Article Studies Show Spiritual Care Linked to Better Health Outcomes

March-April 2013 By: Studies Show Spiritual Care Linked to Better Health Outcomes

BY DAVID A. LICHTER, D.MIN. Research is an essential mark of any clinical profession, and the quality of research denotes the discipline's development. Research on chaplaincy services spans nearly a half century, and it is growing and improving. Clinical health care researchers are strengthening the chaplaincy profession by providing evidence that spiritual issues need to be addressed or health outcomes falter. In this Health Progress issue, the Mayo Clinic Department of Chaplaincy Services has contributed its research on the spiritual needs of hospitalized Catholics. (See page 58.) The chaplaincy profession has benefitted from two previous studies of patient needs conducted by the Mayo Clinic chaplaincy group.1 These studies, along with Mayo's productivity data on chaplaincy activity, have informed the Mayo Clinic's decisions for the spiritual care department's staffing and services. Their research allowed them to confidently link patient needs to adequate staffing, as well as to demonstrate increased patient satisfaction when spiritual care needs are being met. This article is intended to situate the Mayo research within the broad and growing arena of research on the chaplaincy profession, patients' spiritual needs and how meeting or not meeting their religious or spiritual needs affect patient perception of the quality of care and their health outcomes. George Fitchett, professor and director of research at Rush University Medical Center in Chicago, offered three reasons for integrating research into professional chaplaincy. The first is the most important: to strengthen one's professional practice in order to improve service to patients and families. Secondly, publishing the results of this research will increase awareness of what and how chaplains contribute to the health care team. And finally, such research will promote and strengthen interdisciplinary relations.2 Other researchers have agreed with Fitchett.3 As one report states, "In addition to improving care, making chaplaincy a research-informed profession will promote the constructive dialogue about the roles of religion, spirituality, and professional chaplains in healthcare settings."4

METHODOLOGY AND SCHOLARLY REVIEWS In 1990, John Gartner and colleagues reviewed the quantity and quality of quantitative research of articles published in four pastoral counseling journals between 1975-1984.5 In 2003, The Journal of Pastoral Care and Counseling provided another review, "An Evaluation of the Quantity and Quality of Empirical Research in Three Pastoral Care and Counseling Journals, 1990-1993: Has Anything Changed?"6 The latter noted improvements in compliance with some of the criteria used for internal validity but reported no improvement in the sophistication of statistical analysis and research design. Research on chaplaincy continued to develop. In 2011, the Journal of Health Care Chaplaincy again published a review of chaplaincy research, "A Methodological Analysis of Chaplaincy Research: 2000-2009."7 This article aimed to assess the sophistication of the research studies compared to studies before 2000, and it found improvements in reporting of response rates and use of inferential statistics and statistical controls and increases in sample sizes. Yet, the article noted that few discussed validity and reliability of measures, and still too many relied on cross-sectional survey of convenience samples versus experimental or quasiexperimental studies which allow for making greater generalizations. They urged more research that employed hypothesis testing, but acknowledged that such hypothesis models need to be based on theories about chaplaincy service, which are lacking in the field. Although these critiques might have significance only to a seasoned researcher, they signal the seriousness with which the profession takes its goal to improve clinical research and the clarity of the critique and direction it provides to its fellow researchers. The review also was helpful in classifying the areas of research being examined: attitudes about the roles of chaplains, the nature of chaplain visits and interventions, referrals to chaplains, instrument development, patient and family satisfaction with chaplains, intervention studies, other studies with patient populations, chaplaincy staffing, chaplain attitudes and perceptions, chaplain well-being and chaplain education. In England, Dr. Harriet Mowat published the 2008 milestone work The Potential for Efficacy of Healthcare Chaplaincy and Spiritual Care Provision in the NHS (UK): A Scoping Review of Recent Research.8 It was commissioned in 2006 as part of the Caring for the Spirit National Health Service (NHS) Project initiated by NHS Yorkshire and the Humber. Since NHS required all health service treatment to be evidenced-based, so it was for chaplaincy. Mowat entitled one of her subpoints in the section on context of chaplaincy as "movement from an assumption of chaplaincy to a case for chaplaincy." Her study included review of research in the United Kingdom and beyond. It was groundbreaking in scope and depth and provided a framework and a bar of excellence for future research reviews and mandates. A caveat she offered remains a valuable caution for the field of research and those who work with professional chaplains: "healthcare chaplaincy has a very limited evidence base for a number of reasons." She cautioned that "a lack of evidence of efficacy does not mean that the work of the hospital chaplain and spiritual care giver is not

efficacious." Put succinctly, she said, "Absences of evidence does not mean evidence of absence." Research continues this quest for evidence. In 2011, the Journal of Health Care Chaplaincy provided one of the most useful reviews of chaplaincy research in the article "Testing the Efficacy of Chaplaincy Care," by Katherine R. B. Jankowski, et al.9 Work for the article was funded by the John Templeton Foundation, which also is funding the major research project "Growing the Field of Chaplaincy Research in Palliative Care."10 In their article, Jankowski and her colleagues noted, "Research into chaplaincy outcomes falls roughly into two general categories: studies of patient satisfaction with chaplaincy care and studies of actual chaplaincy interventions and their relationship to health outcomes. The patient satisfaction studies are generally stronger methodologically than the intervention studies and tend to show the chaplain visits have a positive effect on overall patient satisfaction The outcome studies are very few in number and most have serious methodological shortcomings." They asserted that these studies needed "targeted and enhanced replication." The article is most useful in identifying what is known about chaplaincy and spiritual care's effectiveness and the gaps that need to be addressed through further research. The major ones include: religious and spiritual needs and resources; who chaplains are, what chaplains do and the desired outcomes of chaplain interventions; the efficacy of chaplains (where, when, how are they helpful?); and research methodology. Although helpful lists of research on chaplaincy service exist, the profession has a way to go. However, the chaplaincy profession is grateful that HealthCare Chaplaincy, a New York-based nonprofit that serves as a hub for professional chaplaincy education, research and practice, in 2011 was awarded a three-year, $3 million grant to advance scientific research on professional chaplaincy's contributions to health and health care, particularly palliative care. HealthCare Chaplaincy has awarded $1.5 million to six project grants to advance the field of research on chaplaincy in palliative care. All proposals for these grants required professional clinical researchers and an interdisciplinary team, including a board-certified chaplain, as part of the research team. We look forward to the research results. RESEARCH BY OTHER HEALTH CARE PROFESSIONALS The Mayo Clinic's 2010 research (see page 58) explores another very important area, the religious or spiritual needs of patients. Clinical researchers, sometimes with the help of professional chaplains, have examined the connections between identifying and addressing religious or spiritual needs and patients' perception of and satisfaction with care. This type of research not only augments, but strengthens the evidence-based foundations of the importance of health care clinicians being trained to screen for such needs and refer to the professional chaplain when indicated, and of spiritual care professionals being trained to address these needs. A team of medical researchers from the University of Chicago-Pritzker School of Medicine showed the relationship of addressing religious or spiritual needs and satisfaction with care, in findings published in 2011 in the Journal of General Internal Medicine. The research provided evidence that addressing a patient's spiritual concerns increases trust in the medical team and

