Post on 04-May-2023
Journal of Health Psychology
18(3) 368 –382
© The Author(s) 2012
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DOI: 10.1177/1359105311434754
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The heart is a mystified organ in the world’s
cultural legacies (Ai, Appel and Pasic, 2008);
while major heart-related events can pose
existential challenges, as do other life-altering
events (Ai , Tice et al., 2011; Joseph and Linley,
2005). Coronary heart disease (CHD) remains
the number one killer of middle-aged and
older Americans (American Heart Association,
2010). Cardiac surgery is a life-changing
event, with many positive outcomes, but at the
cost of surgical complications, physical
trauma, and even operative mortality (Spindler
Pedersen and Elkit, 2009). Surgeons must
inform patients, particularly those with poor
cardiac function, of these risks preoperatively.
Many patients in these circumstances face
existential challenges and distress; a reality
underscoring the importance of investigating
Existential relatedness in light of eudemonic well-being and religious coping among middle-aged and older cardiac patients
Amy Lee Ai1, Faith Hopp2, Terrence N. Tice3
and Harold Koenig4
AbstractThis study examined the prediction of preoperative faith factors for perceived spiritual support, indicating
existential relationship as a dimension of eudemonic well-being (EWB), at 30 months after cardiac surgery
(N=226). The study capitalized on data from preoperative surveys and the Society of Thoracic Surgeons’
National Database. Controlling for demographics, cardiac indices, and mental health, hierarchical regression
showed that preoperative prayer coping, subjective religiousness, and internal control were positive
predictors of spiritual support. Negative religious coping was a negative predictor. Internal control mediated
the role of positive religious coping. Certain faith-based experiences may enhance aspects of EWB, but
future research should investigate mechanisms.
Keywordscardiovascular diseases and surgery, eudemonic and hedonic well-being, health locus of control, prayer and
religious coping, religion, spirituality, and spiritual support eudemonic
1Florida State University, USA2Wayne State University, USA3University of Michigan, USA4Duke University, USA
Corresponding author:
Amy Ai, Florida State University, School of Social Work,
296 Champions Way : University Center, Building C,
Tallahassee, FL 32306-2570.
Email: aai@fsu.edu
434754 HPQ18310.1177/1359105311434754Ai et al.Journal of Health Psychology2012
Article
Ai et al. 369
factors that predict their existential outcomes.
Our recent research indicates that preoperative
faith-related coping strategies (eg, using prayer
for coping and subjective religiosity) pre-
dicted less depression and anxiety (Ai et al.,
2010), indicators of hedonic well-being
(HWB), posttraumatic growth (Ai, Tice et al.,
2011) and posttraumatic growth, an indicator
of eudemonic well-being (EWB) (Ai, Hall et
al., in press). At 30 months following cardiac
surgery, faith effects in both studies mani-
fested after controlling for key demographics,
mental health, protective factors, and cardiac
severity. The importance of spirituality and
religion as a key component of one’s cultural
make-up in well-being has been delineated in
these studies (Ai et al., 2010; Ai, Hall et al., in
press). In the present study, we address a dif-
ferent indicator of EWB that has received less
attention in aging research. We argue for a
need to explore factors that can potentially
enhance existential relatedness in older
patients, indicated by perceived spiritual sup-
port at the follow-up.
Hedonic versus eudemonic
well-being
Pathology reduction (eg, less depression) in the
hedonistic paradigm and holistic functioning-
building (eg, deep connections) in the eudemonic
paradigm present two views of outcomes from
challenging life events. The two traditions can be
traced back to ancient ethics. Hedonism was ini-
tiated by Greek philosopher Aristippus of Cyrene
(4th century BC), who believed that pleasure (the
supreme good in life) is the universal (Annas,
1995). British philosopher Jeremy Bentham (1789
/1907), the father of utilitarianism and selfless
hedonism, asserted that all actions should be
directed toward achieving the maximized amount
of happiness and personal interest upon which
good society is built. Hedonic psychologists
adapted this philosophy, focusing on well-being
primarily in light of subjective pleasure versus dis-
pleasure of the mind and the body (Kahneman
Diener and Schwarz, 1999; Kubovy, 1999). The
hedonistic paradigm defines well-being in terms of
attaining happiness and avoiding pain with respect
to primary human motives and needs (ie, life satis-
faction, positive mood, and absence of negative
mood), which reflect subjective well-being (SWB)
(Diener and Lucas, 1999; Ryan and Deci, 2001;
Ryff et al., 2004). Whereas hedonic happiness
highlighted being away from problems and nega-
tive emotions, the eudemonic holistic view was
more associated with being challenged and drive
fulfillment (Waterman, 1993), and this is the case
more often in aging. Including the latter as an out-
come in research may lead to a more balanced
view (Ai, Tice et al., 2011; Joseph and Linley,
2005; Ryff, 1989a).
