i x A). We a l s o f o u n d t h a t m e d i c a t i o n a d h e r e n c e d i d n o t
a f f e c t "life is b e t t e r " d i r e c t l y o r i n d i r e c t l y t h r o u g h h e a l t h s t a -
JGIM
tus/health concerns. Therefore, we dropped medication adh e r e n c e f r o m t h e a n a l y s i s . Also, w e o b s e r v e d t h a t s o c i a l
s u p p o r t a n d s e l f - e s t e e m do n o t d i r e c t l y a f f e c t "life is b e t t e r , "
b u t b o t h a f f e c t it i n d i r e c t l y . I n t h e a n a l y s i s below, we p r e s e n t
f i n d i n g s f r o m r e f i n e d e q u a t i o n s , i.e., e q u a t i o n s i n c l u d i n g o n l y
those variables that have statistically significant effects
(see A p p e n d i x C).
Healthy Beliefs, H e a l t h y beliefs h a s t h e l a r g e s t effect o n
"life is b e t t e r " ( A o d d s / S D I = 110%), t h a t is, a 1-SD i n c r e a s e in
h e a l t h y b e l i e f s i n c r e a s e s t h e o d d s of feeling t h a t life is b e t t e r b y
1 1 0 % (Table 2, c o l u m n 6}. O n l y h e a l t h s t a t u s / h e a l t h c o n c e r n s
i n t e r v e n e s b e t w e e n h e a l t h y beliefs a n d "life is better," b u t t h i s
i n d i r e c t effect a c c o u n t s for o n l y a s m a l l s h a r e of t h e i n f l u e n c e
o f h e a l t h y b e l i e f s o n "life is b e t t e r " ( A o d d s / S D I = 1 4 . 2 5 % ;
T a b l e 2, c o l u m n 4). H e a l t h y beliefs h a s a m o d e r a t e effect o n
h e a l t h s t a t u s ([~ = 0 . 2 8 ; T a b l e 2, c o l u m n 1) a n d a s d i s c u s s e d
below, h e a l t h s t a t u s / h e a l t h c o n c e r n s h a s a m o d e r a t e effect o n
t h e o d d s of f e e l i n g t h a t life is better. M o s t o f t h e effect of h e a l t h y
b e l i e f s o n "life i s b e t t e r " is d i r e c t ( A o d d s / S D I = 9 5 . 5 1 % ) . T h u s ,
m o s t of t h e effect of h e a l t h y beliefs o n "life is b e t t e r " o p e r a t e s
through mechanisms (intervening variables) that are not capt u r e d in o u r m o d e l .
Spirituality~Religion. T h e m o s t p r o x i m a l v a r i a b l e i n o u r
m o d e l , s p i r i t u a l i t y / r e l i g i o n , h a s t h e s e c o n d l a r g e s t effect o n
"life is b e t t e r " (68% A o d d s / S D I ; T a b l e 2; Fig. 1). M o r e t h a n h a l f
o f t h e effect of s p i r i t u a l i t y / r e l i g i o n o n "life is b e t t e r " is i n d i r e c t
(38% A o d d s / S D I ; T a b l e 2, c o l u m n 4) a n d t h u s , is d u e to t h e
i n t e r v e n i n g v a r i a b l e s in o u r m o d e l . T h e b a l a n c e ( A o d d s /
SDI = 2 9 . 9 7 % ) is d u e to t h e d i r e c t effect o f s p i r i t u a l i t y / r e l i g i o n
o n "life is b e t t e r . " T h e t a b l e s h o w s t h e c o n t r i b u t i o n of e a c h pot e n t i a l i n d i r e c t p a t h f r o m s p i r i t u a l i t y / r e l i g i o n to "life is b e t t e r . "
T h e s e p a t h s a r e g r o u p e d to p r e s e n t e a c h o t h e r v a r i a b l e i n t h e
m o d e l in t u r n a s t h e p r i n c i p a l i n t e r v e n i n g v a r i a b l e t h r o u g h
w h i c h s p i r i t u a l i t y / r e l i g i o n a f f e c t s "life is b e t t e r , " i.e., t h e v a r i a b l e d e f i n i n g t h e g r o u p h a s a d i r e c t effect o n "life is b e t t e r . " If
o n e o r m o r e v a r i a b l e s a r e a n t e c e d e n t to t h e p r i n c i p a l i n t e r v e n i n g v a r i a b l e i n a p a t h , it or t h e y a r e t h e m e c h a n i s m s
t h r o u g h w h i c h s p i r i t u a l i t y / r e l i g i o n o p e r a t e s to affect t h e
principal intervening variable.
