PHD Dissertation

Religiosity and coping in a secular society:

Prevalence, characteristics, and associations to quality-of-life among Danes

facing life-threatening lung disease and other stressful life events

Heidi Frølund Pedersen

Unit for Psycho-oncology and Health Psychology Research

Department of Psychology and Behavioural Sciences

Aarhus University

July 2013

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Religiosity and coping in a secular society: Prevalence, characteristics, and associations to

quality-of-life among Danes facing life threatening lung disease and other stressful life events

© Heidi Frølund Pedersen

Department of Psychology and Behavioural Sciences

School of Business and Social Sciences

Aarhus University

Bartholins Allé 9

DK – 8000 Aarhus C

Supervisor:

Robert Zachariae, professor affiliated at Unit for Psycho-oncology and Health Psychology, Aarhus

University Hospital and Aarhus University, Denmark

Co-supervisors:

Jan Tønnesvang, professor affiliated at Department of Psychology, Aarhus University, Denmark

Christina Gundgaard Pedersen, post. doc. affiliated at Unit for Psycho-oncology and Health

Psychology, Aarhus University Hospital and Aarhus University, Denmark

Cover design: Arne Hougaard Pedersen

Illustration: Elin Karlsnes. Trykt med tilladelse af Tidsskrift for Den Norske Legeforening, der

først bragte illustrationen 21. januar 2011 i volume 131 (2): 138-140

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The cords of death entangled me;

the torrents of destruction overwhelmed me.

The cords of the grave coiled around me;

the snares of death confronted me.

In my distress I called to the LORD;

I cried to my God for help.

From his temple he heard my voice;

my cry came before him, into his ears.

…

He reached down from on high and took hold of me;

he drew me out of deep waters.

He rescued me from my powerful enemy,

from my foes, who were too strong for me.

(Phalms, 18, verses 4-6, 16-17)

To my father!

You faced the entanglement of death and torrents of destruction.

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Contents

Original papers ................................................................................................................................................................... vi

Acknowledgements ........................................................................................................................................................ vii

Preface .................................................................................................................................................................................... ix

List of abbreviations ......................................................................................................................................................... 1

English summary ................................................................................................................................................................ 2

Dansk resumé (Danish summary) ............................................................................................................................. 6

Introduction ....................................................................................................................................................................... 10

The Danish context ......................................................................................................................................................... 11

The concepts of religion and spirituality in a secular society.................................................................... 12

A conceptual framework ............................................................................................................................................. 13

Religious coping ............................................................................................................................................................... 14

Measurement of religious coping ....................................................................................................................... 15

Empirical findings ...................................................................................................................................................... 16

Negative religious coping .................................................................................................................................... 17

Positive religious coping ...................................................................................................................................... 17

Longitudinal studies .............................................................................................................................................. 18

Predictors of religious coping ............................................................................................................................ 18

The application of religious coping theory among Danes ........................................................................... 19

Empirical findings on religiosity during stressful events in Denmark .................................................. 20

Aim of this present thesis ............................................................................................................................................ 22

Study design .................................................................................................................................................................. 22

Summary of the four studies ................................................................................................................................. 24

Study 1: Religious coping and quality of life among severely ill lung patients in a secular

society .......................................................................................................................................................................... 24

Study 2: Coping without religion? Religious coping, quality of life and existential well-being

among lung disease patients and matched controls in a secular society ....................................... 25

Study 3: Psycho-social factors associated with religious struggles during negative life events

in a secular society ................................................................................................................................................. 26

Study 4: Studying religious and spiritual coping in a secular culture: A question of validty . 26

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Discussion ........................................................................................................................................................................... 27

Prevalence of religious beliefs and religious coping among Danish lung disease patients .... 27

Increased relevance of religiosity and religious coping during illness? .......................................... 28

Religious, spiritual, and existential concerns among lung disease patients .................................. 29

Addressing religious, spiritual, and existential concerns ....................................................................... 30

Associations between religious coping and QoL ......................................................................................... 31

Negative religious coping......................................................................................................................................... 31

Positive religious coping ...................................................................................................................................... 32

Individual characteristics associated with religious struggles ............................................................ 33

Negative events ........................................................................................................................................................ 33

The impact of individual differences............................................................................................................... 34

Religious characteristics ...................................................................................................................................... 35

Methodological considerations and limitations ............................................................................................... 37

The validity of Brief RCOPE in a secular society .......................................................................................... 37

A critical comment on the theoretical and empirical work on religious coping .......................... 39

Integrating a hermeneutical approach to religious coping? .................................................................. 42

Generalizabilty ............................................................................................................................................................. 43

Conclusion: A soda-analogy? ..................................................................................................................................... 45

Perspectives and future studies ............................................................................................................................... 48

Clinical implications .................................................................................................................................................. 48

Research implications .............................................................................................................................................. 49

References .......................................................................................................................................................................... 51

Appendix ............................................................................................................................................................................. 64

Paper 1

Paper 2

Paper 3

Paper 4

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vi

Original papers

This thesis is based on the following original papers presented in the order in which they were

written:

1. Pedersen, H.F., Pargament, K.I., Pedersen, C.G., & Zachariae, R. (2013). Religious Coping

and Quality of Life among Severely Ill Lung Patients in a Secular Society. International

Journal for the Psychology of Religion, 23: 188-203

2. Pedersen, H.F., Pedersen, C.G., Pargament, K.I., & Zachariae, R. (2013). Coping without

religion? Religious coping, quality of life, and existential well-being among lung disease

patients and matched controls in a secular society. Research in the Social Scientific Study of

Religion, 24: 163-192

3. Pedersen, H.F., Pedersen, C.G., & Zachariae, R. Psycho-social factors associated with

religious struggles during negative life events in a secular society (submitted for The

Psychology of Religion and Spirituality)

4. Pedersen, H.F. & Tønnesvang, J. Studying religious and spiritual coping in a secular culture:

A question of validity (submitted for Mental Health, Religion, and Culture)

The present volume includes an introduction to the field of research, original papers, discussion of

the study results, and conclusions of the work presented in study 1-4 as well as suggestions for

future research and clinical implications

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Acknowledgements

This Ph.D. thesis was carried out in collaboration with Unit for Psycho-oncology and Health

Psychology Research, Aarhus University and Aarhus University Hospital, the respiratory medical

clinics in Aarhus, Aalborg, Holstebro, Randers, and Rønne, and Statistics Denmark. I greatly

acknowledge the financial support provided by: Aarhus University, The Danish Cancer Society,

Danish Knowledge and Research Centre of Complementary and Alternative Medicine (ViFAB) in

collaboration with Center for Cross-Scientific Evaluation Studies on Complementary and

Alternative Medicine (CCESCAM) at University of Southern Denmark and Aarhus University,

Lykfeldts Legat, Max og Inger Wørzners Mindelegat, and Fritz, Georg og Marie Gluds Legat.

Many individuals have been involved in the different studies and provided guidance and support

during the 6 years that I have been working on this present thesis. I wish to thank the following:

First of all I want to thank all the participants included in the studies, especially the lung disease

patients who despite difficult circumstances spend time and energy responding to long

questionnaires, and the ten lung cancer patients who let me come close to their experience of illness

and existential concerns in individual interviews. Half a year after these interviews had been

conducted eight patients were not alive anymore, which reminded me about the gravity of their

situations and hopefully this thesis gives voice to some of their experiences of facing life’s ultimate

challenge.

I want to thank my supervisor professor Robert Zachariae, for giving me the opportunity to go into

research on a rather controversial topic and for his support during the process. He has sharpened my

critical sense in research on psychology of religion and health and was always efficient and

supportive in his guidance and contributions to study design and the single papers included in this

thesis. Furthermore he has created a fruitful research environment on psycho-oncology and health

psychology and my thanks are also directed at every single colleague at Unit for Psycho-oncology

and Health Psychology Research for encouragement, practical and statistical help, and vivid

discussions at our research meetings.For good and thought provoking discussions I thank Jan

Tønnesvang, my co-supervisor, who first awakened my interest in the psychology of religion and

for always insisting on taking a theoretical approach to the rather complex phenomena of religion.

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I want to thank Christina G. Pedersen, my co-supervisor and mentor, for giving me the opportunity

to work together with her on the lung disease project. Her positive and careful attitude has been an

important support to me, and her skills in project managing and statistics have helped me carry this

thesis through.

For being an encouraging and inspiring mentor, I wish to thank Kenneth I. Pargament. During my

visit at Bowling Green State University, Ohio, in 2011 he willingly shared his passion and wide

knowledge in the psychology of religion, as well as his personal qualities as a mentor. He is one of

the main reasons why I carried through with this project.

