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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