S p i r i t u a l i t y / r e l i g i o n i n d i r e c t l y i n f l u e n c e s "life is b e t t e r "
p r i n c i p a l l y t h r o u g h i t s effect o n h e a l t h y b e l i e f s ( A o d d s /
SDI = 2 9 . 1 5 % ) . T h a t is, a 1-SD i n c r e a s e i n s p i r i t u a l i t y / r e l i g i o n
p r o d u c e s a 2 9 . 1 5 % i n c r e a s e in t h e o d d s of f e e l i n g t h a t life is
b e t t e r t h r o u g h i t s e f f e c t s o n h e a l t h y beliefs. H a l f of t h i s effect
( A o d d s / S D I = 15.13%) is d u e to t h e d i r e c t effect of s p i r i t u a l i t y /
religion o n h e a l t h y beliefs. T h e b a l a n c e is d i v i d e d a m o n g t h e
possible paths through which spirituality/religion indirectly
i n f l u e n c e s h e a l t h y beliefs. F o r e x a m p l e , a A o d d s / S D I of 5 . 9 9 %
is a t t r i b u t a b l e to a n i n c r e a s e i n s p i r i t u a l i t y / r e l i g i o n r e s u l t i n g
in a n i n c r e a s e in s e l f - e s t e e m , w h i c h , i n t u r n , l e a d s to a n i n crease in healthy beliefs and then an increase in the likelihood
o f b e l i e v i n g t h a t "life is b e t t e r . "
H e a l t h s t a t u s / h e a l t h c o n c e r n s is t h e o n l y o t h e r p r i n c i p a l
intervening variable through which spirituality/religion affects
"life is b e t t e r . " W h i l e i t s overall effect is v e r y s m a l l ( A o d d s /
SDI = 9 . 3 9 % ) , s p i r i t u a l i t y / r e l i g i o n p r o d u c e s b o t h u p w a r d a n d
d o w n w a r d p r e s s u r e s o n "life is b e t t e r " t h r o u g h h e a l t h s t a t u s /
h e a l t h c o n c e r n s . A s d i s c u s s e d below, h e a l t h s t a t u s / h e a l t h
c o n c e r n s h a s a p o s i t i v e d i r e c t effect o n "life is b e t t e r . "
C o n v e r s e l y , t h e d i r e c t effect of s p i r i t u a l i t y / r e l i g i o n o n h e a l t h
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Table 2. Direct, Indirect, a n d Total Effects of Paths Affecting View that Life is Better
Path to Life Is Better
Standard Deviation
Change in Penultimate
Variable in Causal Chain
per Standard Deviation
Increase in Most Distal
Variable in Path
Direct or
Indirect
Effects
Spirituality/Religion
Social Support
Self-Esteem
Social Support ~ Self-Esteem
Healthy Beliefs
Social Support --~ Healthy Beliefs
Social Support ~ Self-Esteem ~ Healthy Beliefs
Self-Esteem ~ Healthy Beliefs
Health Status/Health Concerns
Social Support ~ Health Status/Health Concerns
Social Support ~ Self-Esteem --, Health Status/Health Concerns
Social Support ~ Healthy Beliefs --~ Health Status/Health Concerns
Social Support ~ Self-Esteem --~ Healthy Beliefs
Health Status/Health Concerns
Self-Esteem ~ Health Status/Health Concerns
Self-Esteem --~ Healthy Beliefs --~ Health Status/Health Concerns
Healthy Beliefs ~ Health Status/Health Concerns
Social Support
Self-Esteem
Healthy Beliefs
Self-Esteem ~ Healthy Beliefs
Health Status/Health Concerns
Self-Esteem --~ Health Status/Concerns
Self-Esteem ~ Healthy Beliefs --. Health Status/Health Concerns
Healthy Beliefs ~ Health Status/Health Concerns
Self-Esteem
Healthy Beliefs
Health Status/Health Concerns
Healthy Beliefs ~ Health Status/Health Concerns
Healthy Beliefs
Health Status/Health Concerns
Health Status/Health Concerns
s t a t u s / h e a l t h c o n c e r n s is s m a l l , b u t n e g a t i v e ([3= 0.10;
T a b l e 2, c o l u m n 1). T h e r e a r e 7 i n d i r e c t effects of s p i r i t u a l i t y / r e l i g i o n o n h e a l t h s t a t u s / h e a l t h c o n c e r n s ; all a r e p o s i t i v e
a n d s m a l l , b u t s u m to a s m a l l effect (13= 0 . 2 9 ) . T h u s , a n inc r e a s e in s p i r i t u a l i t y / r e l i g i o n r e s u l t s in a n e g a t i v e effect o n
h e a l t h s t a t u s / h e a l t h c o n c e r n s a n d , in t u r n , o n "life is b e t t e r "
( A o d d s / S D I = 4.52%), b u t a l s o in a positive effect via s o c i a l
s u p p o r t , s e l f - e s t e e m , a n d h e a l t h y beliefs, o n h e a l t h s t a t u s /
h e a l t h c o n c e r n s , a n d , in t u r n , o n "life is b e t t e r " ( A o d d s /
SDI = 14.25%). Social s u p p o r t a n d s e l f - e s t e e m a r e n o t p r i n c i pal intervening variables t h r o u g h which spirituality/religion
a f f e c t s "life is better."
Social Support. Social s u p p o r t h a s a m o d e r a t e effect o n
"life is b e t t e r " ( A o d d s / S D I = 5 4 . 1 2 % ) . Social s u p p o r t d o e s n o t
directly affect "life is better." Therefore, all of t h e i n f l u e n c e of
s o c i a l s u p p o r t o n "life is b e t t e r " is i n d i r e c t a n d d u e to t h e
i n t e r v e n i n g v a r i a b l e s in o u r m o d e l .
H e a l t h y beliefs a n d h e a l t h s t a t u s / h e a l t h c o n c e r n s a r e t h e
p r i n c i p a l i n t e r v e n i n g v a r i a b l e s t h r o u g h w h i c h social s u p p o r t
a f f e c t s "life is better." T h e effect of social s u p p o r t via h e a l t h y
beliefs is slightly l a r g e r t h a n its effect via h e a l t h s t a t u s / h e a l t h
0.29
0.20
0.14
0.21
0.06
0.06
0.09
~).10
0.07
0.04
0.02
0.02
Total
Effect
Percent Change in Odds of
Believing that Life is Better
per Standard Deviation
Increase in Most
Distal Variable in Path
Direct
Effect
Indirect
Effects
29.97
38.54
0.00
0.00
0.00
15.13
3.89
4.14
5.99
-4.52
3.45
2.00
0.76
0.81
0.29
0.33
0.41
0.19
0.06
0.02
0.06
0.00
0.47
0.20
0.21
0.25
0.14
0.06
0.06
0.47
0.41
0.44
0.31
0.12
0.44
0.31
0.28
0.28
0.51
0.00
95.51
60.64
2.88
1.16
2.84
54.12
0.00
14.10
15.04
12.42
7.09
2.82
2.66
45.16
23.41
15.66
6.09
14.25
14.25
0.00
Subtotal
Indirect
Effects
Total
Effect
68.50
0.00
0.00
29.15
9.39
54.12
0.00
29.13
24.99
45.16
23.41
21.75
109.75
14.25
60.64
c o n c e r n s , b u t b o t h effects a r e s m a l l { A o d d s / S D I = 2 9 . 1 3 % v s
2 4 . 9 9 % , respectively).
