J Relig Health (2010) 49:317

DOI 10.1007/s10943-008-9227-5

ORIGINAL PAPER

Determining Relationships Between Physical Health

and Spiritual Experience, Religious Practices,
and Congregational Support in a Heterogeneous
Medical Sample

James D. Campbell Dong Phil Yoon Brick Johnstone

Published online: 9 December 2008

Blanton-Peale Institute 2008

Abstract Previous research indicates that increased religiosity/spirituality is related to

better health, but the specific nature of these relationships is unclear. The purpose of this
study was to determine the relationships between physical health and spiritual belief,
religious practices, and congregational support using the Brief Multidimensional Measure
of Religiousness/Spirituality and the Medical Outcomes Scale Shortform-36. A total of 168
participants were surveyed with the following medical disorders: Cancer, Spinal Cord
Injury, Traumatic Brain Injury, and Stroke, plus a healthy sample from a primary care
setting. The results show that individuals with chronic medical conditions do not auto-
matically turn to religious and spiritual resources following onset of their disorder.
Physical health is positively related to frequency of attendance at religious services, which
may be related to better health leading to increased ability to attend services. In addition,
spiritual belief in a loving, higher power, and a positive worldview are associated with
better health, consistent with psychoneuroimmunological models of health. Practical
implications for health care providers are discussed.

Keywords Health
Spiritual belief
Religious practices
Congregational support

Psychoneuroimmunological models

Introduction

According to general public surveys, the vast majority of Americans (9095%) say they
believe in God and that for many (60%) religion is very important in their lives. A majority

J. D. Campbell (&)
D. P. Yoon
B. Johnstone

Department of Family and Community Medicine, University of Missouri,
MA306 Medical Sciences Bldg, Columbia, MO 65212, USA
e-mail: campbellj@health.missouri.edu
D. P. Yoon
e-mail: yond@missouri.edu
B. Johnstone
e-mail: johnstoneg@health.missouri.edu

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also express a need for spiritual growth and support (Lee and Newberg 2005). It is no
surprise, then, that patients regard religion and spirituality (R/S) as important. Previous
research indicates that increased R/S is related to better health (George et al. 2000; Koenig
et al. 2001; Lee and Newberg 2005; McCullough et al. 2000; Moreira-Almeida et al. 2006;
Mulligan et al. 2005; Powell et al. 2003). More specifically, there have been investigations
of R/S and Cancer (Devins et al. 2001; Devins et al. 2006; Sherman et al. 2001), medical
rehabilitation (Faull and Hills 2006; Fougeyrollas et al. 1998; Kim et al. 2000; Magyar-
Russell 2005; Moreira-Almeida and Koenig 2006; Treloar 2002) including patients with a
spinal cord injury (Brillhart 2005; Nissim 2003; Noreau and Fougeyrollas 1996; Van Ness
and Kasl 2003), patients who have had a stroke (Giaquinto et al. 2007), and patients with a
traumatic brain injury (Kalpakjian et al. 2004). There have also been several investigations
of R/S and general primary care patients (Astin and Forys 2004; Ellis et al. 2002; George
et al. 2002; Sloan et al. 1999; Thoresen 1999; Thoresen and Harris 2002). The specific
nature of these relationships, however, is unclear, especially with regard to comparisons
between physical health, illness, and disability.

Distinguishing between Religious and Spiritual Variables

As previously stated, a primary weakness in religion, spirituality, and health research to