To Peter la Cour I direct my deepest appreciations for being the spearhead of the psychology of

religion in Denmark, and for taking a differentiated and critical focus on theories and methodology

in this field. His friendly personality and strong integrity has been a personal inspiration to me.

For making the way for the Interdisciplinary Research Network on Faith and Health in Denmark

and Scandinavia and for encouragements to go into research, I thank Niels Christian Hvidt.

For sharing ups and down, victories and worries on the journey of the Ph.D. study I wish to thank

Berit Kjærside Nielsen, Dorthe Toudal Viftrup, Hanne Fentz Nørr, and Yoon Lia Keci Frederiksen,

You have all in Your unique ways made work life a little funnier.

To my family: my mother, Erik, my sister and three brothers and their families, my father in-law,

Elly, and the rest of my family in-law, and my cousin, Anitta Callesen and her family: Thank you

for being good company, for solicitude, for practical help, for encouragements and genuine interest

in this project.

To my three beautiful daughters, Gry, Liv, and Sif: You all arrived during the Ph.D. period and

have been a great blessing to me. I thank you reminding me about the important things in life and

how to prioritize these, and for being loving and forgiving, when I did not succeed.

Many more deserves to be mentioned, but my absolute greatest acknowledgments and thanks are

directed at my husband, Arne, who has supported me unconditionally, encouraged me and loved

me, and patiently laid ear to major and minor concerns of mine about this thesis during six years.

You truly have proven that you want to “walk all the way and back again” with me!

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Preface

I am often asked the question: “Why did you choose to get into research on faith and health?” It

would seem that you need a particular reason for doing that, because this kind of research is still

rather controversial in Denmark. My personal motivation was fired by a curiosity about whether

and how some of the deepest feelings and considerations on existential and religious matters

become important when adjusting to stressful life circumstances in a society where religion is not

exactly the first topic to be discussed at a dinner party! My own frame of reference is Christianity,

in which I was born and raised. To me, belief in God has always been an important and integrated

part of my life. Especially during life-changing experiences belief in a transcendent reality has been

a source of comfort, challenge, joy, gratitude, and hope. I have witnessed how belief offered a

reference of interpretation and support to family members and friends who suffered from life

threatening disease such as cancer, and how they in their religious interpretation, miraculously lived

longer than expected or even survived a severe diagnosis. To others, traumatic events became a

stumbling block that threw them into doubts and struggles which changed their beliefs and relations

to others radically. However, I know that “to be a believer” means a lot of different things to Danes

today, and that these beliefs may be hard to express – even for people who can be characterized as

having traditional religious beliefs. Given my personal background, I do have my pre-assumptions

which may have influenced the course of the project and the choices of methodology and measures.

Trying to be open and critical about my own potential biases, I also consider my background as a

Christian to have guided me to be sensitive towards this controversial topic – especially during

qualitative interviews with patients to whom existential and religious questions were very present

and for some a heavy burden. I also consider this project as a “case of learning by doing”. Situated

in a quantitative oriented research unit I may have been methodologically biased in approaching the

research topic at hand with tools of systematic literature reviews to guide my choice of methods and

measures. Furthermore, taking a functional approach to the study of religion, focus has been

directed towards what “religion does” to people in crisis, rather than “what it is”, and thereby

looking for effects instead of unfolding the phenomenology of beliefs among Danes during major

negative life events. Because this present study is one of the first on religious coping in Denmark, it

was decided to rely on theoretical work and measures developed in the United States because no

validated measures on religious coping existed at the time of preparing the studies underlying this

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thesis (2007). However, as the project proceeded other methods were needed to shed new light on

the research questions and methods used. As such, this thesis also reflects some of the decision-

making processes and assumptions underlying much research but seldom made entirely explicit.

Heidi Frølund Pedersen

Aarhus, July 2013

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List of abbreviations

BDI Becks Depression Inventory

Brief RCOPE Brief Religious Coping Scale

Brief SCOPE Brief Spiritual Coping Scale

CAM Conventional and Alternative Treatment

CBI The Cancer Behavior Inventory

CCI Charlson Co Morbidity Index

COPD Chronic obstructive pulmonary disease

FACIT The Functional Assessment of Cancer Illness Therapy Scale

FACIT-Sp The Functional Assessment of Chronic Illness Therapy - Spiritual Well-

being Scale

LDP Lung disease patients

LRE List of Recent Event

NEO-FFI NEO Five Factor Inventory

PSS Perceived Stress Scale

RAAS Revised Adult Attachment Scale

RCOPE Religious Coping Scale

QoL Quality of life

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English summary

The assumption that people turn to religion when faced with major negative life events – especially

during life threatening disease - has received increased attention in research on faith and health

during the last 15 years. It is suggested that religion can represent a coping resource to the

individual during adjustment to negative life events. Empirical studies have mainly found religious

coping to be associated with positive outcomes such as higher well-being and lower levels of

distress, although some contradictory results have been found. In recent years the measurement of

religious coping has been refined, and studies have revealed that some forms of religious coping

reflecting religious doubts, feelings of spiritual abandonment and thoughts about Gods punishments

(negative religious coping) appears to be burden in adjustment and have been associated with lower

well-being, higher amount of distress, and increased mortality among medically ill patients.

However, the majority of empirical work has been conducted in the United States, which is

characterized as the most religious of the modern, Western societies. Less is known about the role

of religion during major negative life events in more secularized societies like Scandinavia. In this

present thesis the main aim was to investigate to which degree newly diagnosed Danish lung

disease patients (LDP) turn to religion as a coping recourse when compared to healthy individuals

of whom some reported negative life events. Furthermore, it was explored to which degree religious

coping was associated with quality of life (QoL) and whether individual psychosocial

characteristics were associated with negative religious coping (religious struggles). Finally, it was

explored to which degree measures on religious coping developed in the United States are valid and

applicable in a secular context.

With the aim of providing novel data on religious coping in secular societies, four independent

empirical studies was conducted including a group of newly diagnosed LDPs (mainly lung cancer

and chronic obstructive pulmonary disease (COPD) and an age- and gender matched control group.

The two samples responded to questionnaires on socio-demographic information, religious coping

measured by Brief religious coping scale (Brief RCOPE), religious, spiritual, and existential

concerns, QoL, existential well-being, and personality factors such as personality traits and

attachment style. The healthy control group was asked to report if they had experienced negative

life events within the last 12 months. Furthermore a qualitative study was conducted among three

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focus groups of healthy Danes, and ten individual interviews with lung cancer patients. Participants

were asked to respond to a questionnaire on religious (Brief RCOPE) and spiritual coping and

reflect on the content and relevance of the questionnaire when adjusting to negative life events.

In study 1 it was found that LDPs did report to engage religious coping strategies during illness

adjustment to some degree. Positive religious coping was more prevalent than negative religious

coping strategies. However, the level of religious coping was considerably lower than that found in

studies from the U.S. Patients characterized as believing or spiritual reported more positive

religious coping than non-believing patients, but no differences were found between believing,

spiritual, or non-believing patients regarding negative religious coping. Positive religious coping

was not found to be significantly associated with QoL, however negative religious coping was

significantly associated with lower QoL among LDPs. Furthermore it was found that a small part of

the patients reported to have more existential, spiritual, and religious concerns following the lung

disease, and a minority expressed a need to talk to a health care professional about existential or

spiritual concerns, whereas no one wished to talk about their religious concerns with a health care

professional.

In study 2, LDPs was found to report significantly more positive religious coping, especially

positive religious meaning-making and asking forgiveness, when compared to a group of healthy

Danes of whom some reported negative life events. Positive religious coping was not found to be

associated with QoL or existential well-being in any of the participating samples, however negative

religious coping was found to be associated with lower QoL among LDPs only. Furthermore,

reporting to receive support from one’s congregation was associated with higher QoL and

existential well-being among the healthy control participant who did not report negative life events.

In study 3 it was investigated whether different psychosocial factors was associated with reporting

religious struggles in a group of middle-aged- and elderly Danes of whom some reported negative

life events. Initial analyses suggested the that impact of event on QoL, lower income, higher levels

of neuroticism, insecure attachment, higher frequency of church attendance and reporting

congregational support was associated with reporting religious struggles. However, in a final

regression model testing the significant variables from the initial analyses, it was found that higher

levels of the personality trait neuroticism and reporting congregational support were the only

statistical significant variables associated with religious struggles.