A b o u t h a l f of t h e effect of social s u p p o r t via h e a l t h y beliefs
( A o d d s / S D I = 14.10%) o c c u r s t h r o u g h t h e d i r e c t effect of social s u p p o r t o n h e a l t h y beliefs (13= 0 . 2 0 ) . T h e b a l a n c e is d u e to
social s u p p o r t ' s i n d i r e c t i n f l u e n c e o n h e a l t h y beliefs via selfe s t e e m ( A o d d s / S D I = 15.04%).
Similarly, a b o u t h a l f of t h e effect of social s u p p o r t via h e a l t h
s t a t u s / h e a l t h c o n c e r n s ( A o d d s / S D I = 12.42%) o c c u r s b e c a u s e
of t h e d i r e c t effect of social s u p p o r t o n h e a l t h s t a t u s / h e a l t h
c o n c e r n s (13= 0 . 2 5 ) . T h e b a l a n c e ( A o d d s / S D I = 12.57~ is d u e
to social s u p p o r t ' s i n d i r e c t i n f l u e n c e s o n h e a l t h s t a t u s / h e a l t h
c o n c e r n s via s e l f - e s t e e m a n d h e a l t h y beliefs.
Self-Esteem, S e l f - e s t e e m also h a s a m o d e r a t e effect o n
"life is b e t t e r " ( A o d d s / S D I = 4 5 . 1 6 % ) . S e l f - e s t e e m d o e s n o t directly affect "life is b e t t e r " - - a l l of its i n f l u e n c e o n "life is b e t t e r "
is i n d i r e c t a n d d u e to t h e i n t e r v e n i n g v a r i a b l e s in o u r m o d e l .
H e a l t h y beliefs a n d h e a l t h s t a t u s / h e a l t h c o n c e r n s a r e t h e
principal intervening variables through which self-esteem
affects "life is b e t t e r . " T h e effect of s e l f - e s t e e m via h e a l t h y
beliefs is a b o u t t h e s a m e a s its effect via h e a l t h s t a t u s / h e a l t h
Szaflarski et al., Modeling the Effects of Spirituality
$34
c o n c e r n s , b u t b o t h effects are small ( A o d d s / S D I = 2 3 . 4 1 % vs
21.75%, respectively). The effect of self-esteem via h e a l t h stat u s / h e a l t h c o n c e r n s (Aodds/SDI = 15.66%) o c c u r s b e c a u s e of
t h e direct effect of s e l f - e s t e e m on h e a l t h s t a t u s / h e a l t h conc e r n s (13=0.31). The b a l a n c e is due to self-esteem's indirect
influence on health s t a t u s / h e a l t h c o n c e r n s via h e a l t h y beliefs
(Aodds/SDI =6.09%).
Health Status~Health Concerns. Health s t a t u s / h e a l t h
c o n c e r n s is the third s t r o n g e s t predictor of "life is better"
(Aodds/SDI =60.64%). It is the ultimate d e t e r m i n a n t of "life
is better" in the model; t h u s , its effect is direct.
DISCUSSION
O u r results confirm our h y p o t h e s e s t h a t spirituality/religion
is positively associated w i t h the feeling t h a t life h a s improved
in p a t i e n t s with HIV/AIDS. 18 Our findings are t h u s similar to
findings from s t u d i e s of p a t i e n t s with cancer, w h i c h have
f o u n d t h a t greater levels of overall well-being are a s s o c i a t e d
w i t h hope 40'41 a n d b e t t e r psychological a d j u s t m e n t . 4~
Our
s t u d y a d d s to the c u r r e n t literature by exploring a n e w outcome in p a t i e n t s with HIV/AIDS, feeling t h a t life h a s improved
s i n c e diagnosis. Also, a n e w finding from this s t u d y is t h a t
spirituality/religion h a s the s e c o n d s t r o n g e s t a s s o c i a t i o n with
feeling t h a t life h a s improved, n e x t to h e a l t h y beliefs, or a positive life outlook. F u r t h e r m o r e , we were able to d e m o n s t r a t e
t h a t half of spirituality/religion's association with believing
t h a t life is b e t t e r is a direct effect w h e r e a s the o t h e r h a l f is indirect, mostly t h r o u g h h e a l t h y beliefs. Both direct a n d mediating effects of spirituality/religion on h e a l t h a n d well-being
are s u p p o r t e d by other r e s e a r c h as well. 14
A proportion of the direct influence of spirituality/religion
r e m a i n e d u n e x p l a i n e d b y o u r model, a n d the c o n t r i b u t i o n
of social s u p p o r t a n d self-esteem as mediating factors w a s
small. O t h e r r e s e a r c h h a s s h o w n t h a t social ties, along with
h e a l t h behaviors a n d i n d i c a t o r s of welt-being, a t t e n u a t e b u t
do not eliminate the a s s o c i a t i o n b e t w e e n religion a n d b e t t e r
functioning. 44 Also, spirituality/religion m a y foster n o t only
self-esteem b u t also o t h e r a s p e c t s of the c o n c e p t of self/selfperception, e.g., p e r s o n a l m a s t e r y . 4a Spirituality/religion may
m a k e serious health p r o b l e m s less t h r e a t e n i n g to one's core
s e n s e of self, partly by raising a w a r e n e s s of other, n o n p h y s i c a l
a s p e c t s of self-definition (e.g., talents, traits, character, morality) t h a t m a y b e c o m e m o r e central for p e r s o n s confronting
h e a l t h crises, a'46 Our m e a s u r e of self-esteem a n d the conceptual model may have c a p t u r e d only a p a r t of the mediating
effect of the larger self-concept.
