Religion and Health: Anxiety, Religiosity, Meaning of Life and Mental ...

J Relig Health (2015) 54:35–45 DOI 10.1007/s10943-013-9781-3 ORIGINAL PAPER

Religion and Health: Anxiety, Religiosity, Meaning of Life and Mental Health Yung-Jong Shiah • Frances Chang • Shih-Kuang Chiang I-Mei Lin • Wai-Cheong Carl Tam

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Published online: 17 October 2013 Ó Springer Science+Business Media New York 2013

Abstract We examined the association among anxiety, religiosity, meaning of life and mental health in a nonclinical sample from a Chinese society. Four hundred fifty-one Taiwanese adults (150 males and 300 females) ranging in age from 17 to 73 years (M = 28.9, SD = 11.53) completed measures of Beck Anxiety Inventory, Medical Outcomes Study Health Survey, Perceived Stress Scale, Social Support Scale, and Personal Religiosity Scale (measuring religiosity and meaning of life). Meaning of life has a significant negative correlation with anxiety and a significant positive correlation with mental health and religiosity; however, religiosity does not correlate significantly anxiety and mental health after controlling for demographic measures, social support and physical health. Anxiety explains unique variance in mental health above meaning of life. Meaning

Y.-J. Shiah (&) Graduate Institute of Counseling Psychology and Rehabilitation Counseling, National Kaohsiung Normal University, No. 116, Heping 1st Road, Kaohsiung 802, Taiwan e-mail: [email protected] F. Chang Department of Applied Foreign Languages, Chienkuo Technology University, No. 1, Chiehshou North Road, Changhua 500, Taiwan e-mail: [email protected] S.-K. Chiang Department of Counseling and Clinical Psychology, National Dong Hwa University, No. 1, Sec. 2, Da Hsueh Road, Shoufeng, Hualien 97401, Taiwan e-mail: [email protected] I.-M. Lin Department of Psychology, Kaohsiung Medical University, No. 100, Shiquan 1st Road, Kaohsiung 807, Taiwan e-mail: [email protected] W.-C. C. Tam Department of Psychology, Chung Yuan Christian University, No. 200, Chung Pei Road, Chungli 32023, Taiwan e-mail: [email protected]

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J Relig Health (2015) 54:35–45

of life was found to partially mediate the relationship between anxiety and mental health. These findings suggest that benefits of meaning of life for mental health can be at least partially accounted for by the effects of underlying anxiety. Keywords

Anxiety Chinese Meaning of life Mental health Religiosity Stress

Introduction Interest in the scientific study of religion in relation to psychology by scholars not directly involved with either field has increased exponentially during the past few years (Levin 2009; Pargament and Saunders 2007; Constantine Sedikides 2010; Seybold 2007). However, this interest has not been matched by those who are directly involved in religion or psychology as academic disciplines. The ignoring of religion by these researchers is especially unfortunate because there is evidence that some aspects of religiosity play an important role in enhancing health (Ano and Vasconcelles 2005; Koenig 2009; Levin 2009; Pargament and Saunders 2007; Park 2007; Powell et al. 2003; Rasic et al. 2009; Seybold 2007; Smith et al. 2003; Weaver et al. 2006) and reducing deaths (Chida et al. 2009; Park 2007). Religion can improve psychological adjustment in cases of illness or adversity (Bowen et al. 2006; Chapman and Steger 2010; Koenig 2009; Koenig et al. 2004, 1998; Koszycki et al. 2010; Lizardi et al. 2008; Park 2007; Shreve-Neiger and Edelstein 2004). One important proposition is that religion affects health (Bowen et al. 2006; Ellison et al. 2009; Lizardi et al. 2008; Lockenhoff et al. 2009; Vasegh and Mohammadi 2007) by decreasing anxiety (Lizardi et al. 2008; Vasegh and Mohammadi 2007). However, studies aimed at answering this question have yielded inconsistent results (Hill and Pargament 2003), with some studies suggesting that religion neither promotes health (Sloan et al. 1999). Obviously, the nature of the association, if any, between religion and health remains unresolved, and further investigation is needed. Specifically, a review of 17 studies revealed inconsistent results regarding the above assumption (Shreve-Neiger and Edelstein 2004). Later, several more recent studies have supported it. For example, Muslin found a negative relation between religiosity and anxiety in a medical student sample (Vasegh and Mohammadi 2007). Religiosity has also been found to relate to reduced anxiety in adults from the general population (Ellison et al. 2009), pregnant women (Mann et al. 2008), depressed inpatients (Lizardi et al. 2008), sufferers from panic disorders (Bowen et al. 2006) or generalized anxiety (Koszycki et al. 2010) and members of a person-to-person-contact prayer group (Boelens et al. 2009). How do we explain inconsistent results regarding the above assumption that religion affects health by decreasing anxiety? One important function of religion is to provide meaning for life (Park 2007; Sedikides 2010). The search for meaning is one of the strongest human motivations, and it gives hope to people confronted with adversity (Frankl 1963). Research supports the hypothesis that seeing meaning in life helps people cope with personal traumas, such as the aftermath of the 9/11 terrorist attacks (Ai et al. 2005; Updegraff et al. 2008) and other stressful events (Park 2010). Another is religion which provides social and psychological resources such as social support, locus of control, positive thinking and encouragement for a healthy lifestyle (Koenig 2009; Park 2007). Furthermore, if a traumatic event is unexpected and serious, religion provides a quick and systematic aid. This might partly explain why religion can improve psychological adjustment in cases of illness or adversity (Bowen et al. 2006; Chapman and Steger 2010;

