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Religious Involvement, Coping, Social Support, and
Psychological Distress in HIV-Seropositive African
American Mothers
Guillermo Prado,1,2 Daniel J. Feaster,1
Seth J. Schwartz,1 Indira Abraham Pratt,1
Lila Smith,1 and Jose Szapocznik1
1
Department of Psychiatry and Behavioral Sciences, Center
for Family Studies, University of Miami School of
Medicine, Miami, Florida 33136.
2Correspondence
should be directed to Guillermo Prado, Center for Family
Studies, 1425 NW 10th Avenue, 3rd Floor, Miami, Florida
33136; e-mail:
gprado@med.miami.edu
.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1480649
Abstract
This
study used a cross-sectional design to examine the role
of religious involvement within a stress-process
framework. Participants were 252 urban, low-income HIV-seropositive
African American mothers. The relationships among
religious involvement, stress, coping responses, social
support, and psychological distress were examined using
structural equation modeling. The number of stressors
reported by the mother was related to greater religious
involvement, which in turn was negatively related to
psychological distress. Furthermore, the results suggest
that social support, active coping, and avoidant coping
responses mediated the relationship between religious
involvement and psychological distress. According to the
present results, interventions to attenuate
psychological distress in HIV-seropositive African
American mothers might focus on increasing social
support, promoting active coping, and decreasing
avoidant coping. The present findings suggest that this
may be accomplished, in part, by promoting involvement
in religious institutions and practices. However, in
light of the cross-sectional design used in the present
study, and given that religion may have both positive
and negative consequences further research is needed to
determine the extent to which promoting religiosity may
increase or alleviate distress.
Keywords:
religion, HIV/AIDS, African Americans, coping, social
support, psychological distress, stress-process model |
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INTRODUCTION
HIV/AIDS Epidemiology in African American Women
African Americans have been disproportionally affected
by the HIV/AIDS epidemic. Although African Americans
comprised approximately 12% of the U.S. population in
2001, they accounted for over half of all new HIV
infections reported in the United States during that
year. African American women, in particular, are among
the leading demographic groups in terms of HIV
prevalence (Centers
for Disease Control and Prevention [CDC-P], 2002a,b,c,
2003).
In 2001, African American women accounted for 64% of HIV
cases reported among women in the United States (CDC-P,
2003). Among women of childbearing age (i.e.,
22–44), the rate of HIV infection for African Americans
was four times the rate for Latinas and more than 16
times the rate for non-Hispanic Whites (CDC-P,
2003).
Religion in HIV-Seropositive African American Women
Religion has historically been an important aspect of
African American culture. Religion and religious
institutions have often provided African Americans with
emotional, economic, and social support (Lincoln
and Mamiya, 1990). Religion has also been
linked with positive mental health outcomes in African
Americans (Levin
and Taylor, 1998;
Williams et al.,
1991), especially those with chronic,
terminal illnesses (Simoni
et al.,
2002;
Woods et al.,
1999). For HIV-seropositive African American
women, it has been suggested that religion may serve as
a protective factor against declines in physical and
psychological health, as well as against progression of
HIV (Morse
et al.,
2000). In spite of the empirical evidence
suggesting that religion is associated with improved
psychological health in African Americans (Levin
et al.,
1995;
Woods et al.,
1999), little empirical research has been
conducted on the mechanisms (e.g., social support and
coping) that account for these associations (cf.
Ellison et al.,
2001). However, research has indicated that,
among HIV-seropositive individuals from other ethnic
groups, religious involvement tends to be associated
with lowered levels of distress (e.g.,
Simoni and Ortiz, 2003). Moreover,
Jenkins (1995) found that, among
HIV-seropositive military personnel, religious
involvement was most often utilized as a response to
stress among African Americans and among women.
Religious involvement appears to have physical-health
benefits for HIV-seropositive individuals as well.
Ironson et al.
2002 found that religious involvement was
associated not only with less psychological distress,
but also with long-term survival, among HIV-seropositive
individuals.
Specifying the mechanisms by which religious involvement
is related to reduced distress in HIV-seropositive
African American women may help facilitate the design of
intervention programs to modulate psychological
distress, and to help maintain good health, in African
Americans (cf.
Szapocznik et al.,
in press). Preventing psychological distress
is particularly important for those with HIV, given that
psychological distress is associated with HIV
progression (Cruess
et al.,
2000a,b).
Accordingly, the primary goal of this article is to
examine the mechanisms by which religious involvement is
related to psychological distress in a sample of
HIV-seropositive African American mothers.