We were s u r p r i s e d t h a t social s u p p o r t a n d self-esteem
were not directly a s s o c i a t e d with feeling t h a t life h a s improved;
instead, they operate t h r o u g h h e a l t h y beliefs. F u t u r e r e s e a r c h
s h o u l d look at the role of social isolation experienced b y pat i e n t s with H1V/AIDS, 14 e.g., social isolation m a y affect people
variably d e p e n d i n g on p e r s o n a l a t t i t u d e s (e.g., "I d o n ' t n e e d
anybody," "I'll be fine w i t h o u t them"). The effect of social s u p port m a y operate exclusively t h r o u g h psychological factors,
s u c h a s a positive life outlook. In addition, a n overlap b e t w e e n
positive life outlook a n d t h e view t h a t life h a s improved may
r e s u l t in the strong relationship t h a t we observed. The c h a n g e s
in a s e n s e of m e a n i n g a n d p u r p o s e in life e x p e r i e n c e d by
people affected by HIV/AIDS, a n d the resulting f r e s h p e r s o n al insights, 47 are difficult to disentangle. Although h e a l t h y
JGIM
beliefs a p p e a r to play a n i n s t r u m e n t a l role in the view that
life h a s improved, a closer e x a m i n a t i o n of t h e overlap b e t w e e n
the 2 c o n c e p t s is needed.
We also tested a 2-factor distal-proximal model of spirituality/religion. We found t h a t the distal factors (e.g., frequency
of a t t e n d i n g services) a n d the proximal factors (e.g., religious
coping) did n o t r e p r e s e n t 2 different d i m e n s i o n s of spirituality/religion in our s a m p l e of p a t i e n t s with HW/AIDS. Thus,
the various spirituality/religion m e a s u r e s a p p e a r to be closely
related to e a c h other a n d contribute a s a group to the overall
construct. However, our results do confirm t h e i m p o r t a n t contribution of previously identified e l e m e n t s of the c o n s t r u c t ,
e.g., formal religious participation, religious coping, etc., as
well as t h e c o n s t r u c t ' s complex a n d multifaceted c h a r a c t e r 11
with m a n y overlapping c o m p o n e n t s t h a t are difficult to disentangle (e.g., frequency vs c o n t e n t of prayer), w h i c h m a y be why
we could n o t clearly see a distinction b e t w e e n the distal and
the proximal factors. One contradiction with previous res e a r c h 2s w a s the finding t h a t negative religious coping did
not fit into t h e spirituality/religion m e a s u r e m e n t model. Furt h e r e x a m i n a t i o n of this m e a s u r e a s well a s s t u d i e s a d d r e s s i n g
the possible negative (undesirable) implications of certain asp e c t s of spirituality/religion (e.g., pathological coping app r o a c h e s s u c h a s feelings of a n g e r at God, guilt, or shame)
are r e c o m m e n d e d .
In this study, we u s e d logistic r e g r e s s i o n and p a t h analysis c o m b i n i n g logistic a n d ordinary l e a s t s q u a r e s regression.
Ordinary l e a s t s q u a r e s regression is a b o u t partitioning varia n c e while p a t h analysis a d d s the p e r s p e c t i v e of partitioning
covariance. For any pair of variables in a p a t h model, their
correlation c a n be partitioned into c a u s a l a n d n o n c a u s a l effects. Also, t h e c a u s a l effects, if any, c a n b e partitioned into
direct effect a n d indirect effects. The i m p o r t a n c e of this
"additional" perspective is t h a t we c a n t e s t our various explanations for t h e association of variables. The indirect effects are
the p o s t u l a t e d "causal m e c h a n i s m " p r o d u c i n g a n association
b e t w e e n variables. The direct effects r e p r e s e n t the causal
effect of the i n d e p e n d e n t variable d u e to all u n m e a s u r e d
m e c h a n i s m s ; a s such, it is a type of residual.
Logistic regression is not ordinary regression; it begins
with a d i c h o t o m o u s outcome. Ideas a b o u t predictors are u s u ally theoretical ideas a b o u t the d e t e r m i n a n t s of the underlying
probabilities of some variable. Logistic regression coefficients
are often converted to ORs to m a k e the relationships more intuitive. There are s o m e p s e u d o - s t a n d a r d i z e d coefficients for
logistic regression, b u t their use with o r d i n a r y least s q u a r e s
s t a n d a r d i z e d coefficients is u n t e n a b l e . We developed a semis t a n d a r d i z e d coefficient as p a r t of t h i s project. T h e s e coefficients yield information as if the p r e d i c t o r s are s t a n d a r d i z e d
(z-scores) a n d contributing to the resulting ORs. The coefficients allow u s c o m p a r e the relative s t r e n g t h of predictors. The
idea w a s e x t e n d e d to develop coefficients for direct a n d
indirect effects. These coefficients allowed a s s e s s m e n t a n d
c o m p a r i s o n of the w a y s in w h i c h a predictor a c t s o n the
d i c h o t o m o u s d e p e n d e n t variable.
As with a n y research, this s t u d y h a s several s h o r t c o m ings. In particular, the d a t a u s e d in t h i s analysis are crosssectional, a n d our outcome m e a s u r e is b a s e d on self-report at
one point in time. Quality of life w a s a s s e s s e d retrospectively
a n d r e s p o n s e s reflect only p a t i e n t s ' c u r r e n t p e r c e p t i o n s of
their p r e s e n t v e r s u s past-QoL. S u c h "transition questions"
m a y reflect a r e s p o n s e shift resulting from a c h a n g e in u n d e r -
JGIM
Szaflarski et al., Modeling the Effects of Spirituality
lying health, 4s may or m a y n o t mirror serially a s s e s s e d
m e a s u r e s , a n d may m e a n different t h i n g s to different people48-51--and yet s u c h retrospective a s s e s s m e n t m a y be preferable to serial a s s e s s m e n t . 19'52 F u t u r e s t u d i e s u s i n g
longitudinal d a t a a n d multiple a n d more objective i n d i c a t o r s
of c h a n g e s in p e r c e p t i o n s of living with HIV/AIDS w o u l d be
helpful. About half the effect of spirituality/religion o n feeling
t h a t life is b e t t e r now, the direct effect, is due to m e c h a n i s m s
(intervening variables) t h a t are n o t included in the m o d e l a n d
t h u s r e m a i n for future r e s e a r c h .