date has been the ambiguous use of the terms religious and spiritual, as these terms
are related but distinct. Until there is more clear delineation between these terms, however,
research in this area will remain limited.
The Fetzer Institute and the National Institute on Aging Working Group (Multidi-
mensional measurement 1999) brought together a group of experts in religion and health to
develop a measure to address the deficiencies in existing measures of religion and spiri-
tuality. This group created the Multidimensional Measure of Religiousness and Spirituality
(MMRS), and its short form, the Brief Multidimensional Measure of Religiousness/Spir-
ituality (BMMRS). Subscales were developed to measure distinct aspects of spiritual
experience and religious practices, and were chosen because they seemed promising to
determine the causal mechanisms that exist between religious, spiritual, and health vari-
ables (i.e., reduction of behavioral risks, expansion of social support, enhancement of
coping skills, and physiological mechanisms). Several studies have identified the psy-
chometric properties of the BMMRS (Kendler et al. 2003; Mokuau et al. 2001; Pargament
1999; Pargament et al. 2000; Underwood and Teresi 2002; Yoon and Lee 2004) and its
factor structure (Idler et al. 2003; Neff 2006; Piedmont et al. 2006; Stewart and Koeske
2006), but only one has been used to determine how the BMMRS scales are related to
health for a sample with serious medical conditions. Specifically, Rippentrop et al. (2005)
studied a group with chronic pain and indicated that 3% of the variance in physical health
and 12% of the variance in mental health scores were explained by BMMRS subscales
after demographic and pain variables were considered.
Johnstone et al. (in press) completed a factor analysis of the BMMRS with persons with
heterogeneous medical conditions (i.e., the current sample) and suggested that it was most
appropriate to conceptualize the BMMRS as measuring three rather than two domains of
religious/spiritual experience including: (a) the emotional experiences associated with
feelings of connectedness with a higher power/the universe (termed spiritual experience);
(b) culturally based activities such as prayer, meditation, reading religious texts, attending
services, etc. (termed religious practices; and (c) the support provided by fellow congre-
gants (termed congregational support). By conceptualizing the BMMRS in this manner it
was suggested that it would be possible to determine the specific mechanisms by which

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religious and spiritual variables impact health, i.e., through emotional experiences,
cultural behaviors, and/or social support.
With this in mind, the current study was completed to determine the relationships that
exist between physical health and spiritual experiences, religious practices, and congre-
gational support for persons with significant health conditions.

Methods

Research Design

A cross-sectional research design was used in order to determine the relationships among
spiritual experiences, religious practices, congregational support, and physical health sta-
tus. The instruments were administered to study participants by research assistants after
obtaining written informed consent. This study was approved by the Health Sciences
Institutional Review Board of the University of Missouri. To be considered for inclusion in
this study, participants had to be at least 18 years of age, have English as a first language,
and have no identifiable cognitive deficits.

Sample and Data Collection

A convenience sample of 168 patients was obtained from the University of Missouri
academic health center, as well as a private practice Primary Care group. To ensure
adequate representation of the diverse patient groups, a quota sampling method was used.
The number of participants in each group is as follows: 25 Primary Care; 25 Cancer; 25
Spinal Cord Injury (SCI) participants; 61 Traumatic Brain Injury (TBI) participants; 32
Stroke participants. Demographic characteristics of the entire sample, and for each dif-
ferent group, are provided in Table 1.

Measures

Religiousness/Spirituality

To measure spiritual experiences, religious practices, and congregational support, eight

scales of the Brief Multidimensional Measures of Religiousness/Spirituality (BMMRS)
were used (Multidimensional measurement 1999). Based on a recent factor analysis of the
BMMRS (Johnstone et al., in press), this measure was conceptualized as measuring
spiritual experiences (i.e., emotional experience of feeling connected to a higher power),
religious practices (i.e., culturally based rituals), and congregational support factors. For all
BMMRS subscales, lower scores reflect higher degrees of spiritual experience, more fre-
quent religious practices, and greater congregational support.

BMMRS Spiritual Scales

Daily Spiritual Experiences measures the individuals experience of a transcendent (i.e.,

God, the divine) in daily life, including the experience of interaction with a higher power
(e.g., I feel Gods presence.; I feel deeper peace or harmony.). This subscale consisted

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Table 1 Characteristics of
Variable Frequency Percentage
the participants
Sex (N = 168)
Male 71 42.3
Female 97 57.7
Age (N = 167)
\ 31 32 19.2
3140 31 18.5
4150 35 21.0
5160 33 19.7
[ 60 36 21.6
M = 48, SD = 18.3, range = 1893
Type of patient (N = 168)
Primary Care 25 14.9
Cancer 25 14.9
Spinal Cord Injury 25 14.9
Stroke 32 19.0
Traumatic Brain Injury 61 36.3
Marital status (N = 168)
Married 79 47.0
Cohabitating 7 4.2
Divorced 27 16.1
Single 40 23.8
Other 15 8.9
Education (N = 167)
Some high school 24 14.4
High school (HS) diploma 65 39.0
12 years post-HS 29 17.4
34 years post-HS 26 15.6
[4 years post-HS 23 13.8
Annual income (N = 148)
Under $10,001 26 17.6
$10,001 to $20,000 25 16.9
$20,001 to $30,000 18 12.2
$30,001 to $50,000 33 22.2
Over $50,000 46 31.1
Religion (N = 166)
Protestant 91 54.8
Christian 33 19.9
Catholic 27 16.3
Other 3 1.8
No 12 7.2