overall satisfaction with care.11 Part of the strength of this study is its sample, over 3,000 medical patients treated at the University of Chicago who represented a broad racial and ethnic mix, as well as a mix of religious and non-religious people. Another example is research published in the Journal of Clinical Oncology by a medical team at St. Vincent's Comprehensive Cancer Center in New York City.12 The study of very diverse patients with cancer examined the relationship between patients' spiritual needs and perceptions of quality and satisfaction with care. The research showed that most patients (73 percent) had spiritual needs; a majority (58 percent) thought it was appropriate for physicians to ask about these needs, and 18 percent reported that their spiritual needs were not being met. A significant finding, however, was that those 18 percent gave lower ratings to their quality of care and satisfaction with their care. Other research has examined the relationship between religious or spiritual needs and physical and mental health. Several studies have shown the positive associations between religion and health and well-being.13 However, over the past decade there also has been a significant amount of empirical research on religious and spiritual struggle.14 This growing body of research indicates that if spiritual struggle, or distress caused by something in one's belief, practice or experience, is not identified and addressed, it will have an adverse effect on one's health. Such distress could show itself as a single primary emotion (guilt, anger), or as a person's internal struggle to reconcile their experience with their beliefs. Well-known researcher Kenneth I. Pargament categorized religious or spiritual struggle or distress as divine (anger with God), intrapersonal (trying to forgive oneself for something), or interpersonal (being betrayed by a religious leader).15 When these types of distress are not recognized and addressed, they can have an adverse effect on health outcomes. A study by Crystal Park, a professor of psychology at the University of Connecticut, bears this out. Her research published in the Journal of Behavioral Medicine reports that among congestive heart failure patients, higher levels of religious struggle are associated with poorer physical functioning and increased hospitalization.16 The study's longitudinal method permits a somewhat stronger inference that religious struggle contributed to these poorer outcomes. "Religious struggle predicted higher number of nights subsequently hospitalized, higher depression, marginally lower life satisfaction Religious struggle appears to have a potentially negative impact on well-being in advanced [congestive heart failure]; therefore, helping patients address issues of struggle may meaningfully lessen the personal and societal costs of [congestive heart failure]." A team of Pittsburgh researchers published an excellent study in the Journal of Palliative Medicine exploring the relationship between religious coping and well-being in women with breast cancer. This was another longitudinal study in which results indicated "negative religious coping predicted worse overall mental health, depressive symptoms, and lower life satisfaction."17 Such results signal to health care professionals the importance of screening for signs of spiritual distress signs, taking them seriously and referring them to professional chaplains as appropriate.

CONCLUSION The chaplaincy profession presses ahead to undertake research that supports evidence-based practice. The Association of Clinical Pastoral Education, the Association of Professional Chaplains, the National Association of Jewish Chaplains and the National Association of Catholic Chaplains all have research initiatives to strengthen the research literacy of their members, as well as to collaborate on research initiatives for evidence-based practice.18 Most importantly, these associations urge their members to become engaged in research projects at their health care places of employment, making a case that integrating spiritual care into health outcomes research is not an add-on but integral to sound research. Indeed, Standard 12 of the "Standards of Practice for Professional Chaplains in Acute Care Settings" is on research: "The chaplain practices evidence-based care including ongoing evaluation of new practices and, when appropriate, contributes to or conducts research."19 Clinical health care researchers other than chaplains are providing the evidence that spiritual issues need to be addressed or health outcomes falter. The chaplaincy profession is ready to partner in addressing those needs. DAVID A. LICHTER is executive director of the National Association of Catholic Chaplains, Milwaukee. NOTES 1. Katherine M. Piderman et al., "Patients' Expectations of Hospital Chaplains," Mayo Clinic Proceedings 83, no.1 (2008): 58-65, and Katherine M. Piderman et al., "Predicting Patients' Expectations of Hospital Chaplains: A Multisite Survey," Mayo Clinic Proceedings 85, no. 11 (2010): 1,002-1,010. 2. George Fitchett, "Health Care Chaplaincy as a Research-Informed Profession: How We Get There," Journal of Health Care Chaplaincy 12 (2002): 67-72. 3. Larry L. VandeCreek, "Chaplains Yes: Should Clinical Pastoral Education and Professional Chaplaincy Become More Scientific in Response to Health Care Reform?" Journal of Health Care Chaplaincy 12 (2002): XXI-XXII; and Thomas O'Connor and Elizabeth Meakes, "Hope in the Midst of Challenge: Evidence-Based Pastoral Care," Journal of Pastoral Care 52, no. 4 (1998): 359-367. 4. Literature Review Testing the Efficacy of Chaplaincy Care, part of the proposal to the John Templeton Foundation, "Growing the Field of Chaplaincy Research in Palliative Care." Available at www.healthcarechaplaincy.org/templeton-research-project/literature-review.html. 5. John Gartner et al., "A Systematic Review of the Quantity and Quality of Empirical Research Published in Four Pastoral Care Journals: 1975-1984," Journal of Pastoral Care 44, no. 2 (1990): 115-123.

6. Kevin, J. Fannelly et al., "An Evaluation of the Quantity and Quality of Empirical Research in Three Pastoral Care and Counseling Journals, 1990-1999: Has Anything Changed?" Journal of Pastoral Care and Counseling 57, no. 2 (2003): 167-178. 7. Kathleen Galek et al., "A Methodological Analysis of Chaplaincy Research: 2000-2009," Journal of Health Care Chaplaincy 17 (2011): 126-145. 8. Harriet Mowat, The Potential for Efficacy of Healthcare Chaplaincy and Spiritual Care Provision in the NHS (UK): A Scoping Review of Recent Research (Aberdeen, Scotland: Mowat Research Ltd., 2008) Available online at www.nhs-chaplaincycollaboratives.com/efficacy0801.pdf. 9. Katherine R. B. Jankowski et al, "Testing the Efficacy of Chaplaincy Care," Journal of Health Care Chaplaincy 17, no. 3-4 (2011): 100-125. 10. Literature Review Testing the Efficacy of Chaplaincy Care. 11. Joshua Williams et al., "Attention to Inpatients' Religious and Spiritual Concerns: Predictors and Association with Patient Satisfaction," Journal of General Internal Medicine 26, no. 11 (2011): 1,265-1,271. 12. Alan B. Astrow et al., "Is Failure to Meet Spiritual Needs Associated with Cancer Patients' Perception of Quality of Care and Their Satisfaction with Care?" Journal of Clinical Oncology 25, no. 36 (2007): 5,753-5,757. 13. Harold G. Koenig, Kenneth I. Pargament and Julie Nielsen, "Religious Coping and Health Status in Medically Ill Hospitalized Older Adults," Journal of Nervous and Mental Disease 186, no. 9 (1998): 513-521; also see Harold G. Koenig, "Religion, Spirituality, and Medicine: Research Findings and Implications for Clinical Practice," Southern Medical Association 97, no. 12 (2004): 1,194-1,200. 14. Julie J. Exline, "Religious and Spiritual Struggles," in APA Handbook of Psychology, Religion, and Spirituality Vol. 1, eds. Kenneth I. Pargament, Julie J. Exline and James W. Jones (Washington D.C.: American Psychological Association Press, 2013), 459-475. 15. Kenneth I. Pargament, Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred (New York: Guilford, 2007). 16. Crystal L. Park et al., "Religious Struggle as a Predictor of Subsequent Mental and Physical Well-Being in Advanced Heart Failure Patients," The Journal of Behavioral Medicine 34, no. 6 (2009): 426-436. 17. Randy Hebert et al., "Positive and Negative Religious Coping and Well-Being in Women with Breast Cancer, Journal of Palliative Medicine 12, no. 6 (2009): 537-545.

18. The Association for Clinical Pastoral Education (www.acpe.edu), the Association of Professional Chaplains (www.professionalchaplains.org), the National Association of Catholic Chaplains (www.nacc.org), the National Association of Jewish Chaplains (www.najc.org), the Canadian Association of Spiritual Care (www.spiritualcare.ca) and the American Association of Pastoral Counselors (www.aapc.org) were the six professional associations that developed and adopted the Common Standards for Professional Chaplaincy. Chaplains must show they meet these standards of professional knowledge and skills to become certified by the Board of Chaplaincy. See http://professionalchaplains.org/. 19. The Standards of Practice for Professional Chaplains in Acute Care Settings were adopted in 2010 by the associations noted above. Available at http://professionalchaplains.org/content.asp?admin=Y&pl=198&sl=198&contentid=200.