A n o t h e r limitation is t h e s t u d y ' s u s e of a single indicator
of life is better now. Usually, multiple indicator m e a s u r e s are
one of 2 types. One d e p e n d s o n t h e composite being m o r e reliable t h a n the average individual item. The average item often
less directly m e a s u r e s the c o n s t r u c t of interest, a n d t h e validity of a n e w composite is t e n u o u s . Our single m e a s u r e is a
straightforward question a b o u t o u r c o n c e r n and, a s s u c h , is
b e i n g s h a p e d by a r e s p o n d e n t ' s s e n s e of w h e t h e r h i s / h e r life is
b e t t e r now. It certainly h a s m o r e face validity t h a t t h e typical
n e w composite. Also, typically, a composite likely would
achieve the reliability of o u r q u e s t i o n only t h r o u g h having a
s u b s t a n t i a l n u m b e r of items. The o t h e r c o m m o n type of multiple indicator m e a s u r e u s e s i t e m s to m e a s u r e different p a r t s
of t h e whole. The validity of t h i s s e c o n d type is generally more
difficult to e s t a b l i s h b e c a u s e it m u s t define the essential p a r t s
of t h e whole. This is very difficult, a n d this is a less c o m m o n l y
c h o s e n route of m e a s u r e m e n t . It does offer the intriguing opp o r t u n i t y to explore the d e t e r m i n a n t s of different p a r t s of the
whole. We decided to explore possible e x p l a n a t i o n s for a relat i o n s h i p b e t w e e n spirituality/religion a n d "life is better" before
exploring the i s s u e of w h a t p o s s i b l e s u b d i m e n s i o n s of "life is
b e t t e r now" might contribute to this relationship.
Despite its limitations, this s t u d y provides n e w i n s i g h t s
into the m e c h a n i s m s t h r o u g h w h i c h spirituality/religion affects p a t i e n t s ' p e r c e p t i o n s of living with HIV/AIDS. F u t u r e res e a r c h s h o u l d validate our n e w c o n c e p t u a l model u s i n g o t h e r
s a m p l e s a n d longitudinal s t u d i e s . Alternative models s h o u l d
also b e developed a n d tested, focusing on the a s s o c i a t i o n s bet w e e n specific d i m e n s i o n s of spirituality/religion (as o p p o s e d
to t h e b r o a d c o n s t r u c t of spirituality/religion t h a t we used)
a n d o u t c o m e s in p a t i e n t s with HIV/AIDS.
The r e s u l t s of this s t u d y have 2 m a i n implications. First,
t h e finding t h a t m a n y p a t i e n t s n o t only can cope a n d a d a p t to
s u c h a serious i l l n e s s - - b u t actually r e a c h a point w h e r e t h e y
believe t h a t life is better t h a n before being diagnosed w i t h HIV/
AIDS---offers hope for n u m e r o u s people infected with a virus
t h a t once p o r t e n d e d only suffering a n d death. Clinicians m a y
u s e t h e s e Findings in c o u n s e l i n g p a t i e n t s newly d i a g n o s e d with
HIV/AIDS, with the caveat t h a t one does not k n o w h o w long it
t a k e s to feel t h a t life h a s b e c o m e better. Second, the findings
p o i n t to the need to raise a w a r e n e s s a m o n g clinicians a b o u t
the i m p o r t a n c e of spirituality/religion in the lives of p a t i e n t s
with HIV/AiDS. Tools a n d t e c h n i q u e s to help e d u c a t o r s
a n d clinicians incorporate spiritual a s s e s s m e n t s are readily
available. 53-57
$35
alternative scaling s c h e m e after a failed a t t e m p t to include
the 2 latent variables in a p a t h model.
Confirmatory Factor A n a l y s i s
We c o n d u c t e d confirmatory factor a n a l y s e s of spirituality/religion (2 factors: distal a n d proximal) a n d h e a l t h s t a t u s / h e a l t h
c o n c e r n s (3 factors: HAT-QoL, HSI, a n d CESD-10) by u s i n g
LISREL, version 8.3 (Scientific Software International, Inc.,
Chicago, IL). The results for each of t h e 2 latent variables were
a s follows:
Spirituality/Religion. A 2-factor m o d e l of distal a n d
proximal spirituality/religion did not fit the data. Instead, a
1-factor model b a s e d on the DUREL, FACIT-Sp-Ex, and RCOPEPositive yielded a plausible solution (Z2 = 3 . 9 7 , d f = 5 , P = . 5 5 4 ;
root m e a n s q u a r e error of a p p r o x i m a t i o n = 0 . 0 0 0 ; goodness-offit i n d e x = 0 . 9 9 2 ) . The factor loadings were 0.633 (DURELORA), 0.656 (DUREL-NORA), 0.826 (DUREL-IR), 0.606
(FACIT-Sp-Ex), a n d 0.814 (RCOPE-Positive). The RCOPENegative scale did not fit the model.
Health Status/Health Concerns. The h e a l t h s t a t u s /
h e a l t h c o n c e r n s model b a s e d on the HAT-QoL, HSI, a n d
CESD-10 w a s a perfect fit with our d a t a b e c a u s e the model
w a s j u s t identified, as Often in factor analysis, t h e n u m b e r of
u n k n o w n s , i.e., factor loadings, is fewer t h a n the n u m b e r of
e q u a t i o n s d e s c r i b i n g the model being fitted. Factor analysis
p r o d u c e s a best-fit solution for the loadings, b u t the loadings
m a y r e p r o d u c e the correlations a m o n g the observed variables
poorly, i.e., t h e fit may be a poor one. In a just-identified
e q u a t i o n s y s t e m , the n u m b e r of u n k n o w n s equals t h e
n u m b e r of equations, a n d the model h a s a solution. T h e s e
factor loadings r e p r o d u c e perfectly t h e actual correlations
a m o n g the i t e m s (hence the t e r m "a perfect fit"). In a j u s t identified model, the criterion of a good fit is n o t statistical, b u t
h i n g e s on theoretical e x p e c t a t i o n s - - w h e t h e r t h e loadings are
the size one w o u l d expect, given the logic of t h e model. Here,
the loadings were moderately high (0.69, 0.84, a n d 0.85),
indicating a good fit.