Religion and the Stress-Process Model
The
relationship between stress and psychological distress
has been the subject of extensive theoretical and
empirical work. One of the approaches that have been
advanced to examine the processes by which stress
affects psychological distress has been the
stress-process model (Folkman
and Lazarus, 1988a,b;
Lazarus and Folkman, 1984;
Pearlin et al.,
1981;
Pearlin and Schooler, 1978). The
stress-process model holds that the relationship between
stress and distress operates through coping resources
and coping responses (Schmitz
and Crystal, 2000). Coping resources include
relational factors such as social support (Cohen
and Wills, 1985). Coping responses refer to
the ways in which individuals manage stress, including
active coping (i.e., facing the problem directly),
avoidant coping (i.e., attempting to evade the problem),
and support coping (i.e., seeking help from others in
addressing the problem). Active coping, in particular,
has been found to be associated with well being (Simoni
et al.,
2000), and avoidant coping is often
associated with psychological distress (Feaster
et al.,
2000;
Feaster and Szapocznik, 2002). When
confronted with a stressor or constellation of
stressors, the individual is hypothesized to consider
her/his coping resources and, given these resources, to
make a decision as to which coping responses to employ.
In a relatively basic formulation of the stress process,
the constellation of stressors, coping resources, and
coping responses will determine the extent to which the
process leads to increased or decreased psychological
distress.
The
relationships between religious involvement and elements
of the stress-process model have been explored in
various studies. Briefly, religious involvement has been
positively associated with perceived social support (Simoni
et al.,
2002), negatively associated with
psychological distress (Simoni
and Ortiz, 2003), and positively associated
with active coping (Wright
et al.,
1985). However, these relationships have been
examined in piecemeal fashion, with each study examining
one or two stress-process correlates of religious
involvement. One study examining elements of the stress
process variables as mediators of the effects of
religious coping (not religious involvement) on
depressive symptoms in HIV+ African American women found
that active coping and self-efficacy mediated the
association (Woods
et al.,
1999).
The
objective of the present study was to empirically test
the role of religious involvement in the psychosocial
aspects of the stress-process model in the context of a
more comprehensive framework including stress, social
support, general coping strategies, and psychological
distress. Evidence suggests that relationships exist
among religion, the physical manifestations of the
stress process (e.g., cortisol), and physical health
outcomes (Ironson
et al.,
2002). However, given that our objective was
to examine psychosocial components of the stress-process
model, the study of biological markers and physical
health outcomes is beyond the scope of this study.
The
role of religious involvement in the stress-process
model may be particularly relevant to HIV-seropositive,
inner-city African American mothers. First,
Feaster and Szapocznik (2002) demonstrated
the relevance of the stress-process model for this
group. Second, religious involvement is particularly
relevant in African American culture (Lincoln
and Mamiya, 1990), and to HIV-seropositive
African American women in particular (Biggar
et al.,
1999). Third, inner-city, HIV-seropositive
African American women face multiple sources of stress
such as long-term illness, poverty, and minority status.
Fourth, a considerable percentage of African American
women who are raising or have raised children in the
inner city do not have male partners (Fields,
2003). For these reasons, a sample of
HIV-seropositive African American mothers may be
especially appropriate in testing the role of religious
involvement within the stress-process model. In the
sections that follow, we review findings that support
the role of religious involvement within the
stress-process framework.
Religion and Stressors.
There is evidence that the stress brought on by chronic
illness leads to increased religious involvement. As
Jenkins (1995, page 131) has stated, “HIV’s uncertain
course and terminal outcome make it a situation where
people may see themselves as having little personal
control, a circumstance where people often turn to
religion for answers (Spilka
and Schmidt, 1983).” Moreover,
Simoni and Ortiz (2003) note that religious
involvement, and the faith that often accompanies it,
afford the individual a sense of self-esteem and mastery
in the face of a life-threatening illness. Religious
involvement, then, may often be invoked in situations
where stress either accompanies or exacerbates a
life-threatening health condition such as HIV.
Religion and Social
Support.
Several studies have postulated social support as the
mechanism by which the apparent benefits of religious
involvement on mental health outcomes are produced
(e.g.,
Ellison, 1994,
1995).
African Americans often view their religious
congregations and church-related activities as a regular
place to meet and share their beliefs, values, ideas,
and morals (cf.
Ellison et al.,
2001). In addition, church members may
provide emotional support, pastoral counseling, and
economic aid to members of their congregation (Taylor
and Chatters, 1988). African American church
members may be especially attentive to those in need of
the extra support and assistance, perhaps increasingly
so for HIV-seropositive women (cf.