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Koenig 2009; Koenig et al. 2004, 1998; Koszycki et al. 2010; Lizardi et al. 2008; Park 2007; Shreve-Neiger and Edelstein 2004). Accordingly, because prior research has not examined the effects of religiosity and meaning of life in a same study, we tested the hypotheses that meaning of life is associated with religiosity and mental health and that meaning of life and religiosity associated with mental health separately in the present study. Studies of the relationship between religion and health are often criticized by rhetorically asking questions that these studies allegedly have not answered. One of the most important of these questions—does religion promote positive outcomes?—has long been a matter of intense debate. Moreover, previous studies have overrepresented Western Caucasians (Ano and Vasconcelles 2005; Hill and Pargament 2003; Smith et al. 2003), especially in the United States (Ano and Vasconcelles 2005; Shreve-Neiger and Edelstein 2004; Yeager et al. 2006). There also might be a publication bias (Chida et al. 2009; Yeager et al. 2006) in the form of journals favoring the publication of positive results at the expense of negative results (Sedikides and Gebauer 2010). Even worse, there are indications that some researchers have selectively cited positive results to support their own religious beliefs (Kier and Davenport 2004) or imposed their own religious orientation on their research participants (Miller and Thoresen 2003). Because it hosts many different religious groups (Shiah et al. 2010) such as Christians, Buddhists and Taoists, Chinese society provides a good background for studying the relationship between religion and health. (Note that in this paper, we define ‘‘religious groups’’ as including nonbelievers.) Also, including a broad spectrum of religious and nonreligious individuals would increase the generalizability of these findings. These problems suggest another question—do different religious activities lead to similar (positive) outcomes? Western and non-Western religious traditions should be studied together to understand the effects of cultural diversity (Henrich et al. 2010; Lehman et al. 2004). Many previous studies on the relations between religiosity and anxiety have suffered from a lack of standardized measures; poor sampling procedures; reliance on homogenous samples of Protestants, Catholics, youth, college students and clinical patients; limited assessments of anxiety; and experimenter bias (Shreve-Neiger and Edelstein 2004). The use of general measures of anxiety instead of standard diagnostic measures has also been suggested, because anxiety disorders are least frequent in older adults (Shreve-Neiger and Edelstein 2004). For these reasons, a general measure of anxiety was used in the present study. Taken together, two proposed mediation models were tested (Fig. 1). Using Model 1, we expected that both anxiety and religiosity would be associated with mental health and

Anxiety

c

Mental health

Anxiety

Mental health

Meaning of life

Religiosity a

c

c Anxiety Model 1

b

a

b Mental health

Anxiety

c Mental health Model 2

Fig. 1 Two mediation models

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that religiosity would partially mediate some of the effects of anxiety on mental health. Using Model 2, we expected that both anxiety and meaning of life would be associated with mental health and that meaning of life would partially mediate some of the effects of anxiety on mental health. Finally, because we expected that anxiety, religiosity, meaning of life and mental health would all be associated with demographic characteristics, social support and physical health (Lockenhoff et al. 2009), we included these variables as covariates in all analyses.