of 6 items rated on a 6-point response format, ranging from 1 (many times a day) to 6
(never). The internal consistency reliability (Cronbachs alpha) was .88 for the entire
sample.

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Meaning measures a sense of meaning in life (i.e., The events in my life unfold
according to a divine or greater plan.; I have a sense of mission or calling in my own
life.). This subscale was composed of 2 items with a 4-point response format, which
ranged from 1 (strongly agree) to 4 (strongly disagree). Cronbachs alpha was .71 for the
entire sample.
Values/Beliefs measures religious values and beliefs (i.e., I feel a deep sense of
responsibility for reducing pain and suffering in the world.; I believe in a God who
watches over me.). This subscale was composed of 2 items with a 4-point response
format, which ranged from 1 (strongly agree) to 4 (strongly disagree). Cronbachs alpha
was .67 for the entire sample.
Forgiveness measures the degree of forgiveness of self, others, and belief in the for-
giveness of God (e.g., I have forgiven those who hurt me.; I know that God forgives
me.). This subscale consisted of 3 items rated on a 4-point response format, ranging from
1 (always) to 4 (never). Alpha reliability was .65 for the entire sample.
Religious/Spiritual Coping measures additional religious/spiritual practices and beliefs
specifically related to coping with lifes problems (e.g., I work together with God as
partners.; I try to make sense of the situation and decide what to do without relying
on God.). Although this scale is labeled as measuring both spiritual and religious
coping strategies, the factor analysis by Johnstone et al. (in press) indicates it loads on a
spirituality factor. This subscale consisted of 7 items with a 4-point response format,
ranging from 1 (a great deal) to 4 (not at all). Alpha reliability was .83 for the entire
sample.

BMMRS Religious Practices Subscales

Private Religious Practice measures the frequency of privately practiced religious

behaviors (e.g., Within your religious or spiritual tradition, how often do you medi-
tate?; How often do you watch or listen to religious programs on TV or radio?).
This subscale was composed of 5 items with an 8-point response format, which ranged
from 1 (more than once a day) to 5 (never). Cronbachs alpha was .71 for the entire
sample.
Organizational Religiousness measures involvement in a formal public religious
institution (e.g., How often do you go to religious service?; Besides religious service,
how often do you take part in other activities at a place of worship?). This subscale
consisted of 2 items with a 6-point response format, ranging from 1 (more than once a
week) to 6 (never). Alpha reliability was .73 for the entire sample.

BMMRS Congregational Support Scale

Religious Support measures the degree to which local congregations provide help, support,
and comfort (e.g., If you had a problem or were faced with a difficult situation, how much
comfort would the people in your congregation be willing to give you?). This subscale
was composed of 4 items and a 4-point response format was used, which ranged from 1
(very often) to 4 (never). Cronbachs alpha was .75 for the entire sample.
In order to determine if individuals with heterogeneous medical disorders experienced
significant changes in their spirituality, the BMMRS Spiritual History subscale was
administered. This scale measures the degree to which individuals have experienced a
change in their faith (e.g., having a religious or spiritual experience that changed ones life;

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having had a significant gain in faith; or having had a significant loss in faith). Given the
yes/no format of the questions on this scale, it was not included in any statistical analyses
(see Table 2).

Physical Health Status

To measure various domains of physical health status, the Medical Outcomes Short-Form-
36-Health Survey (SF-36) was used (SF-36 health survey 2006). For this study, three
subscales were selected to measure various aspects of physical health, including General
Health Perception, Physical Functioning, and Bodily Pain. Lower scores are indicative of
better perceived health for all SF-36 scales.
General Health Perception was composed of 5 items and a 5-point response format was
used, which ranged from 1 (definitely true) to 5 (definitely false). Cronbachs alpha was .75
for the entire sample.
Physical Functioning consisted of 10 items with a 3-point response format, ranging
from 1 (yes, limited a lot) to 3 (no, not limited at all). Alpha reliability was .85 for the
entire sample.
Bodily Pain was composed of 2 items and a 6-point response format was used, which
ranged from 1 (none) to 6 (very severe). Cronbachs alpha was .82 for the entire sample.