Morse et al.,
2000). It is perhaps for these reasons that
African Americans who are more religiously involved tend
to have a larger social support network (Ellison
and George, 1994). Moreover, in the
stress-process literature, greater social support has
been linked with lower levels of psychological distress
(Koenig
et al.,
1997;
Nooney and Woodrum, 2002). Therefore, two
conclusions can be drawn from the literature on
religious involvement and social support. First,
religious involvement is likely to be related to greater
degrees of social support, and second, the relationship
between religious involvement and psychological distress
may operate through social support.
Religion and Coping.
Religion has been studied within the context of the
coping process (see
Moneyham et al.,
1998;
Nooney and Woodrum, 2002;
Pargament et al.,
1990,
1998;
Siegel and Schrimshaw, 2002). Much of the
research on the role of religion in the coping process
has focused on religiously based coping strategies (Koenig
et al.,
1992;
Nooney and Woodrum, 2002;
Pargament, 1997; Pargament
et al.,
1999,
2001). However, given our interest in
ascertaining the role of religious involvement in a
general stress-process model among HIV-seropositive
African American mothers, we focused specifically on the
relationship between religious involvement and general
coping strategies (e.g., active, support seeking, and
avoidant).
Few
studies have examined the relationship between religious
involvement and general coping strategies. The research
that has been conducted indicates that religion
contributes to the coping process by increasing the use
of active coping (e.g., positive reframing), and by
decreasing the use of passive or avoidant coping
strategies, in response to negative life events (Spilka
et al.,
1985;
Wright et al.,
1985). Given that these general coping
strategies are associated with psychological distress,
it may be reasonable to expect that religious
involvement would be related to psychological distress
indirectly through (i.e., mediated by) coping responses.
Religion and
Psychological Distress.
The
relationship of religion to psychological distress and
well-being has been widely examined. However, many of
these studies have used religious coping rather than
religious involvement per se (see
Pargament, 1997, for a review). However, to
maintain conceptual independence between religious
involvement and coping responses in our examination of
the stress-process approach, we focus here only on those
studies that have examined religious involvement in
relation to psychological distress. Religious
involvement has been identified as a negative correlate
of psychological distress in various HIV-seropositive
populations, including African American women (Sowell
et al.,
2000), Puerto Rican women (Simoni
and Ortiz, 2003), and African American men (Koenig
et al.,
1992).
Simoni and Ortiz (2003) found that the
relationship between religious involvement and
psychological distress among HIV-seropositive Puerto
Rican women was mediated by self-esteem and perceived
control. Within the stress-process framework, other
mediating mechanisms might be proposed. Specifically, as
noted above, the stress-process approach might hold that
both social support and general coping strategies would
mediate the relationship between religious involvement
and psychological distress.
The
Present Study
The
present study examined the role of religious involvement
within a stress-process framework. In addition to the
paths proposed within the stress-process model, we
hypothesize that (a) religious involvement will mediate
the relationship between stress and psychological
distress; (b) religious involvement will be negatively
related to psychological distress; and (c) both social
support and general coping strategies will mediate the
relationship between religious involvement and
psychological distress. Specifically (see
Fig.
1), we hypothesize that religious involvement
will relate positively to stress, social support, and to
active and support seeking coping responses, and will
relate negatively to avoidant coping responses.
Fig. 1
The role of religious involvement in the stress-process
model: Hypothesized model of relationships
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METHODS
Participants
Participants in this study were 252 urban, low-income
HIV-seropositive African American mothers. Data for the
present analyses were taken from the baseline assessment
of a larger study testing the efficacy of Structural
Ecosystems Therapy (Szapocznik
et al.,
in press) with HIV-seropositive African
American mothers. Participants in the study were
recruited from a large urban medical center and
affiliated clinics, as well as from agencies that
provide social services to HIV-seropositive individuals.
An interviewer explained the study to each woman and
obtained informed consent from her. The active phase of
recruitment for this study extended from the fall of
1996 to the spring of 1999. To be eligible for
participation in the current study, women had to meet
the following screening criteria: (a) African American;
(b) HIV-seropositive, as determined by self-report; and
(c) at least 18 years of age. Additionally, (a) all
women had to have at least one child, although there
were no limits on the ages of children and children did
not have to live with the mother; and (b) women had to
report at least two interpersonal problems, including
one family related problem, on our Recruitment/Screening
form. Interpersonal problems listed on the screening
checklist included having too much stress, feeling sad
or depressed, feeling anxious or nervous, and feeling
lonely. Family problems listed on the screening
checklist included fear of disclosing HIV status to
family members, conflicts with family, communication
problems with family, drug/alcohol problems in the
family, child custody problems, child-related problems
(e.g., school, behavior, health), and problems with
one’s romantic partner. Nonfamily problems listed on the
checklist included anxiety, depression, loneliness,
transportation problems, and fear that others (outside
the family) will discover one’s HIV status.