Alternative M e a s u r e m e n t for Spirituality/
Religion and Health S t a t u s / C o n c e r n s
We were u n a b l e to fit a s t r u c t u r a l model including the l a t e n t
variable models, so we formed composite m e a s u r e s of spirituality/religion a n d h e a l t h s t a t u s / c o n c e r n s . To form the composite m e a s u r e of spirituality/religion, we converted the
loadings from e a c h of the 5 spirituality/religion variables
(the 3 DUREL s u b s c a l e s , the FACIT-Sp-Ex, a n d the RCOPEPositive) into z - s c o r e s a n d s u m m e d t h e m . Using z-scores
equally weights t h e 5 variables forming t h e composite. Similarly, we converted e a c h of the 3 h e a l t h s t a t u s / h e a l t h c o n c e r n s
variables into z - s c o r e s a n d s u m m e d t h e m to form a composite
m e a s u r e . The C r o n b a c h ' s c( statistic b a s e d on s t a n d a r d i z e d
items w a s 0.83 for the spirituality/religion composite a n d 0.81
for the h e a l t h s t a t u s / h e a l t h c o n c e r n s composite.
APPENDIX A: MEASUREMENT OF SPIRITUALITY/
RELIGION AND HEALTH STATUS/HEALTH CONCERNS
APPENDIX B: PATH ANALYSIS COMBINING
ORDINARY LEAST SQUARES AND LOGISTIC
REGRESSION
To m e a s u r e 2 latent variables, spirituality/religion a n d h e a l t h
s t a t u s / h e a l t h concerns, we First tested the c o n s t r u c t s u s i n g
confirmatory factor analysis. Second, we developed a n
As explained b y Pedhazur, "In a c a u s a l model, a distinction
is m a d e b e t w e e n exogenous a n d e n d o g e n o u s variables. An
exogenous variable is one w h o s e variation is a s s u m e d to be
$36
]GIM
S z a f l a r s k i e t al., M o d e l i n g t h e E f f e c t s o f S p i r i t u a l i t y
d e t e r m i n e d by c a u s e s o u t s i d e the hypothesized model . . . . An
e n d o g e n o u s variable, conversely, is one w h o s e variation is exp l a i n e d by exogenous or o t h e r e n d o g e n o u s variables in the
model" (p. 770). 39 Spirituality/religion is the lone exogenous
variable; the others are e n d o g e n o u s . Path coefficients are
derived from a set of r e g r e s s i o n e q u a t i o n s t h a t describe
t h e model. E a c h e n d o g e n o u s variable is regressed on all of the
variables t h a t precede it in t h e causal chain. For example, "life
is better" is regressed on all the other variables; h e a l t h s t a t u s /
h e a l t h c o n c e r n s is r e g r e s s e d on the 5 variables to its left in
Figure 1; a n d so on, with social s u p p o r t r e g r e s s e d only on
spirituality/religion. Typically, each equation is e s t i m a t e d
with ordinary least s q u a r e s r e g r e s s i o n a n d the coefficients
yield the direct effect of e a c h predictor on each e n d o g e n o u s
v a r i a b l e - - t h e coefficients t h a t would a p p e a r o n t h e p a t h s
s h o w n in Figure 1. Again, typically, s t u d i e s s u c h a s o u r s rep o r t s t a n d a r d i z e d p a t h c o e f f i c i e n t s . Those a p p e a r i n g o n singleh e a d e d arrows, d i r e c t e f f e c t s , indicate t h e d e p e n d e n t variable
c h a n g e in SD u n i t s for a 1-SD change in the i n d e p e n d e n t variable. S u c h coefficients c a n be joined to derive i n d i r e c t e f f e c t s
b y multiplying the p a t h coefficients appearing on a s e q u e n c e of
s t e p s connecting a pair of variables t h a t have at least one
intervening variable. For example, one indirect effect of spirituality/religion on h e a l t h y beliefs is spirituality/religion's direct effect on social s u p p o r t , multiplied by social s u p p o r t ' s
direct effect on self-esteem, multiplied by self-esteem's direct
effect on h e a l t h y beliefs. The model depicts spirituality/religion having o t h e r indirect effects on h e a l t h y beliefs, e.g., spirituality/religion's direct effect on social s u p p o r t t i m e s social
s u p p o r t ' s direct effect on h e a l t h y beliefs. The first variable in a
c h a i n defining a n indirect effect c a n be viewed a s t h e indep e n d e n t variable and the l a s t a s the d e p e n d e n t variable. Like
t h e direct effect, a n indirect effect indicates the d e p e n d e n t
variable c h a n g e in SD u n i t s for a 1-SD change in the indep e n d e n t variable. While u n s t a n d a r d i z e d
coefficients can be
u s e d in p a t h models, s t a n d a r d i z e d p a t h coefficients allow direct c o m p a r i s o n s of any effects in the model b e c a u s e every
variable h a s the s a m e m e t r i c - - S D units. U n s t a n d a r d i z e d
coefficients are meaningfully c o m p a r e d only for t h e s a m e
i n d e p e n d e n t a n d d e p e n d e n t variable, i.e., w h e r e the m e t r i c s of
the variables are comparable. However, t h e typical a p p r o a c h is
not applicable for our s t u d y ' s p a t h model. While ordinary least
s q u a r e s r e g r e s s i o n may be u s e d to e s t i m a t e t h e effects of some
of the m o d e l ' s e n d o g e n o u s variables, "life is better" is binary
a n d typically e s t i m a t e d with logistic regression. Coefficients
from logistic a n d ordinary least s q u a r e s regressions are different s p e c i e s a n d are n o t usually m a t e d . We circumvented
this p r o b l e m b y deriving s e m i - s t a n d a r d i z e d p a t h c o e f f i c i e n t s
to p a r s e the direct a n d various indirect influences o n "life is
better."