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In study 4 it was examined to which degree a measure on religious coping developed in the U.S

(Brief religious coping scale, Brief RCOPE) and a newly developed scale on spiritual coping were

applicable and valid among a group of healthy middle-aged and elderly Danes and Danish lung

cancer patients. In an exploratory thematic analysis three themes in relation to validity emerged: 1)

The importance of the available language and “religious capital” of the individual and 2) the

influence of the specific context of the individual when asked to respond to questions about

religious coping. Furthermore 3) the question of whether religion and spirituality should be

understood as a universal or context-specific phenomenon that is measurable and comparable across

cultures was found to be a crucial theme, and discussed in relation to the methods applied in the

psychology of religion.

It is concluded that religious coping as measured by the Brief RCOPE was to some degree prevalent

among Danes facing major life events, and especially among LDPs, partly supporting the

hypothesis that life threatening disease is likely to make people turn to religion, even among

individuals living in a highly secular society. However, as such, religious coping as operationalised

in the measure of Brief RCOPE did not appear to be a central phenomenon among the participating

individuals, because it assumes a mainly theistic perception of the sacred. Although nearly 65% of

the LDPs and healthy participants reported to believe in God or a spiritual being, sociological

studies suggest that the character of belief in God have changed from concrete beliefs in a personal

and active God to more ill-defined and impersonal concepts of a higher being. The qualitative study

suggested that religious beliefs and experience was a private and often ‘tacit’ issue to the

participants suggesting that quantitative measures may be problematic to apply in especially secular

societies, because participants may face difficulties in accessing their beliefs at a solely cognitive

level. Furthermore, signs of other religious and spiritual strategies of meaning-making in adjustment

to major negative life events that were not captured by the Brief RCOPE were found suggesting that

religious and spiritual beliefs may become important, even to individuals who do not perceive

themselves as very religious, and new measures and methods are called for. Narrative methodology

may allow the individual to come closer to how personal beliefs have formed, what they contain,

and how they become important in interpretation and meaning-making during negative events.

However, as found in this thesis, expressing religious doubts, thoughts about God’s punishment and

feelings of spiritual abandonment during lung disease were associated with lower levels of QoL,

indicating the individual to experience tension and despair in association to illness. Health care

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personnel should take serious this potential threat to the health and well-being of the individual

facing lung disease and be attentive to potential struggles among patients. However, more

knowledge is needed regarding the prevalence of religious, but also spiritual and existential

struggles among different medical samples in secular societies before any interventions can be

suggested, and future studies should pay attentions to the impact of individual differences in the

development of religious, spiritual, or existential struggles.

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Dansk resumé (Danish summary)

Antagelsen at mennesker vender sig til religion, når de bliver konfronteret med større negative

livsbegivenheder – særligt i forbindelse med livstruende sygdom - har fået større opmærksomhed i

tro og helbred forskningen igennem de sidste 15 år. Det er foreslået, at religion kan optræde som en

’coping’ ressource for individet i forbindelse med håndteringen af negative livsbegivenheder.

Empiriske undersøgelser har overvejende fundet at religiøs coping er forbundet med positive udfald

så som større velbefindende samt lavere forekomst af sorg og lidelse (’distress’), om end

resultaterne har været modstridende. De senere år er målingen af religiøs coping blevet forfinet, og

studier har fundet at visse former for religiøs coping, der afspejler religiøs tvivl, følelse af åndelig

forladthed, og tanker om Guds straf (også kaldet ’negativ religiøs coping’), synes at udgøre en

byrde i individets tilpasning, og er blevet associeret med lavere velbefindende, større forekomst af

sorg og lidelse, samt forøget dødelighedsrisiko blandt medicinsk syge patienter. Dog er størstedelen

af de empiriske studier gennemført i USA, der er blevet betegnet som det mest religiøse af de

moderne, vestlige samfund. Vi ved meget lidt om religionens rolle i forbindelse med større negative

livsbegivenheder i mere sekulariserede samfund som de skandinaviske. I nærværende afhandling

var hovedformålet at undersøge, i hvilken grad nydiagnosticerede danske lungepatienter vender sig

til religion som en coping ressource i sammenligning med raske danskere, hvoraf nogle angav

negative livsbegivenheder. Derudover blev det undersøgt, i hvilken grad religiøs coping var

forbundet med livskvalitet, og om individuelle psykosociale karakteristika var forbundet med

negativ religiøs coping (også kaldet ’religiøs anfægtelse’). Slutteligt blev det undersøgt hvorvidt

spørgeskemaer om religiøs coping udviklet i USA er valide og anvendelige i en sekulær kontekst.

Med henblik på at tilvejebringe ny viden om religiøs coping i sekulære samfund blev fire

uafhængige empiriske undersøgelser gennemført, og inkluderede en gruppe nydiagnosticerede

lungepatienter (hovedsageligt patienter med lungekræft og kronisk obstruktiv lungesygdom) samt

en rask kontrolgruppe matchet til lungepatientgruppen på baggrund af alder og køn. De to grupper

svarede på spørgsmål om socio-demografiske forhold, religiøs coping målt med spørgeskemaet

’Brief religious coping scale’ (Bief RCOPE), religiøse, spirituelle, og eksistentielle overvejelser,

livskvalitet, eksistentielt velvære, og personlighedsfaktorer såsom personlighedstræk og

tilknytningsstil. Den raske kontrolgruppe blev bedt om at angive, om de havde oplevet negative

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livsbegivenheder indenfor de sidste 12 måneder. Endvidere blev en kvalitativ undersøgelse

gennemført blandt tre fokusgrupper bestående af raske danskere, samt 10 individuelle interviews

med lungekræftpatienter. Deltagerne blev bedt om at respondere på spørgeskemaet om religiøs

coping (Brief RCOPE) og et nyt skema om spiritual coping, og reflektere over indholdet og

relevansen af spørgeskemaet i forbindelse med håndteringen af negative livsbegivenheder.

I undersøgelse 1 blev det fundet at lungepatienter i nogen grad angav at anvende religiøse coping

strategier i forbindelse med sygdomshåndtering. Positiv religiøs coping forekom oftere end negative

religiøse coping strategier. Dog var forekomsten af religiøs coping betydeligt lavere end niveauet

fundet i studier fra USA. Patienter, der anså sig selv som troende eller spirituelle, angav mere

positiv religiøs coping end ikke-troende patienter, men ingen forskelle blev fundet i forekomsten af

negativ religiøs coping mellem troende, spirituelle og ikke-troende patienter. Positiv religiøs coping

var ikke signifikant forbundet med livskvalitet, mens negativ religiøs coping viste sig at være

signifikant forbundet med lavere livskvalitet blandt lungepatienter. Derudover viste resultaterne at

en mindre andel af lungepatienterne angav at have haft flere religiøse, spirituelle, og eksistentielle

overvejelser som følge af deres sygdom, og mens en minoritet angav at have et behov for at tale

med sundhedspersonalet om eksistentielle og spirituelle overvejelser, ønskede ingen at tale med

sundhedspersonalet om deres religiøse overvejelser.

Undersøgelse 2 viste, at lungepatienter angav signifikant mere positiv religiøs coping, særligt

positiv religiøs mening og behov for tilgivelse, i sammenligning med en gruppe af raske danskere,

hvoraf nogle angav negative livsbegivenheder. Positiv religiøs coping var ikke signifikant associeret

med livskvalitet eller eksistentielt velbefindende i nogen af de deltagende grupper. Derimod viste

negativ religiøs coping sig at være signifikant forbundet med lavere livskvalitet udelukkende blandt

lungepatienter. Ydermere blev det fundet at raske kontrolpersoner, der ikke angav negative

livsbegivenheder og som rapporterede at modtage støtte fra deres trosfæller, havde en højere

livskvalitet og eksistentielt velvære.

I undersøgelse 3 blev det udforsket, hvorvidt forskellige psykosociale faktorer var forbundet med

det at opleve religiøse anfægtelser (negativ religiøs coping) blandt midaldrende og ældre danskere,

hvoraf nogle angav negative livsbegivenheder. I de indledende analyser blev det foreslået, at

indflydelsen af en negativ livsbegivenhed på livskvalitet, lavere indkomst, højere niveauer af

personlighedstrækket neuroticisme, usikker tilknytning, højere frekvens af kirkegang, samt at

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angive støtte fra ens trosfæller var forbundet med det at opleve religiøse anfægtelser. Dog viste den

endelige regressionsanalyse indeholdende de signifikante variable fra de indledende analyser, at

neuroticisme og det at modtage støtte fra ens trosfæller var de eneste signifikante variable forbundet

med det at opleve religiøse anfægtelser.