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Abstract
Objective: To examine the prevalence of religious beliefs and practices in hospitalized patients with congestive heart failure (CHF) or chronic pulmonary disease (CPD), and determine relationships with physical and mental health. Methods: Subjects were a consecutive sample of 196 patients age 55 or over admitted to Duke University Medical Center with a diagnosis of CHF or CPD. Patients underwent a 6090 minute interview and physical exam to assess physical health, social support, mental health, religious activities and attitudes (attendance, prayer and scripture study, intrinsic religiosity). Results: Religious practices were widespread; 98% had a religious affiliation; 48% reported attending religious services weekly or more; 70% reported praying or reading religious scriptures at least daily; and over 85% consistently indicated intrinsic religious beliefs and attitudes. Religious activities and attitudes were inversely related to measures of physical illness severity and functional disability, and were less common among patients with prior psychiatric problems, hospitalizations for depression, drinking problems, and those currently taking psychotropic drugs. Religious activities (especially religious attendance) were associated with greater social support, but were only weakly related to less depression. Conclusions: Religious beliefs and activities are common among patients with CHF and CPD, are associated with less severe illness and functional disability, fewer prior psychiatric problems, and less psychotropic drug use. Treatment implications are discussed.

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Preliminary Findings." Journal of Palliative Medicine (2011): online ahead of print from the journal website as of July 2011. Winslow, G. R. and Wehtje-Winslow, B. J. "Ethical Boundaries of Spiritual Care." Medical Journal of Australia 186, no. 10 (May 21, 2007): S63-66. Wittink, M. N., Joo, J. H., Lewis, L. M. and Barg, F. K. "Losing Faith and Using Faith: Older African Americans Discuss Spirituality, Religious Activities, and Depression." Journal of General Internal Medicine 24, no. 3 (March 2009): 402-407. Yeung, W. J. and Chan, Y. "The Positive Effects of Religiousness on Mental Health in Physically Vulnerable Populations: A Review on Recent Empirical Studies and Related Theories." International Journal of Psychosocial Rehabilitation 11, no. 2 (2007): 37-52. [Online at www.psychosocial.com/IJPR_11/Positive_Effects_of_Religiousness_Yeung_Jerf.html.] Zeckhausen, W. "Ideas for Managing Stress and Extinguishing Burnout." Family Practice Management 9, no. 4 (April 2002): 35-38. Zeckhausen, W. "Spirituality and Your Practice." Family Practice Management 8, no. 5 (May 2001): 60. n.a. "Bibliography: Current World Literature." Current Opinion in Anaesthesiology 13, no. 2 (April 2000): 219-250. [See. p. 247.]

On-Line-Only Journal Articles:

Armbruster, C. A., Chibnall. J. T. and Legett, S. "Pediatrician Beliefs About Spirituality and Religion in Medicine: Associations with Clinical Practice." Pediatrics 111, no. 3 (March 2003): e227-35; http://www.pediatrics.org/cgi/reprint/111/3/e227 [The abstract (only) appears in the print edition on pp. 262-263, referring readers to the journal's "electronic pages."] Barnes, L. K. "New geographies of religion and healing -- part IV: physician engagement, building from a biopsychosocial model, and culturally competent care." Practical Matters: A Transdisciplinary Multimedia Journal of Religious Practices and Practical Theology no. 4 (Spring 2011): n.p. (online journal, with article accessed 6/11/11. Caddell, C. "Specialised Care Staff Attitude to Hospice Policy, Spirituality, and Occupational Quality Of Life." The Internet Journal of Law, Healthcare and Ethics 4, no. 1 (2006): www.ispub.com/ostia/index.php?xmlFilePath=journals/ijlhe/vol4n1/staff.xml. [ISSN

1528-8250, accessed 10/25/06]. Feudtner, C., Haney, J. and Dimmers, M. A. "Spiritual Care Needs of Hospitalized Children and Their Families: A National Survey of Pastoral Care Providers' Perceptions." Pediatrics 111, no. 1 (January 2003): e67-72; http://pediatrics.aappublications.org/cgi/reprint/111/1/e67 [The abstract (only) appears in the print edition on p. 192, referring readers to the journal's "electronic pages."] Harris, S. T., Wong, D. and Musick, D. "Spirituality and Well-Being Among Persons with Diabetes and Other Chronic Disabling Conditions: A Comprehensive Review." Journal of Complementary and Integrative Medicine 7, no. 1 (2010): 27 [article #, online journal at http://www.bepress.com/jcim/vol7/iss1/27]. Huber, S. "Questions about Religion as a Category of Diversity in Medicine." Virtual Mentor--An On-Line Publication of the American Medical Association's Institute for Ethics 3, no. 12 (December 2001): http://www.amaassn.org/ama/pub/category/6813.html Markel, H. "Should Physicians Be Prescribing Prayer?" Medscape Pediatrics 6, no. 2 (November 4, 2004): http://www.medscape.com/viewarticle/491362 [journal index page: http://www.medscape.com/viewpublication/210_index]. Medlock, M., "Prayers for Healing: Reflecting on America's Most Common Complementary Therapy" The Physician Scholar 1, no. 2 (January 22, 2008): www.physicianscholar.org/id/117083. Puchalski, C. M. "Ethical Concerns and Boundaries in Spirituality and Health." Virtual Mentor: American Medical Association Journal of Ethics 11, no. 10 (October 2009): 804-815. [Special issue on Religion, Patients, and Medical Ethics, at http://virtualmentor.ama-assn.org/2009/10/pdf/vm-0910.pdf; see also the Suggested Readings listing on pp. 816-825] Rotella, J., "Deep Doctoring: Spiritual Inquiry in the Doctor-Patient Relationship." Oates Journal 4 (2001): http://journal.oates.org/artical-archive/volume-4-2001/79-deepdoctoring-spiritual-inquiry-in-the-doctor-patient-relationship [accessed 8/21/08] Scobie, G. and Caddell, C. "Quality of Life at End of Life: Spirituality and Coping Mechanisms in Terminally Ill Patients." The Internet Journal of Pain, Symptom Control and Palliative Care 4, no. 1 (2005): http://www.ispub.com/ostia/index.php?xmlPrinter=true&xmlFilePath=journals/ijpsp/vol4n 1/quality.xml Shankland, W. E. II. "Factors that Affect Pain Behavior." CRANIO: The Journal of Craniomandibular Practice 29, no. 2 (April 2011): n.p. (online only journal). Tarpley, M. and Tarpley, J. "The Patient Who Says He Is Ready to Die." Virtual

Mentor: American Medical Association Journal of Ethics 11, no. 10 (October 2009): 761765. [Special issue on Religion, Patients, and Medical Ethics, at http://virtualmentor.ama-assn.org/2009/10/pdf/vm-0910.pdf; see also the Suggested Readings listing on pp. 816-825] VandeCreek, L. "Should Chaplains Encourage Physicians to Give More Attention to Religious and Spiritual Concerns of Their Patients? Yes and No." Oates Journal 3 (February 24, 2000): http://oates.org/journal/mbr/vol-03-2000/articles/vandecreek01.pdf von Gunten, C. F., Ferris, F. D. and Emanuel, L. L. "Ensuring Competency in End-ofLife Care: Controlling Symptoms." BMC Palliative Care 1, no. 5 (July 30, 2002): http://www.biomedcentral.com/content/pdf/1472-684X-1-5.pdf