Similar to hedonism, eudemonism dates back
to both Western and Eastern ancient ethics (Ai
et al., 2010; Fromm, 1981; Ryan and Deci, 2001).
Aristotle posited that virtue (arête), wisdom, and
virtuous activities are the highest human good,
beyond mere external good such as health, wealth,
and beauty (Aristotle/Oswald,trans.1962; Ryff,
1989a). This perspective suggested that well-being
is a concept that goes beyond subjective happiness
and is not simply defined in terms of living well.
Rather, the concept implies objective indicators of
one’s wellness (eg, being loved, or experiencing
good human connections) and conveys the mean-
ing of human flourishing. Such themes have been
emphasized by existential and moral philosophers
(Anscombe, 1958; Sartre, 1965) and by certain
psychologists (eg, Erikson, Allport, Rogers and
Maslow; Ryff, 1989b). Rogers (1963) argued that
the eudemonic position of well-being (EWB) is the
extent to which a person is fully functioning, rather
than simply feeling pleasant. The eudemonic para-
digm defines well-being in terms of values and
purposes in life and/or potential achieving, with
respect to a higher order of the self (ie, realization
of true self, positive relationships, human
strengths, and virtues), which reflect psychological
well-being (PWB) (Ryan and Deci, 2001). Such
foci have gained growing appreciation in the
aging-related literature (Ryan and Deci, 2001).
Ryff, Singer and colleagues (1998) proposed a
lifespan theory of human flourishing. Experiences
in aging can sometimes be overwhelmed by poor
370 Journal of Health Psychology 18(3)
health, accumulative functional decline, and
unexpected negative transitions (eg, heart
attacks, loss of beloved persons, mortality). Pure
happiness in the hedonic perspective thus
becomes less tangible. Much of research, includ-
ing outcomes in our recent report (Ai
et al., 2010), however, have mostly centered on
how to reduce aged-related pathological conse-
quences. Investigating positive EWB experiences
can add knowledge about aging-related resil-
ience, as well as recovery from and adaptation to
illness, a focus beyond those centered on passive
responses to illness conditions. Based on the
Aristotelian EWB notion (belonging and benefit-
ing others, flourishing, striving, and exercising),
Ryff (1989a) and Ryff and Singer (2006) distin-
guished a six-factor structure of EWB (eg, auton-
omy, growth, self-acceptance, life purpose,
mastery, and positive relatedness). Positive relat-
edness is identified as a dimension of PWB (Ryff,
1989a), a defining element in human flourishing
(Ryff and Singer, 2003), a basic human need
essential for EWB (Ryan and Deci, 2001), and a
general resilience factor across lifespan
(Mikulincer and Florian, 1998). Positive related-
ness, a dimension that involves a focus on rela-
tionships, meaning, and spirituality, was found to
be more common among older compared with
younger adults (Ryff and Singer, 2002), while the
quality of interpersonal relations has been linked
with better outcomes (Ryan and Deci, 2001).
Viewed in this light, we see existential related-
ness as a vital dimension of EWB, as is interper-
sonal relatedness, especially for adults who often
encounter increasing losses, illnesses, and disa-
bility as they get older.
Existential relatedness: A
higher-order, intrapersonal
relatedness
Interpersonal relatedness is well grounded on
psychological theories and research about inter-
personal attachment and intimacy as a basic
desire (Bowlby, 1969; Nezlek, 2000). However,
after the 9/11 attacks, many New Yorkers found
the need to care for others, rather than simply a
desire for intimacy (Woike and Maitic, 2004). A
desire to care for others can be viewed as mean-
ingful higher-order relatedness, a human need
in face of severe collective challenges. Ai et al.
(2011) thus proposed a concept of a higher-
order human need for existential relatedness;
that is a sense of deep interconnectedness or
deep connections, defined as a profound rela-
tionship with a significant entity or context in
life that primarily bestows grand purpose and
meaning, be it religious or secular. The latent
concept reflects one’s feeling of existential
relatedness, especially in the face of mortality
or other critical challenges. The phrase existential
relatedness (‘ein unmittelbares existentialver-
hältnis’) was coined by Friedrich Schleiermacher
(l768–l834; Tice trans 1821/1969) in his Kritische
Gesamtausgabe (KGA) I/10 (Schleiermacher,
1821/1990: p. 318). Peiter (2010) interpreted
this broad relatedness in its original meaning: a
deep feeling of connections with divine, human-
ity, the world, and the universe, each viewed as
a whole. Such profound spiritual feelings can
permeate one’s entire life, operating as a power-
ful affective stimulus toward human existence
and growth.