Undersøgelse 4 havde til formål at efterprøve, hvorvidt et spørgeskema om religiøs coping udviklet

i USA (Brief RCOPE) og et nyligt udviklet spørgeskema om spirituel coping var anvendelige og

valide blandt en gruppe af raske midaldrende og ældre danskere samt danske lungekræftpatienter. I

en eksplorativ tematisk analyse fremkom tre temaer med relation til validitet: 1) Betydningen af

individets tilgængelige sprog og ”religiøse kapital” og 2) betydningen af den konkrete kontekst som

individet er situeret i, når vedkommende bliver adspurgt om religiøs coping. Derudover blev temaet

om 3) hvorvidt religion og spiritualitet skal anskues som et universelt eller et kontekst-specifikt

fænomen, der er målbart og sammenligneligt på tværs af kulturer, fundet at være afgørende i

forhold til validitet, og blev diskuteret i relation til de anvendte metoder indenfor

religionspsykologien.

På baggrund af de fire undersøgelser, kan det konkluderes, at religiøs coping som målt ved hjælp af

Brief RCOPE i nogen grad var forekommende blandt danskere, som var konfronteret med større

negative livsbegivenheder, særligt blandt lungepatienter. Dette støtter til dels hypotesen, at

livstruende sygdom kan få folk til at vende sig til religion, selv blandt mennesker der generelt

opfattes som meget sekulariserede. Dog, som sådan kan religiøs coping operationaliseret ved hjælp

af Brief RCOPE ikke siges at have været et centralt fænomen blandt de deltagende personer, fordi

dette spørgeskema forudsætter en teistisk forståelse af ”det hellige” (opfattelsen af en konkret og

handlende Gud). Selvom næsten 65% af lungepatienterne og de raske kontrolpersoner angav at tro

på Gud eller en spirituel kraft, viser sociologiske undersøgelser, at karakteren af gudstro har ændret

sig fra konkret tro på en personlig og aktiv Gud til mere udefinerbare og upersonlige begreber om et

højere væsen. Den kvalitative undersøgelse viste, at religiøs tro og religiøs oplevelse for mange

deltagere var privat og ofte med karakter af ’tavs viden’, hvilket indikerer at kvantitative

måleredskaber kan vise sig at være problematiske at anvende, særligt i sekulære kulturer, fordi

deltagerne kan opleve vanskeligheder ved at skulle tilgå deres personlige tro eller overbevisning på

et rent kognitivt plan. Ydermere fandt den kvalitative undersøgelse tegn på forekomsten af andre

religiøse og spirituelle meningsdannelsesstrategier i håndteringen af negative livsbegivenheder, som

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ikke blev indfanget af Brief RCOPE. Dette antyder at religiøs og spirituel tro er vigtigt, selv blandt

personer der ikke anser sig selv for meget religiøse, men at nye måleredskaber og metoder er

nødvendige i fremtidige studier. Narrativ metode kan måske i højere grad give den enkelte

mulighed for at komme i kontakt med, hvordan personlig tro er blevet udformet, hvad den rummer,

og hvordan den bliver betydningsfuld i tolkningen og meningsdannelsen i forbindelse med negative

livsbegivenheder. Imidlertid, som fundet i denne afhandling, så er det at udtrykke religiøs tvivl,

tanker om Guds straf og følelsen af åndelig forladthed i forbindelse med lungesygdom forbundet

med lavere livskvalitet, hvilket antyder at patienten oplever stor anspændthed og fortvivlelse i

forbindelse med lungesygdommen. Sundhedspersonalet bør derfor tage denne potentielle trussel

mod helbred og velvære alvorligt og være opmærksom på ”religiøs anfægtelse” blandt

lungepatienter. Dog er der brug for mere viden om forekomsten af religiøs, men også spirituel

anfægtelse og eksistentiel fortvivlelse, blandt forskellige medicinske grupper i sekulære samfund

inden forslag til intervention eller forebyggelse kan foreslås. Fremtidige studier kan med fordel rette

opmærksomhed mod den potentielle indflydelse af individuelle forskelle i udviklingen af religiøse

og spirituelle anfægtelser, og eksistentiel fortvivlelse.

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Introduction

In March 2007 the Danish Nursing Journal (Sygeplejersken) published a special issue on “faith and

health” and the main article was titled: “Hospitals disregard patients’ spiritual needs” (Søndergaard

& Christensen, 2007). At that time very little was written or spoken on issues regarding faith and

health in Denmark, and the reluctance to talk with patients about religiosity, spirituality, and

existential issues in the health care system may also have hindered research interest or possibilities

in this field. Internationally, research has found spirituality and religiosity to impact decision-

making, course of illness, and quality of life (QoL) during severe illness such as cancer (Koenig,

King, & Larson, 2012). Furthermore, spiritual or existential needs have been found to be just as

important to address as psycho-social needs (Puchalski et al. 2009), and recently the

implementation of a bio-psychosocial-spiritual model of health in research and health care has been

suggested (Dyer, 2011). However, the majority of studies on faith and health have been conducted

in Northern America, which is far more religiously oriented than Northern Europe where the

relevance of implementing spirituality in research and health care in more secular societies has been

questioned (Salander, 2006). In practice, personnel employed in Danish health care institutions

hesitate in offering spiritual care because the spirituality or religiosity of the patient is considered a

private matter (Christensen & Turner, 2008; Dam, Johansen, Jørgensen, Winck, 2006).

Additionally, a recent study suggests that only 16% of the general population in Denmark expects

the Danish health care system to be able to provide spiritual care during life threatening illness

(PAVI, 2013). Yet, little is known about the actual religious, spiritual, and existential needs and

resources among Danes facing severe illness, or whether religiosity or spirituality impacts the QoL

of the patient. It is argued that due to secularization coherent world views may be lacking among

people living in secular societies, and result in difficulties in coming to terms with major life events

potentially impacting adjustment negatively (Stålhandske, Ekstrand, Tyden, 2011). In 2008, a

Swedish psychologist of religion encouraged the psychology of religion in Scandinavia to take

responsibility for identifying and assessing categories of function and dysfunction for an existential

public health and, in pace with the increased focus on well-being in public health, to provide models

and interventions for enhancing existential well-being (DeMarinis, 2008). Furthermore, a ‘Research

Network on Faith and Health’ was established first in Denmark in 2007 and since extended to

include Scandinavia in 2012 (see: www.faith-health.org), thus enhancing research in this area. The

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main aim of this thesis therefore is to explore, in a Danish context, the prevalence, characteristics

associated with, and influence of religious coping on QoL during severe illness and negative life

events.

The Danish context

The reluctance shown particularly towards religious and spiritual issues in Denmark calls for an

explanation, and in the following a short description of the characteristics of Danish society and

attitudes towards religion is given. Denmark has been named the most secularized society in the

world (Zuckerman, 2008). According to theories of secularization, a society becomes secularized as

a consequence of modernity, and ultimately religion disappears (Andersen & Lüchau, 2008). Due to

the industrial revolution and modernity following this development, Denmark is now one of the

richest societies in the world, having a strong welfare system which allows its inhabitants to enjoy a

relatively high standard of living and security, a well-established democracy, and a high degree of

individual freedom. However, there is a low commitment to religious institutions, while religion as

such has decreased in importance in Denmark. Following interviews with 150 Danes and Swedes,

Zuckerman (2008) arrived at a picture of Danes as ‘cultural Christians’, for whom religion (the

Christian heritage) was mostly about food, culture, and social events that were drained of all

religious content and basically a non-issue. According to the European Value Survey (2008), Danes

seem to prefer a “belonging without believing” relationship to the church. Approximately 80% of

the population are members of the Evangelical Lutheran Church (Den Danske Folkekirke), but only

10% attend church services regularly (e.g. once a month). Furthermore, traditional religious ideas

are declining: Only 36% believe in life after death, 21% in sin, and 9% in Hell. Moreover, the

picture of God has changed during the last 50 years from concrete, personal conceptions into more

ill-defined and vague ideas of an impersonal God (Lüchau, 2005). Despite the limited support for

traditional religious ideas, very few (7%) are willing to characterize themselves as atheists

(European Value Survey, 2008). Neither very religious, nor confessed atheists, 7 out of 10

characterize themselves as “believers”, and the majority of Danes state that they are “Christians in

their own way” (Iversen, 2006). Thus, even though traditional religion has lost its impact and

support, as the original theories of secularization predicted, it has not disappeared, but rather

changed into individualized and privatized forms (Andersen & Lüchau, 2008). Hence, researchers

call for new concepts of religion to capture the changes we are experiencing (Rosen, 2009).