BOOKS

Acadamia Nacionale de Cuidados Paliativos, Manual de Cuidados Paliativos [Portuguese]. Rio de Janerio, Brazil: Diagraphic, 2009. [See: Saporetti, L. A. and Ponte Silva, A. M. O., "Aspectos particulares e ritos de passagem nas diferentes religioes," pp. 309-320.] Alves, J. and Freire, E., ed. Manual de Cuidados Paliativos: Curso de Cuidados Paliativos em Medicina Interna. 3rd ed. [Portuguese] Porto, Portugal: Centro Hospitalar do Porto, March 2011. [See: Freire, E., "Espiritualidade e cuidados palitivos," pp. 156-161.] Australian Government Department of Health and Ageing. Guidelines for a Palliative Approach in Residential Aged Care -- Enhanced Version. Commonwealth of Australia (Prepared by Edith Cowan University, Churchlands): May 2006. [ISBN: 0-64282939-X; http://www.nhmrc.gov.au/publications/_files/pc29.pdf] Benor, D. Personal Spirituality: Science, Spirit, and the Eternal Soul. Medford, NJ: Wholistic Healing Publications, 2006. Berger, A. M., Shuster, J. L. and Von Roenn, J. H., eds. Principles and Practice of Palliative Care and Supportive Oncology. Philadelphia: Lippincott Williams and Wilkins, 2006. [See Puchalski, C. M., "Spirituality," pp. 633-645.] Bird, C. E., Conrad, P., Fremont, A. M. and Timmermans, S., eds. "Handbook of Medical Sociology." 6th ed. Nashville, Tenn.: Vanderbilt University Press, 2010. [See: Cadge, W. and Fair, B., "Religion, Spirituality, Health, and Medicine: Sociological Intersections," pp. 341-363.]

Bose, K. Ecology, Culture, Nutrition, Health, and Disease. Delhi: Kamla-Raj Enterprises, 2006. [See pp. 7 and 19.] Bruera, E. and Yennurajalingam, S., eds. Oxford American Handbook of Hospice and Palliative Medicine. New York: Oxford University Press, 2011. [See: Puchalski, C. M., Ferrell, B. and O'Donnell, E., "Spiritual Issues in Palliative Care," pp. 253-268.] Buckley, J. Palliative Care: An Integrated Approach. Chichester, England: WileyBlackwell, 2008. [See p. 158.] Calderbank, D. and Macer, D. R. J., eds. Asia-Pacific Perspectives on Bioethics Education. Bangkok, Thailand: UNESCO Asia and Pacific Regional Bureau for Education, 2008. [See: Chattopadhyay, S., "An Earnest Appeal: We Need Spirituality in Medical Education," pp. 135-142.] (--ISBN 978-92-9223-221-4; available at http://unesdoc.unesco.org/images/0016/001631/163183e.pdf] Callahan, D., ed. The Role of Complementary and Alternative Medicine: Accommodating Pluralism. Washington, DC: Georgetown University Press, 2002. [See: Larson, D. B. and Larson, S. S., "Spirituality in Clinical Care: A Brief Review of Patient Desire, Physician Response, and Research Opportunities," pp. 84-106.] Capelli, O., ed. Primary Care at a Glance - Hot Topics and New Insights. Rijeka, Croatia: InTech, 2012. [See: Lucchetti, G., Granero Lucchetti, A. L., Bassi, R. M., Vera, A. V. D. and Peres, M. F. P., "Integrating Spirituality into Primary Care," pp. 53-64.] Carson, V. B. and Koenig, H. G. Spiritual Caregiving: Healthcare as a Ministry. Philadelphia: Templeton Foundation Press, 2004. Carter, B. S., Levetown, M. and Friebert, S. E. Palliative Care for Infants, Children, and Adolescents: A Practical Handbook. Second Edition. Baltimore, Maryland: Johns Hopkins University Press, 2011. [See: p. 231 of Lanctot, D., Morrison, W., Koch, K. D., and Feudtner, C., "Spiritual Dimensions," pp. 227-243.] Cassel, C. K., Leipzig, R. M., Cohen, H. J., Larson, E. B. and Meier, D. E., eds. Geriatric Medicine: An Evidence-Based Approach. 4th. ed. New York: Springer, 2003. [See: Clipp, E. C. and Steinhauser, K. E., "Psychosocial Influences on Health in Later Life," pp. 53-63.] Chang, E. and Johnson, A., eds. Contemporary and Innovative Practice in Palliative Care. Rijeka, Croatia: InTech, February 2012. [See: Deena, M., Aljawi, D. M. and Harford, J. B., "Palliative Care in the Muslim-Majority Countries: The Need for More and Better Care," pp. 137-150.] Chila, A. and Fitzgerald, M., eds. Foundations of Osteopathic Medicine. 3rd. ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2011. [See

Section II: The Patient Encounter; Chapter 28: Spirituality and Health Care.] Childress, J. F. BioLaw: A Legal and Ethical Reporter on Medicine, Health Care, and Bioengineering. Bethesda, MD: University Publications of America, 2000 (update to 1986 loose-leaf publication). Vol. 2, p. U-85. Clarke, P. B., ed. Oxford Handbook of the Sociology of Religion. New York: Oxford University Press, 2009. [See: Cadge, W., "Religion, Spirituality, and Health: An Institutional Approach," pp. 836-856.] Cobb, M. R., Puchalski, C. M. and Rumbol, B., eds. Oxford Textbook of Spirituality in Healthcare. New York: Oxford University Press, 2012. [See: Puchalski, C., "Restorative Medicine," pp. 197-210; and Ellis, J. and Lloyd-Williams, M., "Palliative Care," pp. 257265. Commission to Investigate the Introduction and Spread of Severe Acute Respiratory Syndrome (SARS), SARS Commission Final Report: Spring of Fear, vol. 3. Toronto, Ontario: SARS Commission, December 2006. [ISBN 142492814 (vol. 1) and ISBN 14249-2822-2 (vol. 3)] See p. 962, available at www.sarscommission.ca/report/v3pdf/Vol3Chp5.pdf. Coward, H. and Stajduhar, K. I. Religious Understandings of a Good Death in Hospice Palliative Care. Albany, NY: SUNY Press, 2012. [See p. 294.] DeSpelder, L. A. and Strickland, A. L. The Last Dance: Encountering Death and Dying. 6th ed. Boston: McGraw-Hill, 2005. [See p. 81.] Dickinson, G. E. and Leming, M. R., eds. Dying, Death, and Bereavement. 9th Edition. Dubuque, Iowa: McGraw-Hill Contemporary Learning Series, 2007. [See p. 99.] Doka, K. J. Pain Management at the End of Life: Bridging the Gap between Knowledge and Practice. Washington, DC: Hospice Foundation of America, 2006. [See p. 43.] Doyle, D., Hanks, G., Cherny, N. and Calman, K., eds. Oxford Textbook of Palliative Medicine. Third Edition. Oxford: Oxford University Press, 2005. [See: Vachon, M. L. S., "The Emotional Problems of the Patient in Palliative Medicine," pp. 961-985.] Ebersole, P., Hess, P. and Luggen, A. S., eds. Toward Healthy Aging: Human Needs and Nursing Response. 6th ed. St. Louis, Missouri: Mosby, 2004. Evans, M. T. and Walker, E. D., eds. Religion and Psychology. New York: Nova Science Publishers, 2009. [See: Anandarajah G. and Smith, M., "Resident Physicians' Thoughts Regarding Compassion and Spirituality in the Doctor-Patient Relationship: A