Data Analysis

A one-way analysis of variance (ANOVA) was used to explore group differences for
BMMRS and SF-36 scores. Pearson correlations and hierarchical multiple regression
analyses were performed to determine the relationships that exist among spiritual, reli-
gious, and congregational support factors to physical health. In the hierarchical regressions,
the demographic variables consisted of age, gender (dichotomously coded as 1 = female,
0 = male), education (dichotomously coded as 1 = at least post high school education,
0 \ post-high school education), annual income (dichotomously coded as 1 [ $20,000,
0 B $20,000), and history of mental health treatment (dichotomously coded as 1 = yes,
0 = no).

Table 2 Comparison of spiritual history by group

Variable SCI Primary Cancer TBI Stroke Test statistics (v2)
(n = 25) care (n = 25) (n = 60) (n = 32)
(n = 25)

N % N % N % N % N %

BMMRS religious history

Having had a significant gain 7.58
in your faith
Yes 20 80.0 18 72.0 12 48.0 41 68.0 18 56.0
No 5 20.0 7 28.0 13 52.0 19 32.0 14 44.0
Having had a significant loss 7.89
in your faith
Yes 8 32.0 6 24.0 3 12.0 20 33.0 4 12.0
No 17 68.0 19 76.0 22 88.0 40 67.0 28 88.0

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Results

Comparison of Spiritual History by Group

Chi-square analyses indicated there were no statistically significant differences by group

status for the BMMRS Spiritual History questions (see Table 2).

BMMRS and SF-36 Group Mean Differences

For BMMRS variables, analysis of variance indicated that there were no significant group
differences except for the Religious/Spiritual Coping scale (F = 2.42, P \ .05), with the
Scheffe test indicating that both Primary Care and Cancer groups were more likely than the
TBI group to use religious and spiritual coping skills (see Table 3).
For SF-36 variables, analysis of variance indicated that the different groups did not
statistically differ in terms of General Health Perception (F = 1.37, P [ .05). However,
statistically significant differences were indicated in Physical Functioning (F = 11.14,
P \ .001) with the Scheffe test indicating that the Primary Care, Cancer, and TBI groups
reported better physical functioning than the SCI and Stroke groups. In addition, statisti-
cally significant differences were indicated in Bodily Pain (F = 2.48, P \ .05), with the

Table 3 One-way analysis of variance of five group differences in religiousness/spirituality and physical
health status
Variable Primary Care Cancer SCI Stroke TBI Total F test
(n = 25) (n = 25) (n = 25) (n = 32) (n = 61) (n = 168)
M M M M M M

Spirituality
Daily spiritual 13.21 13.70 17.00 16.06 17.18 15.87 2.19
experiences
Meaning 3.20 3.72 3.56 3.84 4.00 3.74 1.92
Values and beliefs 3.08 3.48 3.24 3.34 3.57 3.39 1.04
Forgiveness 4.28 5.12 5.16 4.94 5.16 4.98 1.21
Religious and 10.88 11.60 13.08 12.47 13.72 12.66 2.42*
spiritual coping
Religion
Private religious 18.48 21.68 21.40 22.10 21.98 21.34 0.84
practice
Organizational 6.84 8.20 8.20 7.59 7.73 7.71 0.84
Religiousness
Congregational support
Religious support 5.00 5.94 5.57 5.52 6.10 5.86 1.59
Physical health status
Physical 17.12 17.88 26.32 22.91 18.61 20.24 11.14***
functioning
Bodily pain 5.68 5.56 7.24 4.97 5.80 5.80 2.48*
General health 13.96 15.68 14.28 14.72 13.16 14.12 1.37
perception
* P \ .05; ** P \ .01; *** P \ .001; SCI, spinal cord injury; TBI, traumatic brain injury

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Table 4 Correlational analyses

Variable SF-36 General Health Perception
for variables predicting General
Health Perception among people
BMMRS
with disabilities
Daily Spiritual Experiences .10
Meaning .15
Values/beliefs .14
Forgiveness .07
Religious/spiritual coping .09
Religious practice .05
Organizational religiousness .16*
Note: N = 168
Religious support .17
* P \ .05

Scheffe test indicating that the SCI group was more likely than other groups to report a
higher level of bodily pain (see Table 3).