The Schleiermacher notion has been reflected
in writings of influential German existential theo-
logian Paul Tillich (1958), Austrian Jewish phi-
losopher Martin Buber (1958), American
philosopher John Dewey (1890) and psychologist
William James (1901/1958). Buber (1958) pos-
ited fundamental human relatedness as a triad
connection, composed of society, spirit, and
nature; all involved interplays between humans
and significant objects in the perceived reality. We
believe that Buber’s triad of human relatedness
actually manifests in two major dimensions: a)
physical (society and nature; eg, environmental
attachment, sense of reverence in secular context,
church fellow social support), and b) non-physical
(spirit; eg, perceived spiritual support and sense of
reverence in religious context; Ai et al., 2011; Ai
et al., 2009). In fact, dimension b may primarily
reflect individuals’ existential relatedness, central
to their diverse worldview. Especially in these
dimensions, a sense of deep connections could
Ai et al. 371
emerge and convey meanings, forge transcend-
ence, and enhance positive changes. Parallel to
interpersonal relatedness, existential relatedness is
considered to be an essential impetus in human
life, as defining element in well-being (Ryff and
Singer, 2003), and to be a resilience factor across
the lifespan (Mikulincer and Florian, 1998).
Evidence from non-cardiac samples found that
perceived spiritual support – an indicator of
dimension b) involving existential relatedness,
shared positive effects with perceived social sup-
port with altruism, an indicator of interpersonal
relatedness in the above dimension a) (Ai,
Lemieux et al., in revision; Ai, Tice et al., 2011).
The present study
The existing literature on aging and mental
health has established the critical role of inter-
personal relatedness, such as social support
(Ryan and Deci, 2001). Equally important, and
as an element of EWB, however, existential
relatedness also deserves attention. In EWB, the
desire for higher-order deep connections war-
rants more empirical research. When existential
challenges become pronounced in aging, this
can be essential. Operationalizing an aspect of
the latter, we developed the Perceived Spiritual
Support Scale (SSS) to assess the quality of
existential relatedness among persons in
diverse faith traditions (Ai, Tice et al., 2005).
This concept was defined as intrapersonal
support, strength, comfort, and inspiration,
deriving from ‘a deep connection with a higher
power or a spiritual relationship in a faith’ (Ai,
Tice et al., 2011).
Our recent report documented the effect of
preoperative use of prayer for coping on long-
term SWB outcomes (ie, low levels of depres-
sive and fatigue symptoms) at the 30-month
follow-up in this sample (Ai et al., 2010; Ai,
Wink et al. under review). The present study
aimed to present these influences on a EWB
outcome, measured with SSS, an indicator of
existential relatedness. Some researchers have
suggested that beliefs in prayer and experi-
ences with prayer could enhance perceived
relatedness with others and/or relatedness with
the concept of eternity (Ladd and Spilka, 2002;
2006; Levin, 2004), and these beliefs may also
be important for those facing non-cardiac
events (Ai, Lemieux et al., in revision; Ai, Tice
et al., 2005; Ai, Tice et al., 2011). Accordingly,
our primary objective was to explore whether
such religious factors, assessed pre-operatively,
had direct effects on perceived spiritual support
30 months following cardiac surgery among
middle-aged and older adults, controlling for
key confounders and known outcome predic-
tors. As was done in recent studies, we tested
the influence of multiple faith factors on SSS
at the follow-up. Specifically, despite the
moderate to moderately high inter-correlations
among them, various faith factors had differ-
ent or null effects on SWB or HWB measures
(Ai et al., 2010; Ai, Hall et al., in press). In
cardiac surgery patients, faith and religious
coping have been associated with better short-
term medical and SWB outcomes (Ai et al.,
2007; Ai, Wink et al., 2009; 2011; Oxman et
al., 1995). Therefore, we expected that prayer
coping (Ai et al., 2002), general religious cop-
ing styles (Pargament al., 1998) and subjective
religiosity (indicating faith strength; Chatters et
al., 1992) were similarly predictive of existen-
tial relatedness.
The secondary objective was to explore the
mediation of psychological factors in the pre-
viously mentioned association, as underly-
ing mechanisms. Relatively few studies have
explored the factors behind the role of prayer
in relation to coping with severe illnesses
(Levin, 2004). In the face of life-changing
events, religious coping has been seen as a
unique resource for mastering adversity and
building positive attitudes when personal con-
trol is not tangible (Levin, 2004; McIntosh
and Spilka, 1990; Pargament, 1997). Such
coping is assumed to empower individuals in
distress and to enhance their locus of control
(Benson and Spilka, 1973; Jackson and
Coursey, 1988; McIntosh and Spilka, 1990).