APPENDIX C: DIRECT EFFECTS OF PREDICTOR
VARIABLES ON "LIFE IS BETTER"
E a c h a r r o w in the c o n c e p t u a l model r e p r e s e n t s the association
b e t w e e n t h e adjoining c o n s t r u c t s (Fig. 1), w h i c h is c a p t u r e d
t h r o u g h a regression model (Table A3). For linear relationships, we u s e d ordinary least s q u a r e s r e g r e s s i o n s a n d calculated b o t h u n s t a n d a r d i z e d (B) a n d s t a n d a r d i z e d (~) coefficients
(Table A3, right; t h e s e r e p r e s e n t the direct effects of a predictor
on the d e p e n d e n t variable). For d i c h o t o m o u s outcomes, we
u s e d logistic regression models. We p r e s e n t 3 versions of each
coefficient. The B coefficient s h o w s t h e c h a n g e in the log-odds
of feeling t h a t life is b e t t e r per u n i t i n c r e a s e in the predictor
(Table A3, left). If a coefficient's sign is positive, it indicates t h a t
the probability of feeling t h a t life is b e t t e r n o w i n c r e a s e s a s the
predictor i n c r e a s e s , b e c a u s e the log o d d s a n d the probability
of feeling t h a t life is b e t t e r are positively associated; however, a
coefficient relating to log o d d s is n o t very intuitive. Often, coefficients are converted to the s o m e w h a t more intuitive OR,
Exp(B); the OR equals the e x p o n e n t of t h e regression coefficient, e.g., t h e e x p o n e n t of the B for h e a l t h s t a t u s / h e a l t h
concerns, 0.19, is 1.20. The OR indicates the change in the
o d d s of feeling t h a t life is b e t t e r p e r u n i t i n c r e a s e in t h e predictor. Often, the OR is converted to the p e r c e n t c h a n g e in the
o d d s per u n i t increase in a predictor, calculated by multiplying
a n OR by 100 a n d s u b t r a c t i n g 100; e.g., a 1-point i n c r e a s e in
h e a l t h s t a t u s / h e a l t h c o n c e r n s r e s u l t s in a 20.4% i n c r e a s e in
Table A3. Regression Equations Providing Statistically Significant Direct Effects for Path Model
Predictor
Dependent Variables
Ordinary Least Squares Regressions
Binary Logistic Regression
Life is Better
B*
Health status/health concerns
Healthy beliefs
Self-esteem
Social support
Spirituality/religion
Intercept
Adjusted R2 or Nagelkcrke R2"
0.19
0.11
0.07
-3.11
Health
Status/Health
Concerns
Exp(B)*
Percent
Change in
Odds/Standard
Deviation Increase*
1.20
1.12
60.64
95.51
1.07
0.04
29.97
0.25*
B*
~*
0.12
0.22
0.08
- 0.06
9.51
0.28
0.31
0.25
- 0.10
0.44
Healthy
Beliefs
SelfEsteem
B*
p*
0.76
0.14
0.33
-0.68
0.44
0.20
0.21
0.45
Social
Support
B*
p*
0.20
0.18
12.11
0.47
0.20
0.31
B*
I~*
0.63
37.65
0.29
0.08
* Coefficients s h o w n are significant at P<. 05.
t N a g e l k e r k e R l =(1 - exp( - LR / n)) / (1 - exp( LL/n)), w h e r e LR is the model Likelihood Ratio •2 EL i~S the - 2 log likelihood f o r a n intercept-only model
(i.e., m a ~ m u m value that the numerator m a y have), a n d n is the s a m p l e size.
JGIM
Szaflarski et al., Modeling the Effects of Spirituality
t h e o d d s t h a t life is b e t t e r (not p r e s e n t e d ) . We m o d i f i e d t h e
e x p r e s s i o n of t h e OR to s h o w t h e p e r c e n t c h a n g e in t h e o d d s
per SD i n c r e a s e in a p r e d i c t o r (% A o d d s / S D I ) , e.g., a 1-SD inc r e a s e in h e a l t h s t a t u s / h e a l t h c o n c e r n s r e s u l t s in a 6 0 . 6 %
i n c r e a s e in t h e o d d s t h a t life is better. (In T a b l e A3, % A o d d s /
SDI is c a l c u l a t e d b y (1) m u l t i p l y i n g t h e B coefficient b y t h e
p r e d i c t o r ' s SD; (2) t a k i n g t h e e x p o n e n t of t h e p r o d u c t to o b t a i n
a n OR; a n d (3) m u l t i p l y i n g t h a t OR b y 100 a n d s u b t r a c t i n g
100. I n t h e m a n u s c r i p t ' s T a b l e 2, t h e logic is e x t e n d e d , b u t t h e
c a l c u l a t i o n is m o r e involved.) T h e p e r c e n t c h a n g e in t h e o d d s
per SD i n c r e a s e in a p r e d i c t o r a l l o w s o n e to c o m p a r e t h e relative s t r e n g t h of p r e d i c t o r s in t h e e q u a t i o n . We u s e t h e coeffic i e n t s p r e s e n t e d in T a b l e A3 to develop t h e m o r e c o m p l e t e l y
specified r e s u l t s s h o w n in T a b l e 2. Below, we briefly r e v i e w
t h e s e direct effects p r e s e n t e d in T a b l e A3.
We h y p o t h e s i z e d t h a t a n i n c r e a s e in s p i r i t u a l i t y / r e l i g i o n
w o u l d (directly) r e s u l t in a n i n c r e a s e in social s u p p o r t . T h e
hypothesis was corroborated; spirituality/religion has a
m o d e r a t e effect o n social s u p p o r t ([3= 0 . 2 9 ) .
We h y p o t h e s i z e d t h a t a n i n c r e a s e in s p i r i t u a l i t y / r e l i g i o n
w o u l d r e s u l t in a n i n c r e a s e in self-esteem. The h y p o t h e s i s w a s
c o r r o b o r a t e d ; s p i r i t u a l i t y / r e l i g i o n h a s a s m a l l effect o n self-est e e m ([3 = 0 . 2 0 ) . We also h y p o t h e s i z e d t h a t a n i n c r e a s e in social
s u p p o r t w o u l d r e s u l t in a n i n c r e a s e in self-esteem. T h e h y p o t h e s i s w a s corroborated; social s u p p o r t h a s a s t r o n g effect o n selfe s t e e m ([~= 0 . 4 7 ) . Together, s p i r i t u a l i t y / r e l i g i o n a n d social s u p p o r t a c c o u n t for 31% of t h e v a r i a t i o n in self-esteem (R2 = . 3 1 ) .