Brief Report," pp. 307-316.] Field, M. J. and Behrman, R. E., eds. (for the Institute of Medicine Committee on Palliative and End-of-Life Care for Children and Their Families). When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington, D.C.: The National Academies Press, 2003. Fintelmann, V., ed. Onkologie auf anthroposophischer Grundlage. [German] Stuttgart, Germany: Johannes M. Mayer-Verlag, 2005 . [See: Bussing, A., Ostermann, T. and Matthiessen, P. F., "Spiritualitat als Patientenbedurfnis," Chapter 2.4.1.] Fins, J. A Palliative Ethic of Care: Clinical Wisdom at Life's End. London: Jones and Bartlett Publishers, 2006. Fleming, D. A. and Hagan, J. C., III, eds. Care of the Dying Patient. Columbia, MO: University of Missouri Press, 2010. [See Fleming, D. A., "The Path Ahead: Difficult Lessons for Physicians and Society," pp. 128-144.] Giarelli, G. Medicine non convenzionali e pluralismo sanitario: prospettive e ambivalenze della medicina integrata. [Italian] Milan, Italy: FrancoAngeli, 2005. [See: "La dimensione clinica dell'integrazione: ripensare l'incontroterapeutico," pp. 127-153.] Gloth, M. F. III, ed. Handbook of Pain Relief in Older Adults: An Evidence-Based Approach. Totowa, NJ: Humana Press, 2004. [See: Ranjan, A., Ayele, H., Uma, K. and Mulligan, T., "Spirituality as an Adjunct to Pain Management," pp. 63-72.] Haber, D. Health Promotion and Aging: Practical Applications for Health Professionals. 3rd ed. New York: Springer, 2003. [See: "Social Support," pp. 288-314.] Hester, D. M. Ethics by Committee: A Textbook on Consultation, Organization, and Education for Hospital Ethics Committees. Lanham, Maryland: Rowan and Littlefield, 2007. [See: Schonfeld, T. L., "Religious Values and Medical Decision Making," pp. 133-161.] Hill, R. D. Positive Aging: A Guide for Mental Health Professionals and Consumers. New York: WW Norton and Company, 2005. Hodges, G. F. and Betton, H. B. Spirituality and Medicine: Can the Two Walk Together? Bloomington, IN: AuthorHouse, 2008. Holland, J. C., Greenberg, D. B., and Hughes, M. K., eds. Quick Reference for Oncology Clinicians: The Psychiatric and Psychological Dimensions of Cancer Symptom Management. Charlottesville, VA: International Psycho-Oncology Society (IPOS) Press, 2006. [See: Baile, W., Muriel, A., Rauch, K. and Handzo, G., "Communication Issues," pp. 97-106.]

Inselman, L. S. Pediatric Pulmonary Pearls. Philadelphia: Hanley & Belfus, 2001. [See also: Heffner, J. E. and Byock, I. Palliative and End-of-Life Pearls. Philadelphia: Hanley & Belfus, 2002.] Joint Commission on Accreditation of Healthcare Organizations. Hospital Patient Assessment: Meeting the Challenges. Overbrook Terrace, IL: Joint Commission Resources, 2003. Jonas, W. B. and Crawford, C. C. Healing, Intention, and Energy Medicine: Science, Research Methods, and Clinical Implications. New York: Churchill Livingstone, 2003. Kaiser, P. Religion in der Psychiatrie: Eine(un)bewusste Verdrangung? [German]. Gottingen: V & R Unipress, 2007. [See pp. 569 and 630.] Karvinen, I. Henkinen ja hengellinen terveys: etnografinen tutkimus Kendun sairaalan henkilokunnan ja potilaiden seka Kendu Bayn kylan asukkaiden henkisen ja hengellisen terveyden kasityksista [Spiritual Health: An Ethnographic Research about the Conceptions of Spiritual Health Held by the Kendu Hospital Staff Members, Patients and the Inhabitants of the Kendu Bay Village .] Kuopio University Publications D. Medical Sciences 451 [Monograph series.] [Finnish.] Kuopio, Finland: Kuopio University Publications, 2009. [See pp. 19, 33, 42, and 189.] Kinzbrunner, B. M. and Policzer , J., eds. End of Life Care: A Practical Guide. New York: McGraw-Hill, 2011. [See: Kinzbrunner, B. M., "The Physician's Role in Spiritual Care," pp. 379-392.] Kirkcaldy, B. D. The Art and Science of Health Care: Psychology and Human Factors for Practitioners. Cambridge, MA: Hogrefe Publishing, 2011. [See: Bogue, R. J., Fisak, B. and Lukman, R., "Becoming, Being, and Excelling as a Physician: Physician Motivation, Satisfaction, Wellness, and Effectiveness," pp. 81-101.] Klein, C., Berth, H. and Balck, F., eds. Gesundheit - Religion - Spiritualitat: Konzepte, Befunde und Erklarungsansatze. Weinheim, Germany: Juventa, 2011. [See: Albani, C and Klein, C., "Religiositat/Spiritualitat in somatischer Behandlung, Pflege und Psychotherapie," pp. 375-406.] Kliewer, S. P. and Saultz, J. Healthcare and Spirituality. Oxford: Radcliffe Publishing, 2005. [See Chapter 2: "Toward a Model of Integration," pp. 24-45, Chapter 6: "The Objectives of Integrating Spirituality and Medicine," pp. 109-125, Chapter 9: "Spiritual Interventions," pp. 166-190, and Appendix D: "Suggested Further Reading," 212-214.] Kligler, B. and Lee, R. A. Integrative Medicine: Principles for Practice. New York: McGraw Hill, 2004. [See: "Spirituality and Health," pp. 301-310.] Koenig, H. G. Medicine, Religion, and Health: Where Science and Spirituality Meet. West Conshohocken, PA: Templeton Foundation Press, 2008. [See: "Why Is

Addressing Spirituality In Health Care Important?" pp. 21-25.] Koenig, H. G. Spirituality in Patient Care: Why, How, When, and What. Philadelphia: Templeton Foundation Press, 2002. Koenig, H. G., McCullough, M. E. and Larson, D. B. Handbook of Religion and Health. New York: Oxford University Press, 2001. Kohatsu, W. Complementary and Alternative Secrets: Questions and Answers about Integrating CAM Therapies into Clinical Practice. Philadelphia: Hanley & Belfus, 2002. [See: Olive, K., "Spirituality," pp. 47-53.] Krohm, C. and Summers, S. Advance Health Care Directives: A Handbook for Professionals. Chicago, IL: American Bar Association, 2002. [See: "Involvement of Clergy and Spiritual Advisors," pp. 117-131.] Lake, J. H. and Spiegel, D. Complementary and Alternative Treatments in Mental Health Care. Washington, DC: American Psychiatric Publishing, Inc., 2007. [See: Freinkel, A. and Lake, J., "Religious Beliefs, Spirituality, and Intention," pp. 365-380.] Lawton, M. P., ed. Focus on End of Life: Scientific and Social Issues [Annual Review of Gerontology and Geriatrics, Vol 20, 2000]. New York: Springer Publishing, 2001. [See: Bradley, E. H., Fried, T. R., Kasl, S. V., and Idler, E., "Quality of Life Trajectories of Elders in the End of Life," pp. 64-96.] Lorenz, K., Lynn, J., Morton, S. C., Dy, S., Mularski, R., Shugarman, L., Sun, V., Wilkinson, A., Maglione, M. and Shekelle, P. G. End-of-Life Care and Outcomes [Evidence Report/Technology Assessment No. 110. Prepared by the Southern California Evidence-Based Practice Center (Rand Corporation) for the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; AHRQ Publication No. 05-E004-2]. Rockville, MD: Agency for Healthcare Research and Quality, December 2004. [See Appendix M.] Available on-line at www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.chapter.77852. Lysaught, M. T., Kotva, J. J. Jr., Lammers, S. E. and Verhey, A., eds. On Moral Medicine: Theological Perspectives in Medical Ethics. 3rd ed. Grand Rapids, Michigan: Eerdmans, 2012. [See: Curlin, F. A. and Hall, D. E., "Strangers or Friends? A proposal for a New Spirituality-in-Medicine Ethic," pp. 286-291]. MacKian, S. Everyday Spirituality: Social and Spatial Worlds of Enchantment. New York: Palgrave Macmillan, 2012. Maizes, V. and Low Dog, T., eds. Integrative Women's Health. New York: Oxford University Press, 2010. [See: Mackenzie, E. R. and Rakel, B, "Healthy Aging: The Whole Woman Approach," pp. 646-659.]