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The concepts of religion and spirituality in a secular society

According to Rosen (2009) the previous conceptualization of religion assumed a system of ideas,

institutions and practices that shared the same core, a so-called “packed religion”. However,

religion in Denmark (and other societies influenced by secularization, individualization, and the

privatizing of religion) may be conceptualized rather as “unpacked religion” with several distinct

aspects not sharing a common core. In this new conceptualization, religion as “unpacked” can be

understood as consisting of five independent aspects: as personal beliefs that are actualized ad-hoc

in respect to context; as routinized religion, which refers to the religious institution to which one

can belong; as practices and traditions like passage rites and religious fests that for the majority of

people are devoid of religious content but upheld for social reasons; and, finally religion-as-

heritage, which has no religious content either, but signifies the cultural history, the shared norms

and values, of those whose heritage lies in a given church or religious tradition (Rosen, 2009:9).

The concept of spirituality is not explicitly a part of this definition, but calls for clarification since it

has made its entrance into theoretical and empirical research on faith and health in Scandinavia

(Stifoss-Hansen, 1999). Some have argued that the entry of the concept of spirituality covers a trend

towards individualized beliefs disconnected from organized religion, and is exemplified in the

phrase “being a believer, but not religious”, meaning that the individual relates to something beyond

human life but does not subscribe to traditional religion except for passage rites and feasts (Rosen,

2009; Stifoss-Hansen, 1999). However, internationally, the concept of spirituality is fenced in

conceptual confusion covering state of well-being, belief in a transcendent reality, and existential

concerns (Salander, 2006), and this also seems to be the case in Denmark. In a study among 514

adult Danes, la Cour, Ausker, & Hvidt (2012) found that six distinct understandings of the concept

‘spirituality’ exists: (1) positive dimensions in human life and well-being; (2) New Age ideology;

(3) an integrated part of established religious life; (4) a vague striving, opposed to religion; (5)

selfishness; and (6) ordinary inspiration in human activities. Thus, when operating with the concept

in research projects it is recommended to define “in a few words” what is meant by spirituality. In

this thesis, spirituality is understood as something deeply involved in the personal beliefs and

practices of the individual, hence not stemming from religion-as-heritage − the latter presupposes a

shared cultural heritage from the dominating church or religious tradition, which in Denmark is

Christianity − but represents beliefs influenced by other traditions, such as Eastern religions or other

untraditional beliefs in the transcendent.

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Alongside the religious and spiritual views of life among Danes are the secular, existential

orientations inspired by philosophy, humanism, and existential psychology not centered on a belief

in a transcendent reality. However, the religious, spiritual, and secular existential orientations share

some common features like offering interpretations of meaning, freedom, personal values and value

of life, and may often be present at the same time to the individual facing challenging life situations

(la Cour & Hvidt, 2010). Hence, research on faith and health among people in secularized societies

calls for conceptual clarity and sensitivity to different approaches to meaning-making and

adjustment during severe illness or stressful events.

A conceptual framework

Researchers from Scandinavia have argued that the conceptual umbrella embracing research on

faith and health in secularized areas should be defined as existential health (DeMarinis, 2008), and

a conceptual framework has been developed as a guide for mapping the issue of interest in

secularized societies to be more distinct about what is meant when investigating existential health.

la Cour & Hvidt (2010) proposes to distinguish between religious orientation, spiritual orientation,

and secular existential orientation, although acknowledging that they have common features.

Furthermore for all three meaning-making orientations, three dimensions underlie the nature of

these orientations: knowing (the specific content), doing (any given practice), and being (the

importance to the individual). This thesis mainly focuses on the prevalence and importance of the

religious orientation during life threatening and stressful situations among Danes. However as will

be presented during this thesis, secular existential and spiritual meaning-making orientations are

present and important aspects to investigate in terms of existential health in secular societies too, yet

not the main focus of this thesis. It is argued that Danes hold a “religion in crisis” (la Cour, 2005).

This statement has two senses: That traditional “packed” religion among Danes is in crisis because

it is disappearing. The second sense: That religion among Danes is most likely activated and

becomes important during important life transitions and major negative events such as life

threatening disease. In the definition of religion as unpacked (Rosen, 2009) it is highlighted that

personal beliefs are actualized and developed cognitively ad-hoc through life experiences such as

major negative life events. However, very little theoretical and empirical research has been

conducted in Denmark to highlight how religious orientation develops or unfolds in the three

dimensions of knowing, doing, and being during crisis, and whether religious orientations represent

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a resource in adjustment to crisis among Danes. The theory of religious coping developed by

Kenneth I. Pargament (1997) offers a framework for investigating the content, practice, and

importance of religious beliefs in coping with crisis and may also apply in investigating religious

orientation among Danes.

Religious coping

Research on religious coping has received increased attention since Pargament (1997) formulated

his transactional theory on religious coping. The theory is embedded in a functional approach to

religion focusing on how religion and spirituality is involved in the process of coping during times

of distress. The theory builds on the core assumptions of Lazarus and Folkman’s (1984) functional

transactional theory of coping. Basically, coping is understood as the cognitive and behavioral

processes engaged by the individual to reduce stress and regain psychic equilibrium during

incidences of threat, challenge, or loss. Central to the theory of religious coping is the concept of an

orienting system, which is mainly cognitively based and consists of values, habits, relationships,

generalized beliefs, and personality. The orienting system determines how a given stressor is

appraised, which resources will be activated and which coping strategies are likely to be

implemented (Gall & Guirguis-Younger, 2013). It is assumed that religious beliefs may engender a

sense of optimism, control, and meaning that affects whether a given stressor is appraised as

stressful and thereby affect the level of stress and potentially health (Dull & Skokan, 1995).

However, religious coping is not solely cognitive in nature, but multidimensional (e.g., cognitive,

behavioural, affective, relational), it serves multiple purposes (e.g., meaning-making, intimacy,

control, comfort, closeness with God), and is multi-valent (i.e., potentially helpful or harmful). The

transactional model of religious coping has been criticised for being too static as it does not take

into account the possible changes, developments, or declines of religious beliefs. Therefore,

Pargament (2007) developed the spiritual process model (see model 1). In this model the process of

searching for the sacred, conserving the sacred and transforming the sacred are core concepts. The

sacred is understood as the ‘ultimate concern’ of the individual, and may be secular in nature, such

as family and friends, but becomes spiritual when it is related to divine aspects of life. When the

sacred has been discovered the individual engages in consolidating his beliefs through strategies of

conservation. However, when struck by a major negative life event religious struggle is likely to

occur, and the individual engages in coping strategies to transform and hold on to his beliefs about

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the sacred. During the process of struggle the individual may experience spiritual growth, in which

his beliefs are deepened, and the struggle is replaced by a new process of conservation. The struggle

may on the other hand also lead to spiritual decline, and the individual may engage in searching for

the sacred anew.

Model 1: The spiritual process model (adapted from Pargament, 2007)

Measurement of religious coping

Appropriate ‘measurements’, or the lack of such, present a great challenge to examining religious

coping. The field has been limited by single-item measures such as frequency of religious activities

(church attendance, prayer, meditation) or global measures that broadly assess religion’s role in

coping (e.g. Religion subscale of the Brief Cope, Carver, 1997). Research on religious coping

attempts to take a focused, differentiated look at religious coping strategies, and in an effort to

obtain that goal, Pargament, Koenig, and Perez (2000) developed the religious coping scale,

RCOPE. Based on a literature review the authors identified five key functions of religion in coping:

meaning (positive and negative religious reappraisal); control (active and passive ways of gaining

mastery); comfort (spiritual connection, support, spiritual discontent); intimacy (seeking religious

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support from others; interpersonal spiritual discontent); and life transformation (religious direction,

conversion) (Gall & Guirguis, 2013). These core functions served as the theoretical underpinning of

the measure, and 21 different coping strategies were developed resulting in a 105 item

questionnaire. The measure has been tested and validated, but because of the rather lengthy

questionnaire, a shorter version, Brief RCOPE, was developed including 14 items (Pargament,

Smith, Koenig, & Perez, 1998). This questionnaire includes positive religious coping, referring to a

positive connection with the transcendent, with others, and a vision of the world as good, and

negative religious coping, which involves religious struggles primarily with the transcendent and

others. The Brief RCOPE is the most widely used measurement on religious coping and has shown

good psychometric qualities in several different samples in North America. Furthermore, is has

been revised for use among other religious traditions such as Judaism (Rosmarin, Pargament, &

Mahoney, 2009), Islam (Khan & Watson, 2006), and Hinduism (Tarakeshwar, Pargament, &

Mahoney, 2003), and it is now being translated into several different languages.