Method Participants A convenience sample of 451 participants (150 males and 300 females, one missing sex data) ranging in age from 17 to 73 years (M = 28.9, SD = 11.53) was recruited. One group (N = 155, 41 males and 114 females) ranging in age from 17 to 22 years (M = 18.94, SD = 1.19) consisted of students recruited from Kaohsiung Medical University, and the other group (N = 296, 109 males and 186 females, one missing sex data) ranging in age from 22 to 73 years (M = 34.26, SD = 11.03) was recruited from elsewhere in the city of Kaohsiung. As all participants were recruited from the same city, any possible effect of mood fluctuations due to weather was eliminated. Religious belief was distributed as follows: 10 % Christian (N = 45), 20 % Buddhist (N = 89), 25 % Taoist (N = 113) and 43 % nonbelievers (N = 192). The Christian subsample included 39 Protestants and 6 Catholics. The distribution of Christians is similar to that in a previous study conducted in Chinese society (5.6 %) using stratified random sampling (Soong and Li 1988) and is consistent with the status of Christianity as a minority religion in Chinese culture. The remaining 2 % of the respondents (N = 12) did not answer the religious belief question. All test procedures were approved by the Ethics Committee of the Psychology Department of Kaohsiung Medical University for the protection of human participants. Table 1 describes the sample (N = 451) in detail. Measures Demographic covariates included age, gender, education, physical health and social support. Physical health was measured by the Medical Outcomes Study Health Survey as described later. Social support was measured by the Social Support Scale (SSS). This scale includes six items: (1) number of professional/business organizations belonged to (0–8?), (2) number of offices held in these organizations (0–6?), (3) number of vocational activities (0–8?), (4) number of service activities (0–8 ?), (5) marital status (0 = not married; 1 = married) and (6) living arrangement (0 = lives alone; 1 = lives with someone else) (McCullough and Laurenceau 2005). The six item scores are summed to obtain a total score for the scale. Anxiety was measured by two instruments. The first was the Chinese version of the Beck Anxiety Inventory (BAI) (Beck et al. 1988), a frequently used 21-item self-report measure assessing general symptoms of anxiety. Each question is measured on a 0–3 scale, meaning that total scores can range from 0 to 63: 0–7 means normal, 8–15 means mild anxiety, 16–25 means moderate anxiety and 26–63 means severe anxiety. The Chinese BAI has good reliability and validity (Che et al. 2006).

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J Relig Health (2015) 54:35–45 Table 1 Sample characteristics

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Variable

Score

Age (years)

28.90 (11.53), range 17–73

Gender

67 % female

Religious groups (%) Christians

10

Buddhists

20

Taoists

25

Nonbelievers

43

Education (%) \12 years

2

High school degree

28

College degree

56

Graduate degree

12

Social Support Scale

3.13 (2.40)

Beck Anxiety Inventory

8.14 (8.25)

Perceived Stress Scale

25.08 (8.24)

Personal Religiosity Scale Religious belief subscale

31.38 (9.42)

Religious activities subscale

24.49 (9.46)

Meaning of life subscale

15.40 (3.88)

Medical Outcomes Study Health Survey For continuous variables, the mean is followed by the standard deviation in parentheses

Physical component summary

46.21 (11.24)

Mental component summary

50.52 (10.19)

The second anxiety measure was the Perceived Stress Scale (PSS) (Cohen et al. 1983). The 14-item PSS was designed to measure global psychological stress. Specifically, it measures the degree to which respondents perceive their lives to be stressful, uncontrollable, unpredictable, and overloaded. Respondents answer the items on Likert-type scales ranging from 0 (never) to 4 (very often). Half the items are reverse coded, and all the scores are then summed to obtain a total score. The Chinese version of the PSS has good validity and test–retest reliability (Chu and Kao 2005). We measured participants’ health status with the self-reported Medical Outcomes Study Health Survey, a widely used generic measure of health. This Medical Outcomes Study Health Survey (SF-36) (McHorney et al. 1993; Stewart et al. 1988; Ware and Sherbourne 1992) is a 36-item scale that consists of eight subscales, which measure physical functioning, role physical, pain, general health, vitality, social functioning, role emotional, and mental health. Item scores on each subscale are summed to give a total score for that subscale. These scores can range from 0 (worst possible health) to 100 (best possible health). The eight subscales are divided into two groups: physical component summary (PCS) and mental component summary (MCS). Taiwanese norms for the SF-36 are available in the form of sum scores and standardized algorithms (Lin 2003). The Chinese version of the SF-36 has good reliability and validity (Lu et al. 2003; Tseng et al. 2003). The PCS served as a covariate, and the MCS was as a mental health variable. Personal Religiosity Scale (PRS) (Soong and Li 1988). Written in Chinese, the PRS has 37 items divided into eight subscales derived from factor analysis with satisfactory

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reliability and validity. Items are scored on 7-point scales ranging from agree not at all to agree very much. The religious belief and religious activities subscales are related to religiosity. The meaning of life subscale measures the tendency to see one’s life as valuable and happy. Only these three subscales were used in the present study to measure the constructs of religiosity and meaning of life.