Matzo, M. L. and Sherman, D. W. Gerontologic Palliative Care Nursing: Across Illness Trajectories. St. Louis, MO: Mosby, 2004. Matzo, M. and Sherman, D. W., eds. Palliative Care Nursing: Quality Care to the End of Life. New York: Springer, 2010. [See Chapter 1: Sherman, D. W., "Culture and Spirituality as Domains of Quality Palliative Care."] McCall, J. B. A Practical Guide to Hospital Ministry: Healing Ways. New York: Haworth Pastoral Press, 2002. [See: "Understanding the Hospitalization Process and Patient Needs," pp. 45-72.] Macleod, A. D. The Psychiatry of Palliative Medicine: The Dying Mind. 2nd ed. London: Radcliffe Publishing. Ltd., 2011. [See: Dein, S., "Psychiatry, spirituality, and palliative medicine," pp. 51-57.] McKenna, M. K. and Pugno, P. A. Physicians as Leaders: Who, How, and Why Now? Oxford: Radcliffe Publishing, 2005. [See: "References for Further Reading," pp. 295-321.] McPhee, S. L., McPhee, S., Winker, M. A., Rabow, M. W., Pantilat, S. Z. and J. Markowitz, A. J. Care at the Close of Life: Evidence and Experience. New York : McGraw-Hill Medical, 2011. [See: Sulmasy, D. P., Chapter 29: "Spiritual Issues in the Care of Dying Patients: '...It's Okay Between Me and God.'"] McSherry, W. and Ross, L. A., eds. Spiritual Assessment in Healthcare Practice. Keswick, England: M&K Update Ltd, 2010. [See: Puchalski, C., "The Spiritual History: An Essential Element of Patient-Centered," pp, 79-93.] Micozzi, M. S., ed. Complementary and Integrative Medicine in Cancer Care and Prevention: Foundations and Evidenced-Based Interventions. New York: Springer Publishing Company, 2007. [See: Shih, K. C. and Larson, D., "Religion and Spirituality," pp. 95-120.] Moore, R. J. and Spiegel, D., eds. Cancer, Culture, and Communication. New York: Kluwer Academic/Plenum Publishers, 2004. [See: Gibson, C. A., Pessin, H., McLain, C. S., Shah, A. D. and Breitbart. W., "The Unmet Need: Addressing Spirituality and Meaning Through Culturally Sensitive Communication and Intervention," pp. 281-298.] Munstedt, K., ed. Ratgeber komplementare und alternative Krebstherapien. [German] 3rd ed., updated and expanded. Lansberg, Germany: Ecomed, 2012. [See: Bussing, A., "Spiritualitat/Religiositat als Ressource im Krankheitsumgag," pp. 99-110.] Munstedt, K., ed. Ratgeber unkonventionelle Krebstherapien. [German] 2nd ed. Landsberg, Germany: Ecomed Verlagsgesellschaft, 2005 . [See Bussing, A., Ostermann, T. and Matthiessen, P. F., "Spiritualitat, Religiositat und

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Church attendance is associated with improved health and well-being among older adults, but older adults with functional limitations may have difficulty attending church services. This article examines differences in the association between functional limitations and church attendance in a sample of 987 elderly African American and white individuals. African American and white elderly people without limitations attended church at virtually the same rate (69 percent). Despite their higher scores on religiousness measures, elderly African Americans with one or more limitations were significantly less likely to attend church regularly than were white counterparts. Health status measures did not help explain older African Americans' lower attendance rates. Differences in attendance were associated primarily with educational attainment and cognitive functioning. The article recommends social work intervention to reduce barriers to church attendance for older adults who want to attend services.

KEY WORDS: African Americans; church attendance; elderly people; functional limitations ********** Religious participation and activities are positive resources for many older adults in solving problems and dealing with difficult life issues (Barusch, 1999; Cutler & Hendricks, 2000). There is evidence that religious participation is of particular importance for elderly African Americans (Black, 1999; Chatters &Taylor, 1994). Furthermore, religious service attendance appears to contribute to quality of life and good health for substantial proportions of elderly people (Levin, 1994; McFadden, 1996; Neill & Kahn, 1999) and may be of particular importance for older adults in poor health (Idler & Kasl, 1997). Research has also indicated that older adults with health limitations, people who could potentially benefit substantially from the fellowship and inspirational experiences that religious service attendance can provide, may find that their low functional status makes religious service attendance difficult (Idler, 1987; Koenig, 2002).Thus, some have recommended that social workers help elderly individuals who want to be active in their faith communities to attend religious services and other activities (McInnisDittrich, 2002). The purpose of this study was to determine whether there were differences in the extent to which functional impairments affected religious service attendance among elderly African American and white community-dwellers. If such impairments affected African American and white older adults' religious service attendance differently, the study's second aim was to understand the reasons for these differences. Understanding such differences can help practitioners design more effective, evidencebased intervention strategies that are spiritually and racially sensitive to their clients' needs. Many studies have found positive associations between religious service attendance and better health (see Koenig, McCullough, & Larson, 2001, for a review). Researchers have reported these salutary effects in both studies of elderly African American and white people (Roff et al., 2004) and studies of African American older adults alone (Levin, Chatters, & Taylor, 1995). Several explanations link religious service attendance and better health. Krause (2002) pointed to the spiritual and emotional support elders receive from those in their congregations as well as to the optimism that churchgoers feel because of a close relationship with God. Service attendance may also contribute to good health because it promotes good health behaviors (Roff et al., 2005; Strawbridge, Shema, Cohen, & Kaplan, 2001). For many, religious participation is a critical component of successful aging (Crowther, Parker, Achenbaum, Larimore, & Koenig, 2002). Idler and Kasl (1997) suggested that religious service attendance is especially important for the wellbeing of adults with health limitations. At the same time, some have suggested that the positive associations found in cross-sectional studies between religious attendance and health occur because elderly people in poor health and with poor functional status are unable to attend religious services (Benjamin, 2004; Koenig, 2002, Van Ness, Kasl, & Stanislav, 2003). However, health limitations were not statistically significant predictors of church attendance among a sample of 581 elderly African Americans, who often made extraordinary efforts to continue to attend services despite their disability

(Taylor, 1986). Elderly African Americans have higher rates of functional limitations and lower life-space mobility than do their white counterparts (AARP Minority Affairs, 1995; Allman, Sawyer-Baker, Maisiak, Sims, & Roseman, 2004). Because functional limitations are more prevalent among older African Americans, an initial speculation would be that these limitations would restrict their church attendance. A considerable literature attests to the central importance of religion and church participation in the lives of African Americans (Martin & Martin, 2002; Musick, 1996). African Americans attend church and have higher religious involvement than do white Americans (Levin & Taylor, 1997; Levin, Taylor, & Chatters, 1994). African Americans turn more often than white Americans to religion as a source of help with health problems (Ferraro & Koch, 1994). Because of their stronger orientation to religious participation, African Americans with functional limitations might be expected to attend religious services at greater rates than their white counterparts. This study follows Nagi's (1969) conceptual model of the disablement process. The model presents a pathway through which pathology (for example, injury or disease) leads to impairments (for example, dysfunctions in body systems), and impairments lead to functional limitations (restrictions in physical and mental actions). Functional limitations can result in disability, which is understood as a social consequence of chronic health conditions (Verbrugge & Jette, 1994). Disability is thus "a restriction or inability to perform socially defined roles and tasks expected of an individual within a socio-cultural and physical context" (Jette, 1996, p. 108). Such activities could include working, pursuing recreational activities, and church attendance. Following this model, a number of factors can contribute to the path through which chronic illness leads to disability, including sociodemographic characteristics, external support systems, environmental characteristics, psychological attributes, and coping mechanisms. In our adaptation of this model, we conceptualized functional limitations as difficulties with the basic activities of daily living (for example, getting up from a chair or toileting independently), and we conceptualized nonattendance at religious services as a manifestation of disability among people who are otherwise highly religious. We were interested not only in differences in religious attendance patterns between elderly African American and white individuals who have no functional limitations and those who do, but also in identifying a wide range of sociodemographic, social--environmental, and psychosocial factors that may affect attendance. We examined sociodemographic variables, social support variables, religiousness variables, and a number of health and mental health variables as potential influences on attendance. METHOD Sample This study was a secondary analysis of data collected using in-home interviews from 1999 to 2001 with 1,000 adults age 65 and older. Researchers recruited participants from a stratified, random sample of