Empirical findings

Comprehensive reviews on empirical findings of religious and spiritual coping during illness and

negative events have recently been conducted (Exline, 2013; Gall & Guirguis, 2013; Lavery & Hay,

2010). The following is a short outline based on some of the main findings in this research area. In

general, religious coping resources have been associated with beneficial outcomes on health and

well-being among medically ill patients and participants reporting stressful events such as

bereavement (Gall & Guirguis, 2013). Contradictory findings have nonetheless been found, but as

previous studies mainly relied on uni-dimensional measures of public religious activity as an

expression of religious coping during illness, explaining these findings was made difficult (Thuné-

Boyle, Stygall, Keshtgar, & Newman, 2006). However, since the development of multidimensional

measures like the Brief RCOPE more studies have encompassed these and have been able to

differentiate religious coping strategies to a higher degree (Lavera & O’Hay, 2010). The distinction

between positive and negative strategies of religious coping seems to be able to explain some of the

diversity in findings, and the most consistent results have been found on negative religious coping

also referred to as ‘religious struggle’.

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Negative religious coping

A meta-analysis conducted by Ano & Vasconcelles (2005) on religious coping strategies and

psychological adjustment during stressful events suggests negative religious coping to be associated

with higher levels of depression, anxiety, and distress. Furthermore, in a systematic review of

studies on cancer populations (Thuné-Boyle, Stygall, Kesthgar, & Newman, 2006) 3 out of 17

studies found negative effects between religious coping and adjustment, 7 found some positive

effects, and 7 found no effect. However, the different measures applied did not all distinguish

between positive and negative forms of religious coping. Recent studies applying the Brief RCOPE

have found negative religious coping to be associated with higher levels of depression and anxiety

among breast cancer patients (Thuné-Boyle, Stygall, Keshtgar, Davidson, & Newman, 2013), and

lower QoL among a group of cancer patients (Tarakeshwar and colleagues (2006). Furthermore

Cole (2005), Fitchett and colleagues (2004), and Zwingmann and colleagues (2008) found negative

religious coping to be associated with poorer adjustment to illness in terms of pain frequency,

poorer overall physical functioning, and emotional distresss among groups of congestive heart

failure patients, cancer patients, and diabetes patients.

Positive religious coping

Results on positive religious coping still remain unclear. The meta-analysis conducted by Ano &

Vasconcelles (2005) suggested a moderate positive association between positive religious coping

and outcomes like spiritual growth, positive affect, higher self-esteem, and well-being, but a

negative association between positive religious coping and higher levels of depression and anxiety,

which signify that positive religious coping serves some adaptive functions. However, other studies

have found non-significant associations between positive religious coping and adjustment (Herbert

et al. 2009; Sherman et al. 2005, 2009). Methodological issues are at stake such as time of

measurement – especially among medically ill patients where stage of illness is considered to be

crucial. Furthermore, cross-sectional studies may blur the picture, as positive religious coping is

suggested to affect spiritual growth and thereby over time have a positive effect. Complicating

matters, studies have found positive and negative coping strategies to be positively correlated

indicating that patients may use positive and negative religious coping at the same time

(Zwingmann et al. 2006).

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Longitudinal studies

Sherman and colleagues (2005) argue that the reason why negative religious coping has a higher

impact on adjustment to cancer or other negative events may be that religious struggles are more

likely to represent a change in response to a negative event, whereas positive religious coping may

express maintenance of typical coping response. It is suggested that religious struggles can be

associated with spiritual growth in line with the spiritual process model (Pargament, Desai, &

McConnell, 2006; Pargament, 2007), however, the majority of empirical studies suggest that they

have more severe impact on adjustment, well-being, and physical health if they are maintained over

time. Sherman and colleagues (2009) found that among myeloma patients going through a

transplant operation, negative religious coping at baseline was associated with higher levels of

anxiety, depression and lower levels of well-being six months after the transplant operation.

Furthermore, Exline, Park, Smyth, & Carey (2011) found, on the basis of samples of cancer patients

and bereaved individuals, that religious struggles that lasted longer than a year were at risk of

turning chronic and have even more devastating consequences for the individual in terms of well-

being, and Pargament, Koenig, Tarakeshwar, & Hahn, (2001) found that negative religious coping

at baseline and at two-year follow-up was associated with higher mortality among elderly medically

ill patients. Although studies have found that positive religious coping strategies are far more

prevalent than negative religious coping strategies (Pargament, Koenig, & Perez, 2000), religious

struggle may be a “red flag” to be aware of to prevent harmful effects (Pargament et al., 2003).

Predictors of religious coping

Some studies have investigated the socio-demographic characteristics associated with religious

coping, and it is suggested that mainly elderly, lower educated, poorer people, women, and

minorities engage in religious coping strategies (Pargament, 1997). One explanation states that

people with limited access to secular resources seek spiritual resources to cope with stressful events.

Not surprisingly, studies also find that highly religious people engage in religious coping (Bell-

Meisenhelder & Marcum, 2004), although religious coping strategies may also become relevant to

less religious people facing traumatic events, e.g. bereaved parents (Brotherson & Soderquist, 2002)

and family members of homicide victims (Thompson & Vardaman, 1997). Another study on

spiritual struggles suggests that atheists and agnostics also engage in anger towards a hypothetical

God (Exline, Park, Smyth, & Carey, 2011). In recent years studies have investigated individual

psychological characteristics associated with religious coping. It has been argued that religious

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struggles may represent general poor psychological functioning and stem from multiple factors

(Lavera & O’Hay, 2010; Ano & Pargament, 2012). In a study, Ano & Pargament (2012) explored a

range of psychosocial predictors of spiritual/religious struggles, and suggested that a more negative

appraisal of stressful events, an insecure attachment to God, and neuroticism significantly predicted

spiritual struggles. Similarly, Exline and colleagues (2011) found that social cognitions of holding

God responsible for a traumatic event, perceiving the event as having a high degree of negative

impact to the individual, difficulties finding a meaning with a negative event, and seeing oneself as

a victim predicted spiritual struggles. Finally, Schottenbauer et al. (2006b) also found negative

religious coping to be associated with insecure attachment and viewing events as uncontrollable.

The application of religious coping theory among Danes

The majority of studies on religious and spiritual coping have been conducted in the context of the

United States, which has been characterized as the most religious of the industrialized societies in

the West (Schoenig, 2012). Due to increased fragmentation, deinstitutionalization, and privatization

of experience in the Western world (Bellah, Madsen, Sullivan, Swidler & Tipton, 1985; Gergen,

1991) the prevalence and impact of religious and spiritual orientations are also changing in the U.S.

Knowledge about the prevalence of religious resources in coping and how they affect adjustment

and QoL during stressful events in a far more secular culture like Denmark may potentially add

important knowledge to the U.S. and the rest of the international research in faith and health.

The theory of religious coping suggests that if religious beliefs are coherent and integrated in the

orienting system and supported by the society as an acceptable coping strategy, it is more likely that

religious resources will be activated and involved in coping during major life events (Pargament,

2007; Park, 2005). However, it is also suggested that even though religious ideas only make up a

minor part of the orienting system it may become an important part of the coping process

(Pargament, 1997). This could apply to Danes, who although not very religious, are not totally

removed from religious expressions. The ‘terror management theory’ also suggests that reminders

of one’s mortality such as life threatening disease is likely to activate religious responses to protect

self-esteem and bolster anxiety (Vail et al. 2010). However, less developed and integrated religious

beliefs may also be more easily shattered and incapable of functioning as a resource in crisis

(Pargament, 2007). It has been suggested that people influenced by secularization may to a higher

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degree lack coherent world views and when confronted with major life events such as loss, serious

illness, and accidents, their interpretations of the events and meaning-making becomes a difficult

task (la Cour, 2008; Stålhandske, Ekstrand, & Tyden, 2011). Thus, major life events are likely to

reveal fundamental frailty and shatter the worldview of the individual (Janoff-Bulman, 1992) and

thereby − among Danes − may also involve struggles in coming to terms with a traumatic event.