The
ages of the participants in the sample ranged from 18 to
62 (M
age = 35.34, SD
= 8.50). The median annual income level was $6,864. With
regard to the mothers’ marital status, 109 (43%) were
never married and not cohabitating, 25 (10%) were
married and living with their husbands, 22 (9%) were
married but living apart from their husbands, 48 (19%)
were unmarried but cohabitating, 7 (3%) were widowed, 40
(16%) were divorced, and 1 participant’s marital status
was unknown. Mothers were mostly Baptist (65%),
Pentecostal (8%), or nondenominational Christian (6%).
The median number of children per woman was three. Over
half of the sample (51%) reported having less than a
high school education. Eighty-three percent of the
participants were unemployed and reported receiving some
form of public assistance. The mean CD4 cell count for
the sample was 453.03 (SD
= 300.49). Almost three quarters (72%) of the
participants had been living with HIV for at least 3
years (M
= 5.46 years, SD
= 3.80). Sixty-four percent of the sample met a lifetime
DSM-III-R diagnosis of drug abuse or dependence
(measured in this study by the Structured Clinical
Interview for DSM-III-R (SCID), Non-Patient Version for
HIV-seropositive person) at the time of the assessment (Spitzer
et al.,
1989).
Recruitment
The
mothers in this study were recruited from
community-based agencies that provide HIV care and other
social services to HIV-seropositive individuals in South
Florida. Recruitment occurred through flyers and in
person at these sites. After each mother was recruited
and her eligibility was determined, the recruiter
arranged for an interviewer to explain the study, obtain
consent, and conduct the assessment.
Assessments
All
assessments were conducted at the woman’s home or other
location convenient to the woman (e.g., the home of a
family member). For purposes of confidentiality and
privacy, all efforts were made to conduct the
assessments in a quiet room in the home. Efforts were
made to set up appointments when other family members
were unlikely to be home. For example, a majority of the
assessments were set up during hours when family members
would be at school or at work. In cases where other
family members were present in the home, the assessor
would politely request that these family members leave
the room so that the interview could be private and
confidential. On rare occasions, family members
interrupted an assessment (e.g., by walking into the
room where the assessment was being conducted). In these
cases, the interviewer stopped the assessment until
these family members had left the room. Interviewers
administered the assessments and recorded participants’
responses on laptop computers. Although attempts were
made to maximize privacy, we cannot rule out that lack
of privacy could have affected some of the responses,
and unfortunately we did not collect the data needed to
test this hypothesis. Participants were paid $50 for
completing the assessment. The measures described in
this article were part of a larger assessment battery
administered to participants. The average completion
time for the larger battery ranged from 120 to 150 min.
Assessors were African American, Caribbean American, or
Hispanic females between the ages of 25 and 30.
Assessors either had a master’s degree in counseling
psychology or social work or were enrolled in a
psychology doctoral program. All assessors were trained
for a period of three months by the Project Director
(L.S.) or by the most senior assessor (I.A.P.).
Measures
Religious Involvement.
Although the larger study was not specifically designed
to study religious involvement, the importance of
religious involvement in the HIV-seropositive African
American mothers in our study became evident as the
study progressed. Thus, we identified existing items to
measure religious involvement. The religious involvement
construct was measured by participants’ responses to
four different items. Of the four items, one was adopted
from Carver’s Brief Cope (Carver,
1997), one from the Feetham Family
Functioning Survey (Roberts
and Feetham, 1982), and two from the Support
and Service Utilization Schedule (Kaminsky
et al.,
1989). Items asked the participants about 1)
the frequency with which they attended organized
religious services, 2) the amount of time they spent in
religious and spiritual activities, 3) the amount of
time they spent reading religious materials, and 4) the
amount of time they spent praying or meditating.
Table I lists the four items as well as their
response scales.
Table I
Religious Involvement Items and Rating Scales
|
Item |
Rating Scale |
|
Support and Service Utilization Schedule
(Kaminsky
et al.,
1989) |
|
|
Items 1 and 2 refer to the following statements:
During the past 3 months, how often (indicate
number of times) do you use any of the following
types of religious (or spiritual) support? |
|
|
 1.
Attending organized religious services (church) |
Continuous |
|
2.
Reading religious material |
Continuous |
|
Feetham Family Functioning Survey
(Roberts
and Feetham, 1982) |
|
|
Item 3 refers to the following statement: |
|
|
3.