Correlational Relationships between the BMMRS and SF-36

In order to determine the relative impact of spiritual, religious, and congregational support
variables on physical health when taking demographic and health status variables into
account, Pearson correlations and hierarchical regressions were conducted. Table 4 pre-
sents the results, which indicate that the only BMMRS subscale that was significantly

Table 5 Summary of hierarchi-

Variable SF-36 General Health Perception
cal regression analyses for
variables predicting General Model 1 Model 2
Health Perception among people
with disabilities (standardized Demographics
beta coefficients)
Age .20* .17
Sex -.07 -.04
Education .04 .07
Household income .04 .03
Physical/medical
SF-36 Physical Functioning .19* .18
SF-36 Bodily Pain .51*** .56***
Mental health treatment .04 .02
BMMRS
Daily Spiritual Experiences .29*
Meaning .09
Values/beliefs .19
Forgiveness .02
Religious/spiritual coping .12
Religious practice .06
Organizational Religiousness .16
Religious support .01
Note: N = 168 F 8.84*** 5.76***
* P \ .05; ** P \ .01; R2/adjusted R2 .39/.35 .49/.41
*** P \ .001

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correlated with the SF-36 General Health Perception scale was Organizational Reli-
giousness (i.e., increased attendance at religious services was related to better health).
For the hierarchical regressions, several models were developed to determine if spiri-
tual, religious, and/or congregational support factors significantly predict any variance in
General Health Perception scores above that predicted by demographic and health status
variables. In the first model, demographic and physical variables were used to predict the
SF-36 General Health Perception scale. In the second model, BMMRS subscales were
used to predict the SF-36 General Health Perception scale after considering the variance
already predicted by the demographic/physical functioning variables (see Table 5).
In Model 1, age, physical functioning, and bodily pain significantly predicted 35% of
the variance in General Health Perception scores (P \ .001). In Model 2, when the
BMMRS variables were included as predictor variables, all variables accounted for 41% of
the variance in General Health Perception scores (F = 5.76, P \ .001; adjusted R2 = .41).
Tolerance scores ranged from .28 (religious and spiritual coping) to .84 (gender), indi-
cating that there were no significant problems of multicollinearity. In this model, Daily
Spiritual Experiences explained an additional 6% (P \ .01) of the variance in General
Health Perception scores. Overall, the hierarchical regressions indicated that individuals
who report less bodily pain (b = .56; P \ .001) but more intense spiritual experiences
(b = .29; P \ .05) are more likely to have better general health.

Discussion

Overall, the results help to clarify the nature of the relationships that exist between physical
health and specific spiritual, religious, and congregational support factors, and suggest that
the BMMRS is an appropriate measure by which to differentiate between the impact of
these variables on health. Specifically, the current results suggest that individuals with the
least severe medical conditions, i.e., individuals in Primary Care, report being more reli-
gious, and spiritual than the other groups with more significant health conditions (i.e.,
Cancer, TBI, SCI, Stroke). The results also indicate that nearly two-thirds of individuals
with medical conditions report experiencing a significant increase in their faith, although
approximately one-fourth also report experiencing a significant decline in their faith at
some point in their lives (see Table 2). Correlational analyses indicate that only the
BMMRS Organizational Religiousness scale was significantly related to physical health,
although the hierarchical regression indicated that the Daily Spiritual Experiences scale
was the only BMMRS scale to significantly predict any of the variance in General Health
Perception scores after taking demographic and health status variables into account. In
general, the results indicate that: (1) better physical health is related to a positive world-
view and increased spiritual beliefs regarding a loving God; and (2) private religious
practices and congregational support are not related to physical health status.