Empirical findings on religiosity during stressful events in Denmark

Studies on religious belief and health in Denmark are sparse, but a few studies conducted among

Danish samples give tentative support for the assumption that religious resources become more

relevant during stressful or life-threatening events. In a study among 480 hospitalized Danes

(Ausker, la Cour, Busch, Nabe-Nielsen, & Pedersen, 2008), it was found that religious, spiritual,

and existential practices correlated positively with illness severity, indicating that patients became

more religiously and spiritually engaged as the severity of the illness increased. Correlations were

strongest among the younger patients (>36 years). Furthermore, a study including 3,128 breast

cancer patients (Pedersen, Christensen, Jensen, & Zachariae, 2012) suggested that breast cancer

patients are more likely to be religiously oriented than the general population. In all, 83% of the

breast cancer patients reported to believe in God or a higher being, compared to the normal Danish

population of which approximately 65% report to believe in God or a higher being (The Danish

Value Survey, 2008). A recent twin study on religious coping during negative life events included

3,000 Danish participants, of whom approximately 1,830 had experienced a crisis that led to

increased reflection on religious matters. Even though the level of religious coping was lower

among the Danish participants than levels found in American studies, the tendency was clear:

participants, who had experienced a crisis, reported using both positive and negative strategies of

religious coping to a higher degree than the general sample, and losing a child or a partner led to the

highest score (Hvidtjørn, Hjelmborg, Skytthe, Christensen, & Hvidt, 2013). A qualitative study

among 12 terminally ill patients at hospice holding different views of life suggested that both

positive and negative religious coping strategies were engaged by some of the patients and that

eleven out of twelve prayed or meditated. Furthermore patients found it important and helpful to

talk about their different views of ‘life after death’ with a nurse (Nielsen, 2005). However, a

qualitative, longitudinal study among 21 younger (18-40 years) newly diagnosed cancer patients

suggested that younger Danes do not suddenly become very religious as a consequence of illness, if

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religion was not a part of their orienting system all ready. Instead, the worldview of the individual

was scaled up and engaged in meaning-making and adjustment to illness among both religious and

non-religious patients (Ausker, 2012). Studies on links between religiosity, spirituality, and

psychological outcomes such as QoL and depression following severe illness or stressful events are

still very limited in a Danish context, however a few studies have been conducted among medical

samples. A study on 460 breast cancer patients participating in a study on expressive writing found

that 77% reported to believe in God or a higher being, and 60% believed in the positive effect of

faith on their QoL. However, only 38% believed their faith to have any positive influence on the

course of cancer disease (Jensen-Johansen et al. 2012). Another study on faith and religious coping

among 97 heart attack patients suggested that there were no associations between religious coping

or belief in God/a higher being and depressive symptoms at baseline and at 6 month follow-up after

the heart attack. However, about one-fifth of the patients reported that, to some extent, they found

comfort in religion or spirituality, and one-fourth of the patients reported to have prayed or

meditated when faced with stressful events (Bekke-Hansen et al., 2013).

Although more studies on religion, spirituality and health in a secular context like Denmark have

begun to emerge during the last five years, much has yet to be explored. The extent to which

religious coping has been examined is still limited, and few studies have incorporated

multidimensional research measures but have relied on single-items. Studies are particularly needed

on links between religious beliefs, religious coping, and psychological outcomes, such as QoL

following negative events. Regrettably, at the time of writing, these studies are almost absent in a

Danish context. Furthermore, few international studies (Ano & Pargament, 2012), and none in a

Danish context so far, have examined associations between individual psychosocial characteristics,

such as personality traits and attachment style, and religious coping.

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Aim of this present thesis

In light of the growing interest in faith and health internationally, and recently in more secular

societies as Denmark, the main aim of this present thesis is to explore religious coping and

associations to psychological measures such as QoL and individual characteristics in Denmark. The

following questions were investigated based on two survey studies including:

1) newly diagnosed LDPs; and 2), a group of healthy Danes (of whom some had reported negative

life events); as well as a qualitative study among healthy Danes and lung cancer patients:

1. How prevalent is religious belief and religious coping among Danes facing severe lung

disease?

2. Is religious coping more prevalent among Danes facing severe lung disease and specific

negative life events than Danes coping with general, everyday challenges?

3. Do Danish LDPs report increased religious, spiritual, and/or existential concerns following

their diagnosis, and do they report a need to discuss these concerns with a health care

professional?

4. Is religious coping associated with QoL and existential well-being among Danes coping

with severe lung disease and specific negative life events?

5. Is religious struggle associated with individual psychosocial characteristics?

6. Are measures on religious coping developed in the United States applicable in a secular

context?

This present thesis is based on four independent papers. Before summarizing the results however, a

few remarks on the design and course of the studies on which this thesis is built should be

mentioned.

Study design

In 2007, a larger project on complementary alternative treatment and faith among newly diagnosed

Danish lung cancer patients and chronic obstructive LDPs was being prepared by Christina

Gundgaard Pedersen as a part of her PhD, and the principal investigator of this present thesis (Heidi

Frølund Pedersen) was responsible for the research questions and measures on faith and religious

coping as well as some of the measures of personality dispositions. Furthermore, she was

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23

responsible for establishing a control group matched on age, gender, education, and region to be

compared with the LDPs. Christina G. Pedersen was in charge of the recruitment procedures, and

the lung disease study was launched in the autumn of 2008. The lung disease study was planned to

be a longitudinal nationwide study with 6 month follow-up, and it was expected that, potentially,

1,500 LDPs would participate in the study. However, only five out of twenty-five possible

respiratory medicine clinics in Denmark (four on the main peninsula of Jutland and one on an island

in the eastern part of Denmark) chose to participate in the study, which resulted in an extended

recruitment period. During autumn 2009, the principle investigator of this present thesis took over

the responsibility of the recruitment of LDPs and contacted the five respiratory medicine clinics and

urged them to continue recruiting LDPs for the study for another year, as only 86 out of 337

questionnaires had been returned after one year of data collection. In this process the health

personnel reported that LDPs considered the number of questions to be overwhelming and,

furthermore, that some patients showed a certain reluctance towards the subject of the study,

namely, complementary alternative treatment and faith. Searching through some of the returned

questionnaires by hand, it became obvious that the questionnaires on religiosity and religious

coping suffered from a relatively high degree of missing responses. This led the principal

investigator of this present thesis to conduct a qualitative study among lung cancer patients and

three groups of healthy Danes to test the face validity of the questionnaire on religious coping. The

qualitative study led to insights on the validity of the questionnaires on religiosity and religious

coping, which is presented and discussed in Paper 4. However, since one of the aims of this present

thesis was to compare LDPs with a healthy control group it was not possible to make any

substantial changes in the questionnaires on religious coping in the study of the control group

(presented in Paper 2). The control group was established during spring 2010, and in October 2010

the recruitment of the LDPs ended, including 120 returned questionnaires at baseline, of which 9

were excluded due to a high amount of missing responses. This present thesis includes data from

the baseline study among LDPs, the age- and gender matched control group, and the qualitative

interviews among lung cancer patients and healthy Danes. An outline of the data collection periods

and sample characteristics in the individual studies is presented in Table 1. The content of the 3

baseline questionnaire packages and the specific measures used in the analyses of the four papers

are presented in the Appendix.

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24

Table 1: Demographic characteristics of the study samples

Study 1 Study 2 Study 3 Study 4

Sample Sample 1 Sample 2 Sample 3 Sample 1 Sample 2 Sample 1 Sample 2

Population: Lung Lung Negative

events

Healthy

control

Negative

events

Control Lung Healthy

Number: 111 111 91 246 174 166 10 14

Age (year):

Mean (s.d.)

65.2

(10.2)

65.2

(10.2)

67

(9.7)

68.2

(9.7)

67.8

(9.3)

67.8

(10)

64.7 56.2

Gender

(male):

62

(55.8%)

62

(55.8%)

36

(39.6%)

135

(54.9%)

95

54.6%

88

53%

5

(50%)

6

(43%)

Year of data

collection

2008 –

2010

2008 –

2010

2010 2010 2010 2010 2009 –

2010

2009

Response rate 23.4% 23.4% 34.7% 34.7% 34.7% 34.7% 13% Unknown

Subjects

included in

other studies

Sample 1 is identical with the

sample in study 1. Sample 2 and

3 are part of sample 1 and 2 in

study 2 – however in study 2

participants reporting co-

morbidity were excluded.

Sample 1 and 2 is

part of sample 2 and

3 in study 2 –

however in study 3

participants

reporting no

religious struggles

were excluded.

Summary of the four studies

The results and methods described in the four different papers are summarized in the following, and

presented in chronological order in which they written.

Study 1: Religious coping and quality of life among severely ill lung patients in a secular

society

One hundred and eleven newly diagnosed LDPs, i.e. lung cancer (39.1%) and COPD/other lung

diseases like bronchiecstasia (60.9%) participated in this study on prevalence of religiosity,

religious/spiritual/existential concerns, religious coping and associations to QoL (question 1, 3, and

4). Measures included single items regarding religious/spiritual beliefs, public and private religious

activity, congregational support, religious concerns (thoughts about the existence of God/Allah),

spiritual concerns (thoughts about the existence of a spiritual power), and existential concerns

(thoughts about finding meaning, peace, and purpose), religious coping measured by Brief RCOPE

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25

(Pargament et al. 1998) and QoL (Cella et al. 1993; Peterman, Fitchett, Brady, Pharm, & Cella,

2002). Results suggested that the number of LDPs reporting to believe in God or a spiritual power

was comparable with the general population in Denmark (65%). Furthermore, a minor proportion

reported to have experienced increased existential, spiritual, and/or religious concerns since their

diagnosis, but very few reported a need to discuss existential or spiritual issues with a health

professional, and none reported a need to discuss religious issues. Oneway ANOVA analysis

suggested that patients reporting to believe in God only, or God and a spiritual power, reported a

higher QoL than patients reporting to believe in a spiritual power only. Although positive religious

coping was prevalent, the level was lower than levels found in studies from the U.S. No association

was found between positive religious coping and QoL. Negative religious coping was not as

prevalent as positive religious coping, but hierarchical regression analysis suggested negative

religious coping to be associated with a lower QoL when controlling for socio-demographic and

religious factors.