The amount of time you spend in
religious/spiritual activities? How much time is
there now?a |
7-point Likert scale ranging from 1 =
little
to 7 = very
much |
|
Cope
(Carver,
1997) |
|
|
4.
I’ve been praying or meditating.a |
4-point Likert scale ranging from 1 =
not at all
to 4 = a
lot |
Stress.
Stress was measured using the Difficult Life
Circumstances Questionnaire (Barnard,
1989). This measure was selected because it
is composed of stressors relevant to poor, inner city
women. For each of the 34 stressors listed, the
participant was asked to indicate (a) whether the
stressor was present in her life and (b) the subjective
impact of the stressor (on a scale of 1–7). Sample items
include: (a) Do you need more money for necessities? (b)
Is one of your children being abused sexually,
emotionally, or physically by anyone? (c) Do you have a
problem with alcohol or drugs (prescription or street)?
To avoid confounding stress with psychological distress,
the total count of stressors, rather than their
subjective impact, was used.
Available Social
Support.
Available social support was measured using the Social
Support Questionnaire – Short Form (SSQ-6) (Sarason
et al.,
1987). The SSQ-6 asks the respondent to list
the number of people they can count on for six different
aspects of support (e.g., “Whom can you really count on
to help you feel more relaxed when you are under
pressure or stress?”). The SSQ-6 was used in the present
study to enumerate the size of the woman’s available
support network.
Coping Responses.
Coping responses were measured using the Brief Cope (Carver,
1997), plus 11 additional items for use with
this population (see
Feaster and Szapocznik, 2002). Convergent
validity was established in a validation sample (n
= 44) in which the correlations between the
corresponding scales from the original Cope and the
version used here ranged between 0.51 and 0.83. Although
the Brief Cope was not specifically designed to yield
active, support, and avoidant coping scales, the Cope
has been used extensively to generate these scales in
research on HIV-seropositive persons (Blaney
et al.,
1997;
Feaster et al.,
2000;
Feaster and Szapocznik, 2002;
Goodkin et al.,
1992). A confirmatory factor analysis,
reported in the “Confirmatory Factor Analyses” section
below, was conducted to determine if the Brief Cope also
yielded these three factors. Active coping includes
items measuring positive reframing, planning, and taking
action. Support coping includes items measuring use of
emotional and instrumental support, talking with others,
and use of therapy. Avoidant coping included items
measuring use of suppression of thoughts, denial,
self-blame, ventilation, stoicism, behavioral
disengagement, self-distraction, and yearning for the
past. The support coping and social support measures
used in this study were distinct from one another, in
that support coping refers to the use of or reliance on
sources of support whereas social support refers to the
size of the available support network. Items for this
measure are rated on a 4-point Likert-type scale ranging
from 1 = not at all
to 4 = a lot.
Psychological Distress.
Psychological distress was measured using the Brief
Symptom Inventory (BSI;
Derogatis, 1993). This 53-item instrument
asks respondents to rate, on a 5-point Likert scale
ranging from 0 =
Not at all to 5 =
Extremely,
the extent to which specific items (e.g., feeling
lonely, feeling very self-conscious with others, and
feeling easily annoyed or irritated) have distressed
them in the past week. The BSI assess nine dimensions:
somatization, obsessive-compulsive, interpersonal
sensitivity, depression, anxiety, hostility, phobic
anxiety, paranoid ideation, and psychoticism (Derogatis,
1993).
Means, standard deviations, ranges, and reliabilities
for each of the subscales are reported in
Table II. As explained below, the
reliabilities are calculated using a method similar to
that used to calculate Cronbach’s alpha.
Table II
Descriptive Statistics for the Religious Involvement
Items and the Stress-Process Variables
|
Variable |
Mean (SD) |
Range |
Reliabilitya |
|
Religious involvement |
|
|
.74 |
|
Attendance
at organized religious services |
29.86 (24.70) |
0–99 |
|
|
Reading
religious material |
2.37 (3.75) |
0–30 |
|
|
Time
spent in religious activities |
3.85 (2.15) |
1–7 |
|
|
Praying
or meditating |
3.32 (.99) |
1–4 |
|
|
Stress—Total
count of stressors |
7.77 (4.10) |
0–19 |
N/Ab |
|
Available social support |
13.91 (7.93) |
0–54 |
.84 |
|
Coping strategies |
|
|
|
|
Active |
25.73 (4.57) |
11–32 |
.69 |
|
Support |
21.78 (5.17) |
8–31 |
.75 |
|
Maladaptive |
36.89 (9.59) |
15–59 |
.82 |
|
Psychological distress—Global
Severity Index |
1.03 (.72) |
0–3.34 |
.93 |
aReliability
is estimated using the formula for composite reliability
recommended by
Fornell and Lacker (1981). This formula
posits reliability as the ratio of variance explained by
the construct to the total variance among the
indicators. The formula is an approximation of
Cronbach’sα.
|
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RESULTS
Analytic Plan
A
number of preliminary steps were taken to ascertain the
feasibility of estimating a structural equation model to
test the study hypotheses. First, confirmatory factor
analyses (i.e., measurement models) were performed on
individual measures at the scale level. Because of
sample size (and power) considerations, in each
confirmatory factor analysis we reduced the number of
indicators by combining the items randomly into parcels
composed of two or three items apiece (cf.