Findings from the earlier-recruited partial
sample have indeed shown that prayer coping
372 Journal of Health Psychology 18(3)
was associated with preoperative internal
control in cardiac surgery patients (Ai,
Peterson et al., 2005). Perceived control has
long been related to good outcomes with
respect to health, well-being, and personal
success, despite some conflicting findings
(Mendes De Leon et al.,1996; Menec et al.,1999;
Mendes De Leon et al.,1996; Peterson, 1999;
Rodin, 1986). Accordingly, we speculated that
the internal health locus of control may help
explain certain effects of religious factors on
perceptions of spiritual support (Wallston
et al., 1978).
Method
Participant
We approached patients who survived cardiac
surgery (CABG, aneurysm repairs, and valve
repair or replacement) at a specialty cardiac
center, the University Of Michigan Medical
Center (UMMC). All of these procedures
employed the use of a heart-lung bypass
machine, while inclusion criteria and attrition
issues have been previously described (Ai
et al., 2010). There were no statistical differ-
ences on these measures between consenters
and non-consenters. Initially, 429 patients
completed a previous two-wave preoperative
study at UMMC as a specialty heart center with
more severe cases (eg, cases with congestive
heart failure) than certain centers (Ai et al.,
2002), but many patients had returned to states
from which they had been referred. In the cur-
rent follow-up study, trained research assistants
(RAs) approached available patients by
phone at 30 months after their survival. After
they affirmed their consent, participants were
assessed for perceived spiritual support by a
mailed survey. A computerized, double-entry
system was used for data entry to ensure high
quality for both previous and current surveys.
The follow-up sample included 262 cardiac-
surgery survivors (mean aged=62+, SD=11.94;
married, 72%; male, 57%; Caucasian, 90%;
Judeo-Christian, 86%).
Procedure
The UM Institutional Review Board approved
procedures and assessment for both initial and
follow-up studies. This follow-up study made
use of data collected from middle-aged and
older cardiac surgery patients who participated
in the previous survey (Ai et al., 2002). In that
survey, demographics, medical co-morbidities,
mental health symptoms, and religious factors
were obtained by trained research assistants
two weeks preoperatively via personal inter-
views. Psychosocial protectors (optimism,
hope, social support) and three-factor health
locus of control were assessed using telephone
interviews two days preoperatively.
Standardized cardiac/surgical indices were
obtained from the Society of Thoracic Surgeons’
database (STS) with catheterization and angi-
ography data assessed 2–4 weeks preopera-
tively. In the current study, spiritual support
was assessed at the 30-month follow-up.
Baseline cardiac/surgical indices
To control cardiac function, we retrieved left-
ventricular-ejection-fraction (LVEF; M=52.31,
SD=13.81) and New-York-Heart-Association
(NYHA) Classification (Levels I=36.6%,
II=34.3%, III=25.4%, IV=3.3%). To control
surgical complexity, we used Perfusion Time
(the total minutes spent on cardiopulmonary
bypass; M=129.17, SD=53.94), an indicator for
surgical complexity that often predictive for
postoperative outcomes.
Survey measures
The dependent variable, perceived spiritual
support, was assessed using the 12-item
Spiritual Support Scale (eg, ‘Care from God
provides me with peace and contentment…’;
Ai, Tice et al., 2005). Following cardiac sur-
gery, respondents gave responses on a 4-level
scale concerning each statement (M=42.16,
SD=14.51, α=.98). To reflect the broad scope of
these diverse deep connections, we instructed
Ai et al. 373
respondents to use any appropriate term for a
higher power in their faith (eg, God, Buddha,
angel, life force).
Potential mediators included health con-
trol beliefs, assessed with the 3-dimensional
Multidimensional Health Locus of Control
scale (HLC Form A; Wallston et al., 1978),
internality (M=25.77, SD=4.68, α=.92), pow-
erful-others externality (M=22.50, SD=5.85,
α=.75), and chance externality (M=18.17,
SD=5.09, α=.67).
We measured two forms of religious cop-
ing, prayer coping, employing the Using
Private Prayer for Coping index (Ai et al.,
2002; M=10.06, SD=2.40, α=.89), positive
(M=11.86, SD=6.32, α=.94) and negative
(M=1.32, SD=2.50, α=.86) religious/spiritual
coping styles, using a 14-item Brief Religious/
Spiritual Coping scale (Pargament et al.,1998).
Frequency measures of religiosity were
assessed, using the three-dimensional Religiosity
Scale (Chatters et al., 1992), public (M=11.35,
SD=4.58, α=.87), private (M=10.33, SD=3.82,
α=.78), and subjective (M=6.07, SD=1.72,
α=.88).