the Medicare beneficiary list from five central Alabama counties (three more rural and two mostly urban). The sample was stratified by county, race, and gender and included balanced numbers of African American men and women and white men and women. We analyzed data from the 491 African American and 496 white participants for whom we had complete information on all variables of interest. Measures Religiousness. We measured religious service attendance with a single item that asked how frequently the participant attended church or other religious meetings. Scores ranged from 1 (more than once a week) to 6 (never). Because of very high attendance rates, we recoded this variable as 1 (weekly or more often) or 0 (less than weekly). Participants also reported how often they prayed. We coded this as 1 (more than weekly) or 0 (weekly or less often). We used the three-item intrinsic religiosity measure from the Duke University Religion Index (Koenig, Meador, & Parkerson, 1997). Participants rated how true each of the following three statements was of them: (1) "In my life, I experience the presence of the Divine (i.e., God)," (2) "My religious beliefs are really what lie behind my whole approach to life," and (3) "I try hard to carry my religion over into all other dealings in life." Scores could range from 15 (high intrinsic religiosity) to 3 (low intrinsic religiosity). Cronbach's alpha for these data was .83. Because of high scores in this population, we dichotomized scores on this variable into those who scored 15 (1) and those who did not (0). Participants also rated the extent to which religious participation was a source of help and comfort to them on a four-point Likert scale, ranging from 4 = a great deal to 1 = not at all. Functional Limitations. Participants reported whether they had difficulty with each of nine different activities: (1) turning from side to side in bed, (2) going up and down stairs, (3) getting out of bed or chair, (4) bathing or showering, (5) dressing or undressing, (6) eating, (7) walking, (8) getting outside, and (9) getting to or using the toilet. We coded responses as 1 (at least one functional limitation) or 0 (no functional limitation). Sociodemographic Characteristics. Measures were ethnicity (0 = white, 1 = African American), marital status (1 = currently married, 0 = not currently married), chronological age, gender (0 = male, 1 = female), and residence (1 = rural; 0 = urban). Educational attainment ranged from 6 (six or fewer years of school completed) to 17 (completed professional or graduate degree).We dichotomized the self-rated income sufficiency measure as 1 (income meets needs or better) and 0 (income insufficient to meet needs). Physical Health. We measured physical health by self report (5 = excellent, 1 = poor) and the participant's score on the SF-12 Physical Health subscale (Ware, Kosinski, & Keller, 1995). Mental Health. Measures were the 15-item Geriatric Depression Scale (Sheik & Yesavage, 1986) and the Mental Health subscale of the SF-12 (Ware et al., 1995). Cognitive Functioning. Participants completed the Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975). A score of less than 24 on this measure may suggest cognitive impairment.

Social Support. Measures of social support were whether the participant was currently receiving help from another (1 = yes, 0 = no), the participant's perceived availability of help from relatives and friends (1 = always, 0 = other), and the respondent's perception of the sensitivity of relatives and friends to her or his needs (1 = always, 0 = other). Analysis Plan We calculated the percentage of respondents who attended church weekly or more often by race and by presence of one or more functional limitations. Next, we examined differences between African American and white participants with one or more functional limitation in church attendance, total number of functional limitations, sociodemographic characteristics, physical health measures, mental health measures, social support measures, and religiousness measures. For relationships where there was a statistically significant race difference, we further examined whether there was also a difference between high and low church service attendance. We identified variables that were significantly related to both race and attendance as potential mediators of the relationship between race and religious service attendance. To see whether these variables operated as mediators, we examined each potential mediator in a logistic regression model that also incorporated race. RESULTS Our initial finding was that there was virtually no difference in the proportion of African American and white participants without functional limitations who attended religious services weekly or more often (69 percent for both groups; see Table 1). Presence of any functional limitations was associated with a reduced likelihood of weekly church attendance for both African American and white participants, although the difference for African American participants (69 percent compared with 47 percent) was almost twice that for white people (69 percent compared with 58 percent). Thus, the presence of functional limitations was associated with a much sharper decline in church attendance for older African American than for white individuals. To better understand why functional limitations were more strongly associated with lower frequency of church attendance for elderly African American than for elderly white participants, we used the Baron and Kenny (1986) approach to identifying potential mediating variables. First we examined older African American (n = 247) and white individuals (n = 212) with functional limitations to see if they differed on a number of sociodemographic, health and mental health, social support, and religiousness measures (Table 2). Functionally limited African American participants were considerably more likely than white participants to have MMSE scores suggesting cognitive impairment. Although there were no racial differences in the proportion receiving help from relatives and friends or in the perceived sensitivity of relatives and friends to their needs, elderly African American participants with functional limitations perceived their relatives and friends to be less available to help them than did their white counterparts. Functionally limited older African American participants were, however, considerably more likely than their white counterparts to report that attending church services was very helpful to them and to score

at the maximum on intrinsic religiosity. Next, we examined whether church service attendance was related to the variables on which African American and white participants differed. MMSE scores, educational attainment, reporting that church attendance provided help and comfort, and intrinsic religiosity differentiated functionally limited elderly people who attended church services weekly or more from those who did not. Marital status, income adequacy, and perceived availability of help did not relate to frequency of church service attendance (Table 3).This two-step procedure identified four potential mediator variables (variables related both to race and to attendance): (1) MMSE scores, (2) educational attainment, (3) reporting that church attendance provides help and comfort, and (4) intrinsic religiosity. Finally, we examined the effect of each potential mediator variable on the relationship between race and attendance using logistic regression (Table 4). Inclusion of the measure of level of educational attainment reduced the association of race with attendance from -.410 (p = .030) to -.038 (p = .853) and inclusion of the MMSE reduced the relationship from -.410 (p = .030) to -.044 (p = .830). Thus, both educational attainment and MMSE appeared to mediate the association between race and attendance. Introduction of perception that church attendance provides help and comfort increased rather than decreased the association between race and attendance from -.410 (p = .030) for race alone to -.657 (p = .001) for race and the "religion is a source of help" variable. Seventy-three percent of functionally limited elderly white participants who reported church attendance was a source of help and comfort attended services at least weekly, and 55 percent of African American participants with this belief attended weekly or more. There was, however, no racial difference in attendance among older adults with functional limitations who did not find service attendance to be a source of help (28 percent of white and 22 percent of African American participants attended weekly or more). The pattern for intrinsic religiosity paralleled that for the perception that church attendance is a source of help. Introduction of intrinsic religiosity into the equation also resulted in an increase in the relationship between race and attendance from -.404 (p = .030) for race alone to -.606 09 = .020) for race with intrinsic religiosity in the equation. Sixty-seven percent of the elderly white participants and 50 percent of African American participants who scored the maximum on intrinsic religiosity attended services weekly or more often. There was no racial difference in attendance among functionally impaired people who did not score the maximum on the intrinsic religiousness measure (35 percent of white participants and 35 percent of African American participants attended weekly or more). DISCUSSION Our first aim was to discover whether there were differences in the extent to which functional limitations were associated with religious service attendance among elderly African American and white community-dwellers. We discovered that African American and white participants without functional limitations attended religious services weekly or more often at virtually the same rate (69 percent). However, among the older adults with one or more functional limitations, 58 percent of white