Procedure The experimenter informed participants of the nature of the research and gave assurances of confidentiality. Each participant received a booklet which included demographic items, followed (in order) by the SSS, BAI, SF-36, PSS, and PRS.

Results Anxiety/Perceived Stress and Religiosity/Meaning of Life Table 2 reports partial correlations between religious belief, religious activities, meaning of life, anxiety and perceived stress, controlling for age, gender, education, physical health and social support. As expected, religious belief has a significant positive correlation with religious activities. Meaning of life is significantly associated with religious belief and religious activities. Meaning of life has a significant negative correlation with the BAI and the PPS. However, religious belief and religious activities do not correlate significantly with the BAI. Additionally, the PPS does not have a significant negative correlation with religious belief and religious activities. Anxiety, Religiosity, Meaning of Life and Mental Health Table 3 reports partial correlations between religious belief, religious activities, meaning of life, anxiety, perceived stress and mental health controlling for age, gender, education, physical health and social support. As expected, the MCS has a significant negative correlation with the BAI and the PSS. Meaning of life has a significant positive correlation with the MCS. However, religious belief and religious activities do not correlate significantly with the BAI.

Table 2 Partial correlations between religious belief, religious activities, meaning of life, anxiety and perceived stress controlling for demographic variables (age, gender, education and social support) and physical health

Religious belief subscale


.73***

.17**

.03

.16**

.07

Religious activities subscale Meaning of life subscale Beck Anxiety Inventory ** p \ .01; *** p \ .001 (all two-tailed)

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-.24***

Perceived Stress Scale 0.2 .06 -.38*** .39***


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Table 3 Partial correlations of the mental components summary (MCS) of the Medical Outcome Study Health Survey with religious belief, religious activities, meaning of life, anxiety and perceived stress, controlling for demographic variables (age, gender, education and social support) and physical health

MCS

Religious belief subscale





-.01

-.04

.44***

-.45***

-.70***

** p \ .01; *** p \ .001 (all two-tailed)

Given that the religiosity measures do not correlate significantly with the anxiety and mental health scores, only Model 2 meets the basic prerequisite for hierarchical linear regressions. To examine the relative contributions of anxiety and meaning of life to mental health, two hierarchical linear regressions were performed to determine the unique variance of the mental health scores that is accounted for by the anxiety and the meaning of life scores. Both analyses controlled for demographic variable, social support and physical health in a first block. The second and third blocks differ across analyses. In the first analyses, anxiety scores were included in the second block and meaning of life scores in the third block. The reverse sequence was used in the second analysis. Table 4 summarizes the results of the two analyses. The sum of the predictors in each of the analyses accounts for 57 % of the variance in mental health (p \ .001). In the first analysis, where the anxiety factor was entered before meaning of life, the summed predictors account for 51 % of the variance in the mental health scores. Adding the meaning of life scores in the third block did not increase the explained variance by a significant amount. In contrast, when the meaning of life scores were entered before anxiety, they account for only 19 % of the variance in mental health. Moreover, when the anxiety factor was entered in a fourth block, it added significantly (by 34 %) to the explained variance. These findings suggest that the anxiety scores are more strongly associated with mental health than the anxiety scores themselves, and the anxiety scores account for a unique portion of the variance. Mediation Analyses Figure 1 gives a schematic of the role of mediation in the two models. Given that the religiosity measures do not correlate significantly with the anxiety and mental health scores, only Model 2 meets the basic prerequisite for mediation. We conducted a series of regression analyses to test the different paths of the model shown in Fig. 1. Each of the Table 4 Hierarchical linear regression analyses giving the percentage of variance accounted for by anxiety versus meaning of life DR2 Anxiety entered before meaning of life

Meaning of life entered before anxiety

Block 1: control variables

.04

.04

Block 2

.51***

.19***

Block 3

.03

.34***

Anxiety was measured by the Beck Anxiety Inventory and the Perceived Stress Scale *** p \ .001