Preoperative psychological factors included:
depression, using the 20-item Center for
Epidemiologic Studies Depression Scale (CES-
D) (Radloff, 1977; M=12.86, SD=9.74, α=.88);
optimism, using the 12-item Life Orientation
Test (LOT) (Scheier and Carver, 1985; M=21.88,
SD=4.54, α=.73); hope, using the 12-item Hope
scale (Snyder et al., 1991; M=30.62, SD=4.43,
α=.81); and perceived social support, using the
12-item Multidimensional Scale of Perceived
Social Support (MSPSS) (Zimet et al.,1990;
M=62.27, SD=8.37, α=.89).
Demographics included age (years), gen-
der (0=male, 1=female), race (0=non-White,
1=White), and marital status (0=all other,
1=married).
Statistical analysis
To detect correlations among predictors of
major interest and controls, we employed bi-
variate analysis. To demonstrate the direct
effect of certain preoperative faith factors,
above and beyond that of existing predictors,
we performed hierarchical regression analy-
ses, with perceived spiritual support as the
dependent variable. We estimated the main
effects of preoperative predictors by entering
variables in the following sequence: (1) demo-
graphics, (2) three key cardiac and surgical
indices, (3) psychological symptoms (depression)
and potential protective factors (optimism,
hope, and perceived social support), (4) major
religious factors (three-factor religiosity, ten-
dency to use prayer for coping, and positive/
negative R-cope), and (5) mediators (locus of
control beliefs at the follow-up). All tests
were two-tailed, with significance level set at
p<.05. Co-linearity statistics were inspected,
using a conservative value of variance inflation
factor (VIF) of 4.
Results
Descriptive and bi-variate analyses
Attrition analyses revealed that there were no
differences in age, cardiac indices, depression,
and faith factors between study completers
and study drop-outs. However, compared with
the drop-out population, study completers were
more likely to have a living partner (ps<.01).
Study drop-outs also had greater proportions
of men, were more optimistic and hopeful, and
perceived greater social support (ps<.05).
Bivariate correlations among major factors are
presented in Table 1. Concerning the outcome,
perceive spiritual support was correlated
moderately with most religious factors (rs=.45
to .56, ps<.001), except negative religious
coping and, especially, with the internal and
powerful-others controls (rs=.14 to .23,
ps<.05 to .01), as shown in Table 1. It was also
correlated positively with gender (0=male,
1=female) and negatively with race (0=non-
White, 1=White).
Concerning mediating factors, internal
control was correlated with powerful-others’
control, which was, in turn, related to chance
374
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ealth
Psychology 1
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)
Table 1. Correlations among factors
2 3 4 5 6 7 8 9 10 11 12 13 14
1. Gender .025 .013 -.217*** .212*** .088 -.066 .190*** -.035 -.124* .000 .234*** .127** .306***
2. Age .086 -.131** .145** .023 -.001 -.135** .100** .011 -.034 .068 .149** .087
3. Race .068 -.045 .016 .038 -.100* .048 .044 .019 -.118* -.176*** -.231***
4. Marital status -.115* .008 -.001 -.155** .145** .140** .236*** -.007 -.014 -.093
5. Class NYH -.281*** -.091 .015 .029 -.065 .014 .071 .049 .088
6. LVEF .088 -.047 -.008 .024 .093 .074 -.020 -.005
7. Perfusion .006 -.030 .003 .046 -.099* -.083 -.090
8. Preop. depression -.463*** -.337*** -.173*** .059 .006 .124*
9. Preop. optimism .527*** .307*** .133** .118* .055
10. Preop. hope .377*** .052 .086 .004
11. Preop. soc. Support .095 .115* .102*
12. Prayer cope .564*** .668***
13. Public religion .628***
14. Private religion
15. Subjective Religion
16. Pos. relig. coping
17. Neg. relig. coping
18. Internal
19. Power others
20. Chance 21. Sum social support
Ai et a
l. 375
Table 1. (Continued)
15 16 17 18 19 20 21
1. Gender .255*** .242*** .049 -.135** -.025 -.019 .215**
2. Age .148** .106** -.065 -.031 .279*** .059 .064
3. Race -.160** -.160* -.089 -.030 -.190*** -.147** -.135*
4. Marital status -.080 -.015 -.137* .041 -.059 -.100* -.068
5. Class NYH .117 .093 -.051 -.050 .079 -.011 .001
6. LVEF -.011 -.044 -.034 .059 -.022 .002 -.099
7. Perfusion -.126** -.067 -.007 .028 -.007 .041 -.022
8. Preop. depression .033 .098* .338*** -.082 .043 .173*** .085
9. Preop. optimism .143** .133** -.366*** .202*** .034 -.254*** .048
10. Preop. hope .085 .106* -.288*** .289*** .000 -.070 -.011
11. Perceived. soc support .078 .192*** -.263*** .158** .116* -.080 .110
12. Prayer cope .720*** .695*** .014 -.023 .163** -.032 .552***
13. Public religion .689*** .597*** .043 -.103* .177*** .016 .449***
14. Private religion .695*** .724*** .083 -.085 .133** -.008 .499***
15. Subjective religion .706*** .047 -.046 .232*** .015 .561***
16. Pos. Relig. coping .057 .031 .233*** -.014 .564***
17. Neg. Relig. coping -.026 .065 .142** .002
18. Internal .270*** .039 .136*
19. Power of others .342*** .230***
20. Chance .06721. Spiritual support
*p < .05, **p < .01, ***p < .001
376 Journal of Health Psychology 18(3)
control. Internal control was inversely related to
public religiosity, but not to other religious
factors, and was additionally correlated with
optimism, hope, perceived social support and
female gender. Internal control was also
inversely related to depression only at a mar-
ginal level. Powerful-others control was cor-
related with most religious factors, except
negative religious coping, and with age,
minority race, and social support. Chance
control was correlated with negative religious
coping, but not with other religious factors, and
with depression, minority race, and lack of a
living partner. It was also inversely related to
optimism.