participants, compared with 47 percent of African American participants, attended services weekly or more often. Thus, functional limitations were more strongly associated with lower church attendance for African American than for white participants. The substantially lower percentage of elderly African American participants with functional limitations who attended services weekly or more often was surprising because these African American participants scored higher on intrinsic religiosity and the perceived helpfulness of church attendance than did their white counterparts with functional limitations. This striking difference is also at variance with Taylor's (1986) finding that disability status did not predict service attendance among elderly African Americans. One possible explanation for African Americans' lower attendance rate could be that those with functional limitations had more severe health problems than did their white counterparts with functional limitations. However, there were no statistically significant differences between African American and white participants with at least one functional limitation in the total number of functional limitations, in the percentage reporting their health as good or excellent, or on the SF-12 physical health measure, the depression measure, or the Mental Health subscale of the SF-12. The only variables that appeared to be associated with the African American participants' lower service attendance rates were their lower MMSE scores and lower educational attainment. Furthermore, these data suggest that high intrinsic religiousness and perceptions that church attendance is helpful were more important to functionally limited white elderly people than to elderly African Americans in promoting service attendance. Why would elderly African Americans' lower levels of education and lower MMSE scores be associated with lower religious service attendance, despite their higher intrinsic religiousness and their stronger perceptions that church attendance is a source of help? First, it is important to recognize that MMSE scores and educational attainment were highly correlated (r = .51 in this study). Thus, it is difficult to ascertain whether the effects we found were primarily a result of African American participants' lower educational attainment or of cognitive functioning. Regardless, our findings indicate that these variables individually or in combination help explain why elderly African Americans with functional limitations were less likely to attend church than were their white counterparts. According to Verbrugge and Jette (1994), a limitation may become a disability either because the individual is personally incapable of an activity (for example, church attendance) or because the activity is too demanding for the individual. Our findings of no racial differences on several health variables suggest that older African Americans with functional limitations were not less personally capable of church attendance than were similar elderly white people. However, our health measures were broad and may not have been sensitive enough to specific health disparities that could limit attendance, for example, diabetes (Allman et al., 2004). An alternative explanation for differences in attendance rates is differences in the demands of

attendance. Owing to their lower educational attainment, elderly African Americans may have more trouble managing the effects of a functionally limiting condition such that they cannot attend church regularly. They may experience more psychological distress associated with church attendance (or with asking others to help them with church attendance). Similarly, they may have fewer resources, less personal assistance, or less special equipment available to enable their attendance (for example, friends and family members may not have suitable vehicles or may be disinclined to accompany cognitively impaired elderly people to church; older adults may not have the funds to offer to others who could drive them to church). African American elders with functional limitations may encounter more physical barriers to church attendance (for example, architectural barriers in the church building or unavailability of a church van to transport people with mobility problems to church). They may live at a greater distance from the church they want to attend. Finally, social barriers in the church environment may result in a less-than-welcoming atmosphere to people with lower education or functioning (King, 1998; Stookey, 2003). These explanations for racial differences must be considered tentative, pending replication of these findings and further research concerning barriers to attendance. Future research should explore in greater detail the reasons why elderly African American and white individuals do not attend services as often as they might like to and should also address the effect of specific health conditions on attendance. The present study is limited because of its cross-sectional nature and because it was conducted in a single region of the United States. Other limitations are that the measure of educational attainment many have overestimated some participants' educational attainment. (Of respondents with one or more functional limitations, 37 percent of African American respondents compared with 8 percent of white respondents had completed six or fewer years of school.) Also, MMSE scores were not adjusted for educational attainment. (Of respondents who had one or more functional limitations and an MMSE score of less than 24, 56 percent of African American respondents compared with 21 percent of white respondents had also completed six or fewer years of school.) Finally, although we have no reason to believe that predominately African American churches in this region differ from predominately white churches in this regard, some smaller, more rural churches may not hold weekly services, and this may have influenced the findings. This study found that high proportions of elderly African American (86 percent) and white (69 percent) individuals with one or more functional limitations scored very high on intrinsic religiosity. Also, 76 percent of elderly African Americans with functional limitations reported that attending church services was a source of help and comfort to them, as did 65 percent of elderly white people with such limitations. Clearly, religious involvement was very important in these people's lives. However, only 47 percent of these African American individuals and 58 percent of these white individuals attended religious services weekly or more often. Social workers are concerned with elderly people's selfdetermination and with helping people with limitations participate as actively in society as they wish to (McInnis-Dittrich, 2002). Thus, social workers should find ways to advocate for impaired elderly people who wish to attend church and help them to do so. This view is consistent with the perspective that

disability is a gap between person and environment (Verbrugge & Jette, 1994) and that decreasing the demand of an activity (for example, changing the physical or social environment, providing external supports, or improving psychological coping) can provide more opportunities for participation for older adults with functional limitations. Implications for Practice Intervention to decrease the difficulties associated with church attendance can occur at the individual level when social workers support elderly individuals' wishes to attend church and help them express their wishes to attend to family and friends. Second, intervention with family members and friends may be helpful (Nelson-Becker, 2005). A functionally impaired elderly person is likely to need the assistance and active support of another to dress appropriately for a religious service and to physically make the trip to the church. Some family members may be reluctant to make the effort required, may fear the health effects of leaving the home on the elderly person, or may be concerned that the person may act inappropriately in public. The social worker can help the elderly individual and family consider these issues together and develop plans satisfactory to all. Finally, intervention within communities of faith may be helpful. Congregation members may not consider how architectural barriers at the place of worship make service attendance difficult or impossible for a person with limitations. Churches with smaller budgets may find it difficult to provide special services for elderly members that include transportation to church (Cnaan, Boddie, & Kang, 2005). Another possible problem may be social barriers. Some people with cognitive and physical impairments have reported feeling uncomfortable in their churches because of insensitive attitudes (King, 1998). Social workers can suggest strategies to help faith communities assess their accessibility and take steps to welcome people with disabilities. Acquainting churches with resources available through the National Organization on Disability (for example, National Organization on Disability, n.d., and Thornburgh, 2005) can be an important form of advocacy. Because of social workers' expertise in person--environment interactions, they may also help congregations avoid unintentional insensitivity to people with cognitive and other limitations and find ways to be more inclusive and welcoming (Stookey, 2003). Church members can, for example, become skilled at assessing elderly people's life-space mobility to anticipate and prevent barriers to attendance (Parker, Baker, & Allman, 2002). Faith-based health promotion efforts aimed at elderly churchgoers can help older adults, family members, and congregations develop strategies to prevent and manage health conditions that might otherwise limit attendance (Parker, Bellis, et al., 2002). This study builds on earlier studies that examined the relationship between functional limitations and religious service attendance among older adults (Benjamin, 2004; Idler & Kasl, 1997; Koenig, 2002; Taylor, 1986; Van Ness et al., 2003). Unlike other studies, it focused specifically on differences in religious service attendance among elderly African American and white community-dwellers with and without functional limitations, using a data set that included high proportions of African American and rural eiders. Furthermore, the study identified potential mediators of the relationship between race and

attendance among eiders with functional limitations. Although this study's findings suggest there may be more barriers to church attendance for elderly African Americans with functional limitations than for similar white individuals, intervention in both communities may he indicated to ensure the fullest possible participation of all elderly people who wish to attend religious services. Original manuscript received January 4, 2006 Final revision received February 22, 2006 Accepted July 26, 2006

Functional limitations and religious service attendance among African American and white older adults.
Roff, Lucinda Lee; Klemmack, David L.; Simon, Cassandra; Cho, Gi Won; Parker, Michael W.; Author: Koenig, Ha