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Table 5 Summary of mediation analyses on the indirect effects of anxiety on mental health as meditated by meaning of life Predictor

Moderator

Step 1 Path c

Step 2 Path a

Step 3 Path b

Step 4 Path c0

Sobel


Meaning of life

-.45 (.06)***

-.24 (.02)***

.44 (.12)***

-.36 (.06)***

-3.51***


Meaning of life

-.72 (.05)***

-.39 (.02)***

.44 (.12)***

-.64 (.05)***

-3.60***

Unstandardized regression coefficients are followed by standard errors in parentheses *** p \ .001

regressions controlled for demographic variables, social support and physical health. Table 5 summarizes the results of each step. Step 1 estimates the ‘‘c’’ path by regressing mental health as defined by the anxiety factor. Step 2 estimates the ‘‘a’’ path by regressing the meaning of life factor based on the anxiety factor. Step 3 estimates the ‘‘b’’ path by regressing mental health as defined by the meaning of life factor, including the anxiety factor as a predictor in the same equation. Step 4 estimates the ‘‘c’’ path, distinguishing between partial and complete mediation based on whether the effects of anxiety on the mental health are reduced to zero when the meaning of life scores are included as a predictor in the same equation. As seen in Table 5, the effect of the BAI on the mental health scores is partially mediated by meaning of life. Finally, the effect of the PSS on the mental health is partially mediated by the meaning of life scores.

Discussion This study is among the first to investigate the association among anxiety, religiosity, meaning of life, and mental health in a nonclinical sample from a Chinese society. Consistent with previous studies (Gregory et al. 2007; Henningsen et al. 2003; Rusli et al. 2008), we found that anxiety was positively and significantly correlated with poor mental health and perceived stress. As expected, meaning of life has a significant negative correlation with anxiety and a significant positive correlation with mental health and religiosity. Religiosity was not necessarily the ones with the least anxiety and mental health. Meaning of life was found to partially mediate the relation between anxiety and mental health. These findings suggest that the beneficial effects of seeing meaning in one’s life on mental health can at least partially be accounted for by the effects of underlying anxiety. However, these findings need to be replicated before definitive conclusions can be drawn. How do we explain the result that religiosity is not significantly associated with anxiety and mental health? As mentioned before, religions give meaning to life, provide social and psychological resources, and encourage a healthy lifestyle. Our data emphasize that meaning of life mediates the relationship between anxiety and mental health. However, these findings must be replicated before definitive conclusions can be drawn. The results of the present study have several clinical implications. It is important in the clinical context to assess people’s resources related to meaning of life as a way to cope with adversity. It is also important for clinicians to make their clients aware of other possible resources when religion is not the only resource that can be drawn upon to provide meaning to life. If a client wants to discuss religious matters with them, they should adopt an open-minded attitude toward the client’s religious beliefs (Post and Wade 2009). At the

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same time, they should be aware of the ethical issues involved with religion-based interventions (Baetz and Toews 2009). It would be desirable in future research to use random sampling rather than the convenience sampling employed in this study. Generalizability of the results of the present study is further limited to relatively healthy individuals, as specific illnesses were not sampled. Another limitation of our study is its cross-sectional design; research using longitudinal designs are needed to assess changes in the relation between religious involvement and anxiety over time. A final limitation is our exclusive use of self-report measures, which could have affected the accuracy of the participants’ reports due, for example, to faulty memory. Such subjective data do not necessarily correlate with more objective behavioral or physiological measurements (Gallagher and Brosted Sorensen 2006). Overall, the present study makes an important contribution to our understanding of how anxiety, religiosity and meaning of life are interrelated. In addition to its theoretical relevance, the study has important practical implications, because the mediation analyses suggest that the benefits of seeing meaning in one’s life for mental health are to some extent dependent on anxiety, and religiosity was not found to be associated with anxiety and mental health. These findings imply that interventions aimed at inducing a turn toward religion as a way to improve mental health may be misguided (Lockenhoff et al. 2009). Instead, medical professionals may want to assess their clients’ beliefs and discuss whether they are likely to benefit from access to resources that help provide meaning to one’s life. When further exploring the theoretical perspectives addressed in this paper, future researchers should take account of cultural differences and the availability of the full range of available resources to improve mental health. Acknowledgments This project was supported by a grant from the Kaohsiung Medical University Research Foundation (KMU-Q099033) and the National Science Council (100-2410-H-037-003-MY2).

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