Bandalos and Finney, 2001;
Feldt, 2002). These parcels were then used as
indicators in the confirmatory factor analysis. The
appropriateness of each latent construct was evaluated
primarily in terms of the comparative fit index (CFI),
which compares the hypothesized model to a model
perfectly fitting the data, and the root mean square
error of approximation (RMSEA), which estimates the
degree to which residual (error) variance contributes to
model misspecification. The chi-square statistic is
reported but is not used in interpretation because it is
vulnerable to inflation with large sample sizes (Kline,
1998). Normally, CFI values of .90 (Bentler
and Stein, 1992) or greater, and RM-SEA
values of .08 or less (Bentler
and Bonett, 1980;
Byrne, 2001), are indicative of good model
fit, with RMSEA values of .05 or less considered to be
near-perfect fits (MacCallum
et al.,
1996). Reliability for each latent construct
is estimated using the formula for composite reliability
recommended by
Fornell and Lacker (1981). This formula
posits reliability as the ratio of variance explained by
the construct to the total variance among the
indicators. The formula is an approximation of the
coefficient (i.e., Cronbach’s) alpha that can be
computed using the loadings from a confirmatory factor
analysis. These reliabilities are presented in the text
(see Confirmatory Factor Analyses below) as well as in
Table II.
Second, the full measurement model was estimated with
all measures freely correlated to assess whether the
latent variables included in the model were measuring
distinct constructs (i.e., whether the correlations
among latent variables were low enough to reflect
discriminant validity; cf.
Kline, 1998). Third, provided that adequate
discriminant validity was present, structural equation
models (SEM) including the measurement models (between
the indicator variables and latent constructs) and the
hypothesized paths were estimated. To test the
mediational roles of the variables in the hypothesized
model, the results of three separate path analyses are
presented. The first model tested for the association
between stress and psychological distress. The second
model tested added religious involvement to the model.
The addition of religious involvement allowed us to test
not only the direct paths between stressors and both
psychological distress and religious involvement, but
also the mediating role of religious involvement in the
relationship between stressors and psychological
distress. The final model tested represents the
full-hypothesized model, including coping styles and
social support (Fig.
1). This model allows for the examination of
all of the direct paths as well as the indirect paths
between religious involvement and psychological distress
through social support and the coping responses. Thus,
this final model tests our hypothesis that social
support and coping responses may mediate the effect of
religious involvement on psychological distress. Fit
statistics for the models were evaluated against the
same standards (CFI ≥ .90, RMSEA ≤ .08) used to evaluate
the measurement models. The power to uncover significant
nonfit of an SEM model can be calculated based on the
distribution of the RMSEA (MacCallum
et al.,
1996). For the hypothesized model and a
sample size of 252, there is over 95% power to uncover a
deviation from near perfect model fit (RMSEA = .05) of
.030 (i.e., an alternative hypothesis of RMSEA = .080).
Confirmatory Factor Analyses
Religious Involvement.
Prior to examining the factor structure of the four
items, a Kolmogorov-Smirnov normality test was performed
on each item. These analyses revealed that several of
the items were highly skewed in a negative direction. As
a result, a natural log transformation was performed on
those items. Because of 0 values, a value of 1 was added
to each of the items prior to taking the natural log.
Confirmatory factor analysis was then used to test the
extent to which the four religious involvement items
could be collapsed into a single factor (this was done
for all variables measured). The model provided an
excellent fit to the data:
χ2(2)
= 4.85, p
= .09; CFI > .99; RMSEA < .08. Factor loadings for the
observed variables were all highly significant: praying
or meditating, β
= .50; attendance at organized religious services,
β = .73;
reading religious materials,
β = .62;
time spent in religious or spiritual activities,
β = .73.
Reliability for the religion construct was .74.
Social Support.
The
six SSQ-6 items were posited to load on a single latent
variable. We reduced the number of indicators by
combining the six items randomly into three parcels,
each composed of two items. Reliability for the social
support construct (using the three parcels) was .84. The
CFI for this construct was 1.00.