Differences in Spirituality, Religiosity, and Congregational Support

The results indicate that the Primary Care group, which reported significantly better physical
functioning and less pain than the other groups, was also the most spiritual/religious group.
An analysis of variance indicated that this group (as well as the Cancer group) reported
engaging in more religious/spiritual coping than the TBI groups. However, review of Table 2
indicates a non-significant trend for the Primary Care group to be more spiritual and religious
than all other groups. The reasons for this are unclear. It may be that when individuals

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experience a life threatening illness such as cancer or a chronic disabling condition such as
TBI, SCI, or Stroke, their lives are so disrupted that they begin to question their spiritual and
religious beliefs and sense of life meaning (Devins et al. 2001). In other words, perhaps the
stereotypical belief that all patients become more religious or spiritual as a result of their
illness or disability is inaccurate. A foxhole religious or spiritual experience may not be the
initial response for at least some patients facing a life-altering event.
This hypothesis appears to be supported by the current results, which indicate that
individuals with heterogeneous medical conditions experience both increased and
decreased faith at some point in their lives. Specifically, 64% of the heterogeneous sample
reported experiencing a significant increase in religious faith, but 26% reported experi-
encing a significant decrease in their faith. These findings are consistent with previous
research that indicates that there is a subsample of individuals who report negative R/S
connotations related to their health condition (e.g., that their illness is reflective of aban-
donment by or punishment from God), which is associated with worse health outcomes
(Fitchett et al. 1999; Kim et al. 2000; Pargament and Rye 1998). Although 24% of the
Primary Care group also reported experiencing a significant decline in their faith, it is
likely that they may not have experienced a decline in faith as significant as that experi-
enced by persons with major health conditions given the significant physical, cognitive,
emotional and sensori-motor deficits associated with TBI, SCI, Stroke, and Cancer.

Spirituality and Physical Health

The results are generally consistent with psychoneuroimmunological models of health that
suggest that positive thoughts, including spiritual ones, are associated with improved health
status (Ray 2004). Specifically, it suggests that positive beliefs in a loving God, as well as a
generally positive worldview, are the most important religious/spiritual factors related to
physical wellness. Consistent with the results of Rippentrop et al. (2005), the current
results indicate that age and bodily pain are the primary variables that account for the
variance in SF-36 General Health Perception scores (i.e., 35%), with younger age and less
bodily pain related to better self-perceived health status. However, the regression also
indicated that the BMMRS Daily Spiritual Experiences scale accounted for an additional
6% of the variance in General Health Perception scores, suggesting that spiritual beliefs
are related to the physical health of individuals with heterogeneous health conditions.
Review of the items on the Daily Spiritual Experiences scale indicates that this scale
assesses general beliefs in a loving, higher power that is present in ones life (i.e., I feel
the presence of a higher power; I find strength and comfort in my religion; I desire to
be closer to or in union with a higher power; I feel the love of a higher power for me,
either directly or through others;) or a generally positive worldview (I feel deep inner
peace or harmony; I am spiritually touched by the beauty of creation.). Consistent with
psychoneuroimmunological models of health, these positive thoughts (i.e., psycho) are
associated with changes in physiological responses to stress (i.e., neuro), which in turn lead
to better ability to fight disease (i.e., immunology), which in turn leads to better health
(Ray 2004).

Religion and Physical Heath

Although neither of the BMMRS Religious scales predicted general health perception in
the regression analysis, it is noted that the Organizational Religiousness scale was the
only BMMRS scale that was significantly correlated with the SF-36 General Health

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Perception scale. Specifically, more frequent attendance at religious activities was related
to better physical health. The cross-sectional nature of the current study makes it
impossible to determine the causal mechanism between organizational religiousness (i.e.,
attendance at religious events) and better health. It may be that increased participation in
organized religious services leads to better health given the increased social support
provided by congregations, although this is not supported by the lack of a significant
correlation between the BMMRS Religious Support scale and the SF-36 General Health
Perception scale in the current study. It is likely that better physical functioning leads to
the increased ability to attend religious events, consistent with previous research (Berges
et al. 2007). Stated simply, individuals with health conditions may be better able to
attend services at their church, temple, mosque, or faith center if they are physically
healthier. In the current study, it was noted that the SF-36 Physical Functioning scale
was negatively (non-significantly) correlated with every BMMRS scale except for
Organizational Religiousness, suggesting that worse physical functioning is associated
with decreasing spiritual beliefs and fewer private religious practices such as prayer, but
that better physical functioning is associated with increased ability to attend religious
services.
It is also noted that the Private Religious Practices subscale was not significantly
related to the SF-36 General Health Perception scale. This is also likely due to the fact
that some individuals increase religious practices with increasing severity of illness/
disability (i.e., ask for divine guidance/intervention), while others may offer prayers of
thankfulness for improving health status (Haley et al. 2001; Idler and Kasl 1997). As a
consequence, the results are non-significant as prayer is likely related to both increased
and decreased health status, and it should not be inferred that prayer is not an effective,
meaningful coping strategy for persons with significant health conditions. If anything, the
results suggest that specific religious practices may not directly impact health status, but
that it may be the spiritual beliefs associated with these activities that are most
important.