Concerning potential predictors of major
interests, as expected, all faith factors were
somewhat correlated with each other (rs=.58
to .72, ps<.001), with the exception of nega-
tive religious coping. Some religious factors
were related to medical indices. NYHA
Classification was positively correlated with
subjective religiosity and with private religios-
ity and positive religious coping at a marginal
level. Perfusion time was inversely correlated
with prayer coping and subjective religiosity
and with private and public religiosity at a
marginal level. Positive religious coping
was positively related to both depression and
protective factors, whereas negative religious
coping was highly correlated positively with
depression and inversely with protective factors.
Public religiosity was related to protectors,
optimism and social support, and with hope at
a marginal level. Private religiosity was related
to both depression and two protectors: hope
and social support. Subjective religiosity was
related to optimism and with hope at a mar-
ginal level. Most religiosity factors and posi-
tive religious coping were correlated with age,
female gender, and minority race. Prayer
coping had the same pattern, but was not
related to age. Cohabitation was inversely cor-
related with negative religious coping and
with private religiosity at a marginal level.
Further, being female was correlated with
living alone, NYHA Classification, depression,
and inversely with hope. Older age was
correlated with lack of a living partner, NYHA
Classification, optimism, and less depression
and with white race at a marginal level. Minority
status was related to less depression. Living
alone was correlated with less depression and
all protective factors and inversely with NYHA
Classification. All of the medical indicators had
no association with depression or protective
factors, while LVEF was inversely correlated
with NYHA classification and with perfusion
time at a marginal level. All protective factors
were inter-correlated, whereas all were inversely
related to depression.
Prediction of perceived spiritual support
Table 2 presents results of hierarchical regres-
sion analyses, predicting perceive spiritual
support. Entry of clustered potential predic-
tors followed the predetermined five steps.
Demographics were entered in Step 1. Gender
and race were significant predictors, account-
ing for about 6.9 percent of the variance in
perceived spiritual support at the 30-months
follow-up. After key cardiac and surgical indi-
ces were added to the model, the demographic
influence persisted in Step 2. LVEF, NYHA
Classification, and perfusion time were unre-
lated to perceived spiritual support, while the
R-Square change was not significant. Entering
the baseline depression and protective factors
did not alter the gender effect. However,
LVEF and NYHA Classification both became
inversely associated with perceived spiritual
support, while the race influence vanished.
Preoperative depression, optimism, hope,
and social support were unrelated to the out-
come, while the R-Square change was not
significant.