Coping Responses.
A
confirmatory factor analysis of the Brief Cope items
indicated that the coping responses measured by the
Brief Cope loaded on latent variables corresponding to
active, support, and avoidant coping. To reduce the
number of indicators, items for each of the three coping
strategies (i.e., active, support-seeking, and avoidant)
were randomly combined into parcels (each parcel
composed of two items). Reliability for the active,
support seeking, and avoidant coping were .69, .75, and
.82, respectively. The CFI index for the Cope
measurement model is .96 (RMSEA < .06).
Psychological Distress.
To
reduce the number of indicators, and because the initial
standardization sample showed that all dimensions loaded
on an overall construct (Derogatis,
1993), the nine scales from the Brief Symptom
Inventory were combined randomly into three parcels,
each composed of three scales. The reliability
coefficient for the psychological distress construct is
.93 (CFI = 1.00).
Findings
Estimation of the model including only stress and
psychological distress produced a good fit to the data:
χ2(2)
= 3.42, p
< .20; CFI > .99; RMSEA < .06. Path coefficients
indicated that stress and distress were significantly
and positively related,
β = .21,
p <
.01. When paths between (a) stress and religious
involvement and (b) religious involvement and
psychological distress were added to the stress-distress
model, model fit remained good:
χ2(18)
= 30.27, p
< .05; CFI > .99; RMSEA < .06. Consistent with our
hypothesis, the results indicated that stress and
religious involvement were positively related,
β = .17,
p <
.05, and that religion was directly and negatively
related to psychological distress,
β = −.15,
p <
.05. However, the direct path between stress and
psychological distress remained statistically
significant, β
= .23, p
< .001, indicating that religious involvement did not
mediate the relationship between stress and
psychological distress. Moreover, the indirect
relationship between stress and psychological distress
through religion was small,
β = .17 ×
−.15 = −.03, relative to the size of the direct effect.
The
full-hypothesized model tests the relationships between
religion and psychological distress and possible
mediators of the relationship between religion and
psychological distress. The three dimensions of
coping—active, support, and avoidant—were allowed to
correlate freely (i.e., residuals in these equations are
correlated). The results indicate that the model fit the
data well: χ2(189)
= 323.05, p
< .001; CFI > .93; RMSEA < .06.
Figure 2 shows the standardized regression
weights for each of the paths3.
As with our previous models, stress was positively
related to religious involvement,
β = .19,
p <
.05, indicating that mothers who experienced more
stressors were more likely to be religiously involved.
In this model, religious involvement was not related to
psychological distress. However, religious involvement
was positively related to social support,
β = .15,
p <
.05, active coping,
β = .21,
p <
.05, and support coping,
β = .21,
p <
.01, and negatively related to avoidant coping,
β = −.16,
p <
.05. Thus, mothers who were more religiously involved
were more likely to report more perceived social
support, as well as more active and support coping
responses, and less avoidant coping responses. Active (β
= −.29, p
< .01) and avoidant (β
= .73, p
< .001) coping were directly related to psychological
distress, while social support (β
= −.04, ns)
and support coping were not (β
= −.001, ns).
Moreover, the path between religious involvement and
psychological distress (β
= .03) was reduced to non-significance when social
support and coping were added to the model. Thus,
according to
Baron and Kenny’s (1986) definition of
mediation, we concluded that active and avoidant coping
mediated the relationship between religious involvement
and psychological distress. Moreover, (a) available
social support was negatively related to avoidant
coping, and (b) avoidant coping responses were
positively related to psychological distress. Therefore,
it can be inferred that social support and coping style
both partially mediate the relationship between
religious involvement and psychological distress.
Fig. 2
The role of religious involvement in the stress-process
model: Results from the model estimation.
Even
though active coping, avoidant coping, and available
social support all either mediated or partially mediated
the relationship between religious involvement and
psychological distress, avoidant coping appeared to be
the strongest mediator. The standardized (total)
indirect relationship between religion and psychological
distress through avoidant coping was
β = −.14.
This relationship is represented as the sum of two
indirect effects: (a) the indirect relationship between
religious involvement and psychological distress through
avoidant coping, and (b) the indirect relationship
between religious involvement and psychological distress
through available social support and avoidant coping. In
comparison, the standardized (total) indirect
relationship between religious involvement and
psychological distress through active coping was
β = −.07. |
|
DISCUSSION
In
the present study, we examined the relationship between
religious involvement and psychological distress in a
sample of poor, inner-city, HIV-seropositive African
American mothers. Specifically, we sought to extend
previous research by exploring the role of religious
involvement within a stress-process framework. Religious
involvement was posited as mediating the relationship
between stress and psychological distress, and social
support and coping were posited as mediating the
relationship between religious involvement and
psychological distress.