Congregational Support and Health Status

Although religiously based social support has been shown to be related to health (Cohen
et al. 2001), the current results indicate that the social support provided by fellow
congregants is not related to the health status of individuals with heterogeneous medical
disorders. In the current study, the BMMRS Religious Support subscale was not sig-
nificantly correlated with the SF-36 General Health Perception scale, nor did it
significantly predict this outcome variable in the hierarchical regression. However, it is
noted that this may be due to the fact that many individuals with chronic disabilities and
serious health conditions may not be able to attend religious services or related activities
due to their physical impairments and associated environmental handicaps (e.g., unable
to leave their home, inaccessible transportation, difficulties navigating religious centers
in wheelchairs, etc.), and therefore, cannot avail themselves to such support. It is also
possible that the social support provided by congregations can improve the emotional
state of individuals with medical conditions (Giaquinto et al. 2007), but that it may not
be sufficient to impact the extensive physical limitations that often are associated with
TBI, SCI, Stroke, and Cancer, consistent with previous research, which suggests that
religious/spiritual factors do not prevent physical disability (Colantonio et al. 1993;
Goldman et al. 1995).

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Limitations and Future Directions

The current results are limited in that they are cross-sectional in nature so that the causal
mechanisms that exist between religion and health cannot be determined. The ability to
generalize results is also limited given the sample was primarily Christian. Future longi-
tudinal research is needed to clarify the causal mechanism among religious, spiritual,
congregational support, and health variables, and will benefit by including individuals from
multiple faith traditions. Furthermore, future research can help clarify whether or not
different spiritual abilities (e.g., meaning, values/beliefs, forgiveness, religious/spiritual
coping) are distinct, unitary constructs, and if so, how they can be used in health care
practices to improve health (e.g., what are the most important spiritual variables that relate
to health: finding meaning in ones life/illness; having strong beliefs in a loving higher
power; being able to forgive others for causing a disability or to forgive God for allowing
one to become ill/injured; using specific spiritual coping strategies such as turning ones
problems over to God, etc.). The current results also suggest there is a need to determine
the relationships that exist among religious, spiritual, congregational support, and health
conditions for persons with negative religious and spiritual beliefs (i.e., that their illness is
a reflection of punishment from or abandonment from God).
The results are promising in that they suggest that the physical health of individuals
with heterogeneous medical conditions may be impacted by enhancing or promoting
positive spiritual beliefs. As Ray (2004) suggests, spiritual beliefs are likely to improve
psychoneuroimmunological functioning by reducing stress and leading to better immu-
nological functioning and physical health. Just as health psychologists promote physical
health by using positive psychological coping strategies (e.g., psychological stress man-
agement, biofeedback, cognitive reframing, etc.), the current results suggest that the
spiritual beliefs of individuals with significant health conditions (i.e., Cancer, TBI, SCI,
Stroke) should also be relied upon to promote better health. This encouragement/practice
of spiritual interventions may be promoted by religious leaders, hospital chaplains, and/or
health professionals (e.g., physicians, nurses, psychologists, social workers, etc.), although
questions still exist about the best manner by which health professionals can address these
religious/spiritual matters in their practices (B. Johnstone et al. 2007, unpublished man-
uscript). Further research investigating the efficacy of spiritual interventions with
medical populations is warranted, including religious-based counseling (Koenig 2002),
forgiveness protocols (Baskin and Enright 2004; McCullough et al. 2000), and meditation
practices (Kabat-Zinn et al. 1998).

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