Entering religious coping and involvement
in Step 4 diminished the role of gender and
NYHA classification, while the effects of LVEF
persisted. Among new factors, preoperative
prayer coping significantly predicted perceived
spiritual support, while both subjective religios-
ity and positive religious coping were also
Ai et a
l. 377
Table 2. Hierarchical regression analysis predicting spiritual support
Variable Step1Beta (SE)
Step2Beta (SE)
Step3Beta (SE)
Step4Beta (SE)
Step5Beta (SE)
Gender .221 (.165)** .241 (.169)** .233 (.172)** .047 (.147) .068 (.146)
Age .080 (.007) .088 (.007) .084 (.007) -.003 (.005) -.012 (.006)
Race -.130 (.292)* -.134 (.291)* -.129 (.299) -.042 (.257) -.004 (.253)
Marital Status Step 1 R² = .069, F = 4.104 (df = 4, p < .01)
.017 (.194) .011 (.194) .004 (.197) -.033 (.160) -.036 (.158)
NYHA Classification -.124 (.100) -.136 (.100)* -.108 (.081) -.100 (.081)
LVEFPerfusion Time Step 2 R² = .093, F = 3.189 (df = 7, p < .01)
-.131 (.006)-.026 (.002)-.140 (.006)*-.033 (.002)
-.122 (.005)*-.014 (.001)-.115 (.005)*-.020 (.001)
Preoperative DepressionPreoperative OptimismPreoperative HopePreoperative Social Support
.067 (.202)
.123 (.185)-.066 (.181)
.093 (.135)
-.014 (.165).024 (.153)-.076 (.149)-.018 (.114)
-.019 (.164).008 (.155)-.105 (.152)-.033 (.113)
Step 3 R² = .112, F = 2.468 (df = 11, p < .01)
Prayer Coping .253 (.124)** .250 (.122)**
Public religiosity .040 (.019) .063 (.019)
Private religiosity .017 (.028) .048 (.028)
Subjective religiosity .189 (.062)* .177 (.061)*
Positive Religious CopingNegative Religious Coping
.226 (.117)*-.104 (.197).177 (.118)-.126 (.197)*
Step 4 R² = .445, F = 9.870 (df = 17, p < .001)Internal ControlPower Others ControlChance Control Step 5 R² = .469, F = 9.080 (df = 20, p < .001)
.125 (.097)*.077 (.077).020 (.082)
*p < .05, **p < .01, ***p < .001
378 Journal of Health Psychology 18(3)
positively associated. The R-Square change,
accounting for an additional 33.8 percent of the
variance, was significant. Finally, after three
types of health locus of control beliefs were
entered in Step 5 (the step examining mediation),
the influences of LVEF, prayer coping, and sub-
jective religiosity persisted. However, the
effects of positive religious coping diminished,
but negative religious coping became signifi-
cant. The final model accounted for about
52 percent of the variance [F(21, N=223)=10.39,
p<.001]. Internal control predicted perceived
spiritual support.
In summary, patients who preoperatively
favored prayer coping and/or reported greater
faith strengths perceived greater spiritual
support, as did those who held internal locus
control at the follow up. Those with lower
levels of cardiac functioning or those who
used negative religious coping reported less
perceived spiritual support. The R-Square
change, accounting for an additional 7.1 per-
cent of the variance, was significant. All VIFs
were below 3.1. Although internal control
predicted spiritual support and its entry elimi-
nated the role of positive religious coping, the
latter effect in Step 4 was not mediated by the
former due to the lack of correlation between
the two factors.
Discussion
The present study highlights the significance of
existential relatedness as an important domain
of EWB in middle-aged and older cardiac
patients. Concerning the primary objective, the
result shows the positive role of prayer coping
and subjective religiosity on perceived spiritual
support at the 30-month follow-up of cardiac
surgery survivors, after controlling for key
demographic, medical, and psychosocial con-
founders. This finding is consistent with earlier
findings on inner-experience-related religious
involvement in the medical and SWB or HWB
outcomes of these patients (Ai et al., 1998;
2007; 2009; 2010). This study, then, adds new
evidence to previous research that has examined
the role of spirituality and religion-based coping
on PWB or EWB outcomes (Ai, Hall et al., in
press; Cadell et al., 2003; Calhoun and
Tedeschi, 1998; Shaw et al., 2005), by suggesting
the critical role of prayer coping and subjective
religiosity on perceived spiritual support. The
findings also lend support for the overall
importance of religious coping (Levin, 2004;
Pargament, 1997) and for the linkage between
prayer coping and deep connections (Ai, Tice
et al., 2005; Ladd and Spika, 2006). Interestingly,
these effects are not eliminated by entering
mediating factors (various health locus of control
beliefs), as theoretically expected based on
previous research (Levin, 2004; Pargament,
1997). Due to the lack of bi-variate correlations
between religious coping and control factors,
this study fails to confirm the role of mediation,
as we speculated in our secondary objective.
However, internal control has a direct positive
effect on perceived spiritual support.
Among non-religious factors, poor cardiac
function, as objectively measured by LVEF, is
linked with a greater likelihood of perceived
spiritual support. The latter finding seems to be
consistent with the fact that indicators of EWB,
such as posttraumatic growth, are more likely to
associate with greater challenges (Joseph and
Linley, 2005; Waterman, 1993). Put another
way, patients may perceive positive experiences
in terms of perceived spiritual support, despite
the likelihood of encountering preoperative
difficulties such as poor cardiac functioning.