Our
findings were largely consistent with the stress-process
model. Although religious involvement did not mediate
the relationship between stress and psychological
distress, we found that both social support and coping
mediated the relationship between religious involvement
and psychological distress. Specifically, in our sample
of HIV-seropositive African American mothers, (a)
religious involvement was directly related to higher
levels of active coping and to lower levels of avoidant
coping; (b) religious involvement was related to higher
levels of social support, which in turn was related to
higher levels of active coping and to lower levels of
avoidant coping; and (c) active and avoidant coping
styles were negatively and positively related to
psychological distress, respectively.
The
results of the present study support much of the prior
literature on the relationships between religious
involvement and psychosocial functioning (Ellison,
1997;
Levin and Taylor, 1998). The finding that
religious involvement was positively related to active
coping, and negatively related to avoidant coping, is
consistent with other research (cf.
Spilka et al.,
1985;
Wright et al.,
1985). The finding that religious involvement
was positively related to social support was consistent
with research reported by
Ellison and George (1994). Despite the
consistency of these findings with prior research, it
should be noted that the measure of social support used
in this study was a qualitative measure of perceived
social support and not a measure of actual social
support received or social support satisfaction. This is
important because (a) previous research has documented
important differences between perceived and received
social support and (b) measures of perceived and of
received social support are often only weakly correlated
(Furukawa
et al.,
1998;
Goodwin and Plaza, 2000). Nevertheless,
within the context of the current model, perceived
support is more consistent with the view of social
support as a coping resource, whereas in the literature
received support would seem to be a consequence of both
perceived support and the decision to utilize social
support (i.e., the support coping response) (cf.
Furukawa et al.,
1998).
The
integrative model examined in the present study affords
the benefit of including all of these previously
reported relationships in a single model and testing for
potential mediating effects. The present model also
contextualizes religious involvement in relation to
multiple components of the stress-process model.
However, it must be noted that not all aspects of the
stress-process model were included in the present
analyses. Processes such as mastery, self-esteem, and
self-efficacy, which are frequently included in
stress-process models (Pearlin
et al.,
1981), have also been shown to mediate the
relationship between stress and psychological distress (Simoni
and Ortiz, 2003) as well as relationships
between religious coping and psychological distress in
HIV-seropositive individuals (Woods
et al.,
1999).
One
of the more noteworthy findings of the present study is
the prominent role of active and avoidant coping. Coping
responses have been previously established as strong
correlates and predictors of psychological distress (Moneyham
et al.,
1998). Avoidant coping, in particular, was
the strongest correlate of psychological distress
identified in the present study, accounting for 53% of
the variability in psychological distress. In the
present analyses, religious involvement and social
support were significantly and negatively related to
avoidant coping. This set of findings suggests that
religious involvement and social support may serve as
mechanisms by which avoidant coping might be reduced,
and therefore by which psychological distress might be
prevented or ameliorated.
The
finding that religious involvement was related to
psychological distress through general (i.e.,
nonreligious) coping strategies is inconsistent with the
assumption that the effects of religious involvement on
psychological distress operate largely through
religiously related coping mechanisms (cf.
Pargament, 1997). However, it must be
acknowledged that the present study did not include
measures of religious coping or religious support. It is
possible that the inclusion of such measures would have
attenuated the relationships between religious
involvement and indices of general social support and
coping strategies. This limitation notwithstanding,
however, the fact that religious involvement was
strongly related to general nonreligious coping
strategies is noteworthy.
Limitations
First, one of the most important limitations of the
present study is the use of a cross-sectional design.
Although the structural equation model fit the data
well, it is possible that some or all of the paths may
have operated in a direction opposite of that proposed
by the stress-process approach. For example, it may be
that using more active and less avoidant coping leads to
more active involvement in religious activities.
Moreover, the cross-sectional design did not allow us to
examine effects of religious involvement and
stress-process variables on changes in psychological
distress over time.
Second, it must be noted that structural equation
modeling is an extremely constructivist technique
designed to evaluate the fit of a prespecified model to
the data. Unlike more traditional analytic methods,
structural equation modeling is not designed to identify
the best-fitting model from among a set of variables.
Therefore, despite the good model fit observed in the
present study, other models may have provided a
comparable or superior fit to the data.
Third, despite the fact that our measure of religious
involvement provided adequate internal consistency, it
is unidimensional and was not designed to measure
multiple aspects of religiosity or spirituality (cf.
Hill
and Pargament | | | |