We h y p o t h e s i z e d t h a t s p i r i t u a l i t y / r e l i g i o n , social s u p p o r t ,
a n d s e l f - e s t e e m w o u l d e a c h h a v e a direct, positive i n f l u e n c e o n
h e a l t h y beliefs. T h e s e h y p o t h e s e s w e r e c o r r o b o r a t e d . A n inc r e a s e in s p i r i t u a l i t y / r e l i g i o n r e s u l t s in a s m a l l i n c r e a s e in
h e a l t h y beliefs ([3 = 0 . 2 1 ) . A n i n c r e a s e in social s u p p o r t a l s o
r e s u l t s in a s m a l l i n c r e a s e i n h e a l t h y beliefs ([3 = 0 . 2 0 ) . A n inc r e a s e in s e l f - e s t e e m r e s u l t s in a n i n c r e a s e in h e a l t h y beliefs;
its effect ([3 = 0 . 4 4 ) is a p p r o x i m a t e l y twice t h e effects of s p i r i t u a l i t y / r e l i g i o n a n d social s u p p o r t . Together, s p i r i t u a l i t y /
religion, social s u p p o r t , a n d s e l f - e s t e e m a c c o u n t for 4 5 % of
t h e v a r i a t i o n in h e a l t h y beliefs.
We h y p o t h e s i z e d t h a t spirituality/religion, social s u p p o r t ,
self-esteem, a n d h e a l t h y beliefs w o u l d e a c h h a v e a direct, positive influence o n h e a l t h s t a t u s / h e a l t h c o n c e r n s . H y p o t h e s e s reg a r d i n g social s u p p o r t , self-esteem, a n d h e a l t h y beliefs w e r e
c o r r o b o r a t e d . An i n c r e a s e in social s u p p o r t r e s u l t s in a m o d e r ate i n c r e a s e in h e a l t h s t a t u s / h e a l t h c o n c e r n s ([3= 0 . 2 5 ) . An inc r e a s e in self-esteem r e s u l t s in a n i n c r e a s e in h e a l t h y beliefs; its
effect is m o d e r a t e (I3=0.31). A n i n c r e a s e in h e a l t h y beliefs a l s o
r e s u l t s in a m o d e r a t e i n c r e a s e in h e a l t h s t a t u s / h e a l t h c o n c e r n s
(~ = 0 . 2 8 ) . While s p i r i t u a l i t y / r e l i g i o n h a s a direct effect o n h e a l t h
s t a t u s , it is s m a l l a n d negative. A n i n c r e a s e in s p i r i t u a l i t y / r e l i gion r e s u l t s in a s m a l l d e c r e a s e in h e a l t h s t a t u s / h e a l t h conc e r n s ( [ 3 = - 0 . 1 0 ) , w h e n controlling for t h e effects of social
s u p p o r t a n d self-esteem. Together, spirituality/religion, social
s u p p o r t , self-esteem, a n d h e a l t h y beliefs a c c o u n t for 4 4 % of t h e
v a r i a t i o n in h e a l t h s t a t u s / h e a l t h c o n c e r n s .
We h y p o t h e s i z e d t h a t s p i r i t u a l i t y / r e l i g i o n , social s u p p o r t ,
s e l f - e s t e e m , h e a l t h y beliefs, a n d h e a l t h s t a t u s / h e a l t h c o n c e r n s w o u l d e a c h h a v e direct, p o s i t i v e i n f l u e n c e s o n t h e p r o b ability of feeling t h a t life is better. As n o t e d above, social
s u p p o r t a n d s e l f - e s t e e m did not directly affect "life is b e t t e r , "
a n d those 2 h y p o t h e s e s were refuted.
H y p o t h e s e s r e g a r d i n g spirituality/religion, h e a l t h y beliefs,
a n d h e a l t h s t a t u s / h e a l t h c o n c e r n s w e r e c o r r o b o r a t e d . An in-
S37
c r e a s e in s p i r i t u a l i t y / r e l i g i o n r e s u l t e d in a s m a l l increase in the
feeling t h a t life is b e t t e r - - a 1-SD i n c r e a s e in s p i r i t u a l i t y / r e l i g i o n
r e s u l t s in a 2 9 . 9 7 % i n c r e a s e in o d d s of feeling t h a t life is b e t t e r
( A o d d s / S D I =29.970/0). An i n c r e a s e in h e a l t h y beliefs r e s u l t s in
a n i n c r e a s e in t h e feeling t h a t life is better; its effect is s u b s t a n tial a n d 3 t i m e s t h e direct effect of s p i r i t u a l i t y / r e l i g i o n ( A o d d s /
S D I = 9 5 . 5 1 % v s 29.97%, respectively). An i m p r o v e m e n t in
h e a l t h s t a t u s / h e a l t h c o n c e r n s c a u s e s a m o d e r a t e i n c r e a s e in
tile view t h a t life is b e t t e r ( A o d d s / S D I = 6 0 . 6 4 % ) . Together, s p i r ituality/religion, h e a l t h y beliefs, a n d h e a l t h s t a t u s are m o d e r ately predictive of feeling t h a t life is b e t t e r (Nagelkerke R 2 = . 2 5 ) .
This study was funded by the Health Services Research & Development Service, Department of Veterans Affairs (grant # ECI
01-195), and by the National Center for Complementary and
Alternative Medicine (grant # R01 AT01147). Dr. Tsevat is supported by a National Center for Complementary and Alternative Medicine award (grant # K24 AT001676); Dr. Mrus was
supported by a Department of Veterans Affairs Health Services
Research & Development award (grant # RCD-O 1011-2) at the
time this study was conducted; and Drs. Tsevat and Mrus are or
were supported by an AIDS Clinical Trials Unit grant from the
National Institute of Allergy and Infectious Diseases (grant # UOI
A125897).
We thank Susan N. Sherman, DPA, a n d Leigh Ann Chamberlin for conducting interviews; Karen Mandell, PharmD, for
data management; the nurses and physicians at the 4 study
sites for recruiting patients and conducting chart reviews; and
the many patients who participated in the study.
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