For such persons, using prayer for coping prior
to surgery may contribute to the enhancement of
spiritual connections and/or perceived existen-
tial relatedness, a domain in the EWB, long after
(Pargament, 1997; Schleiermacher, 1821/1969).
Investigating this positive dimension of human
well-being is important, because, as proposed
by Joseph and Linley (2005), greater PWB, or
EWB, may eventually lead to better SWB or
HWB outcomes in adversity. Indeed, research
suggests that adults who undergo other non-
cardiac trauma who demonstrate a sense of
deep, as measured with perceived spiritual
support, have lower depression, anxiety, and
Ai et al. 379
posttraumatic stress disorder (Ai, Tice et al.,
2005; Ai, Tice et al., 2011; Ai, Lemieux, in
revision). Taken together, these results suggest
the importance of future work examining the
complex dynamics related to spiritual support as
an indicator of existential relatedness.
Once more, this study fails to identify much
needed explanatory factors for the function of
religion or spirituality in clinical health out-
comes, as did the previous study on SWB out-
comes (Ai et al., 2010) and on EWB outcomes
(Ai, Hall et al., in press). Although a prelimi-
nary study linked prayer coping with internal
control (Ai, Peterson et al., 2005), this was not
the case in the final sample. As does the recent
report on SWB outcomes in which optimism
had a desirable role (Ai, Ladd et al., 2010), this
study does find the direct, positive influence of
internal control. Enriching the literature of
health control beliefs (Mendes De Leon et al.,
1996; Menec et al., 1999; Peterson, 1999;
Rodin, 1986), the independent role of internal
control on perceived spiritual support suggests
that those who had secure existential related-
ness are also those who were already confident
in their own health condition in the first place.
On the other hand, these null effects suggest
that religious or spiritual coping could have its
unique influence on health- and aging-related
outcomes that should be examined in situations
that heighten existential challenges. Given the
motivating nature of prayer-coping conscious-
ness and Ryff et al.’s (2004) association of
EWB dimensions with certain better biomarkers,
future investigation may explore underlying
mechanisms of these experience-based reli-
gious involvement effects in other dimensions
(e.g., motivation for health and well-being,
faith-related health behaviors, or psycho-
immunology indices).
Finally, both our recent reports (Ai, Ladd
et al., 2010) and this study showed no effect of
demographic factors on either SWB or PWB
outcomes in cardiac-surgery patients. These
findings clearly suggest the importance of
controlling for key medical, psychosocial, and
existential factors in clinical studies. While
preoperative negative affects (ie, depression
and anxiety) were associated with symptoms
as SWB or HWB measures at the follow-up
(Ai, Ladd et al., 2010), they had no influence
on perceived spiritual support as a PWB or
EWB measure (also see Ai, Hall et al., in
press). These findings suggest that individuals
may have equal opportunity for positive
changes after a life-altering medical event,
irrespective of their developmental stage,
gender or race. Different domains of human
well-being thus should be investigated sepa-
rately or together to promote scientific under-
standing of health and aging in the era of
collaborative patient-centered care, with a
goal of improving patient-provider relations.
Adding the knowledge of an existential domain
will help fulfill this mission.
Limitations of this study, especially those
concerning the sample and attrition, were
previously presented (Ai, Ladd et al., 2010).
Furthermore, the inclusion criteria constrain the
generalizability of findings to oldest-old patients
and those who underwent emergency surgery,
though the UMMC specialty center has more
severe cases (eg, congestive heart failure).
Attrition analyses found certain differences
between the study drop-outs and completers at
the follow-up. Although none of these factors
influenced perceived spiritual support, the final
sample may have created a selective bias
toward better-off survivors. Yet, none of factors
pertaining to spirituality or religion have shown
difference in participation, a fact that may
enhance the implications of the findings. It is
arguable that faith factors are correlated with
outcome. However, the SSS is a measure for
outcomes, namely the momentary perception of
whether or not an individual has been convinced
that his or her spiritual beliefs have offered
support (eg, comfort, love, strengths, survival)
up to the time of assessment. On the other hand,
prayer coping is measured for process, namely
event-related actions or performance. Both
the current and previous studies have found
different predictive patterns of faith factors on
different outcomes.
380 Journal of Health Psychology 18(3)
Despite the limitations, our findings present
evidence that reinforces patients’ needs for
spiritual practices and existentially deep con-
nections, the existence of which signifies an
important psychological outcome. Most impor-
tantly, while many faith factors are related to
risk factors, such as those of demographics and
cardiac indices, they were also correlated with
preoperative protective factors and the EWB
outcomes. This underscores the value of inves-
tigating not only spiritual and religious factors
as predictors, but also outlook-based health
outcomes. The results from this study should
encourage clinicians and researchers to consider
a more balanced view of aging- and health-
related human well-being in the future.
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