Study 2: Coping without religion? Religious coping, quality of life and existential well-

being among lung disease patients and matched controls in a secular society

Aiming at examining whether religious coping is mobilized among people coping with severe

illness and stressful events compared to a control group (question 2), and whether religious coping

is associated with QoL and existential well-being (question 4), this survey study included 111

newly diagnosed LDPs and a group of 91 healthy Danes reporting stressful life events compared to

a healthy control group matched on age, gender, education, and region (n= 246). Measures included

single items about general religious activity, congregational support, religious coping measured by

the Brief RCOPE (Pargament, 1998), QoL (Cella et al. 1993), existential well-being (Peterman,

Fitchett, Brady, Pharm, & Cella, 2002) and among the two groups of healthy Danes, a revised

version of the List of Recent Events (LRE, Henderson, Byrne, & Duncan-Jones, 1981). Although

no differences in general religious activity was found between the three groups, positive religious

coping was more prevalent among LDPs than the control group, especially with regard to asking for

forgiveness and religious meaning-making. Hierarchical regression analyses suggested that negative

religious coping was associated with a lower QoL among LDPs only, whereas congregational

support was found to be associated with a higher QoL and existential well-being in the control

group. No associations were found between positive religious coping and QoL or existential well-

being in any of the three groups.

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26

Study 3: Psycho-social factors associated with religious struggles during negative life

events in a secular society

Examining the associations between religious struggle and individual characteristics (question 5),

this study included 340 Danes of whom some reported a specific negative life event. Measures

included negative religious coping (Brief RCOPE, Pargament et al, 1998), religious beliefs, general

religious activity measured as public and private religious activity, congregational support, social

support (subscale of FACIT, Cella et al. 1993), personality traits (NEO-FFI, Costa & MaCray,

1992), attachment style (RAAS, Fraley, Waller, & Brennan, 2000), and socio-demographic

information. Between 9% and 24 % of the participants reported negative religious coping to some

degree, e.g. religious struggles. Initial analyses suggested that participants rating the specific

negative events as having low impact on QoL were less likely to report religious struggles, whereas

marginally significant results suggested participants rating the event as having high negative impact

on Q L to be more likely to report religious struggles. Furthermore, participants having a lower

income, having higher levels of neuroticism, attending church, and receiving congregational support

were more likely to report religious struggles. The final logistic regression model found higher

levels of neuroticism and reporting congregational support to be associated with reporting religious

struggles.

Study 4: Studying religious and spiritual coping in a secular culture: A question of validty

To test the face validity of a U.S. developed measure on religious coping (question 6), three focus

groups of healthy Danes (n=14) and 10 individual interviews with lung cancer patients were

conducted. Participants were asked to respond to a revised version of the Brief RCOPE and a scale

called Brief SCOPE measuring whether the respondent turned to God or to a spiritual power when

coping with major negative life events or lung cancer. Participants were asked about their

understandings of the terms “God” and “spiritual power”, their understandings of the items in the

two questionnaires and the relevance of religious coping in their life situations. Exploratory

thematic analysis revealed three themes in relation to validity: The importance of language and the

“religious capital” of the participant when responding to measures about religiousness in secular

society, the influence of the situation-specific context when asked about religious coping, and the

question of universality versus context-specificity in the measurement of religious and spiritual

phenomena such as religious coping.

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27

Discussion

The primary aim of this present thesis was to investigate the following questions:

1. How prevalent is religious belief and religious coping among Danes facing severe lung

disease?

2. Is religious coping more prevalent among Danes facing severe lung disease and specific

negative life events than Danes coping with general, everyday challenges?

3. Do Danish LDPs report increased religious, spiritual, and/or existential concerns following

their diagnosis, and do they report a need to discuss these concerns with a health care

professional?

4. Is religious coping associated with QoL and existential well-being among Danes coping

with severe lung disease and specific negative life events?

5. Is religious struggle associated with individual psychosocial characteristics?

6. Are measures on religious coping developed in the U.S. applicable in a secular context?

In the following, results from Studies 1-3 will be discussed in light of the existing theory and

empirical studies presented in the introduction, and Study 4 will be discussed taking into account

the methodology and limitations of this present thesis.

Prevalence of religious beliefs and religious coping among Danish lung disease

patients

Study 1 suggested that belief in God or a spiritual power was widespread among LDPs, however

not exceeding the level of the general Danish population as found in previous studies from

Denmark including breast cancer patients (Jensen-Johansen et al. 2012; Pedersen, Christensen,

Jensen, & Zachariae, 2012). Studies have found women to be more religiously oriented than men

(Hvidtjørn, Hjelmborg, Skytthe, Christensen, & Hvidt,2013; Paloutzian, 1996) and this may to

some extent explain the findings from the breast cancer studies. The lung disease group included

more men (56%) than women and is more comparable with the general Danish population. Positive

religious coping was prevalent, however the level (mean=3.1) was considerably lower than the level

found among medically ill patients from the U.S. (mean=14.8) (Pargament, Koenig, Tarakeshwar,

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28

& Hahn, 2004). Strategies for seeking God’s love and care, religious transformation, and asking

forgiveness for one’s sins were most prevalent and reported by between 29% and 37% of the total

sample of LDPs (note: discrepancies between the amount of LDPs reporting the individual religious

coping strategies in Study 1 and Study 2 are explained by the fact that in Study 1 the percentage of

the entire patient group is reported including missing responses (N=111), whereas the valid

percentage is reported in Study 2 (N=96)). Not surprisingly, patients who considered themselves to

be a ‘believing’ or ‘spiritual’ person reported more positive religious coping than non-believers.

Still, some non-responders reported on seeking God’s love and care, which may reflect that

religious coping can be mobilized during severe illness, even among patients who do not usually

engage in religious beliefs. Overall, the level of negative religious coping (mean=1.5) was low, but

closer to the level found in the U.S. sample (mean=2.3) established by Pargament and colleagues

(2004). Demonic reappraisal was one of the least reported strategies and confirms the findings of

the European Value Survey (2008) that traditional religious beliefs, including the concept of the

devil, have decreased. Feeling abandoned by one’s religious community was the least reported

strategy (less than 2%) and may be explained by the low commitment to the Evangelical Lutheran

Church in Denmark. However, feelings of abandonment and punishing reappraisal were the most

prevalent strategies reported by between 10% and 16%, and also reported by non-believers. This

supports the finding that religious struggles may appear among atheists and agnostics as well

(Exline, Park, Smyth, & Carey, 2011), and analyses suggested that there were no differences

between believing, spiritual, or non-believing patients regarding negative religious coping

strategies.

Increased relevance of religiosity and religious coping during illness?

Question 2 aimed at testing the generalizability of a finding from U.S. studies that reminders of

mortality and human frailty, such as life threatening disease, are associated with greater

religiousness and religious coping when compared to individuals reporting no negative life events.

Study 2 found no differences in general religiousness − measured by church attendance and

prayer/meditation/scripture reading − between LDPs, individuals reporting negative events

(negative events group), and a healthy control group. Thus, stressful events did not result in

increased religious practice. Overall positive religious coping was more prevalent among LDPs

when compared to the control group reporting no negative events. No differences were found in

overall positive religious coping among LDPs and the negative events group. However the single

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29

coping strategies of asking forgiveness for one’s sins, which was reported by one-third of the LDPs,

and positive religious meaning-making, which was reported by 60.4% of the LDPs, were more

prevalent than among both the negative events group and the control group. It is suggested that due

to life style related factors like smoking in the etiology of a lung disease, patients diagnosed with

lung cancer report greater self-blame (Chapple, Ziebland, & McPherson, 2004). Thus, LDPs

participating in this present study may have felt a greater need to be reconciled with close relatives,

themselves, and ultimately God, by asking forgiveness for an unhealthy life style (De Guzman et al.

2010). Furthermore, receiving a life-threatening disease may increase the need for finding meaning,

and LDPs participating in this present study may have expressed a hope or a trust in a higher, divine

meaning. No differences in negative religious coping strategies were found between the three

groups. Contrary to expectations, no differences in religious coping were found between the control

group and the negative events group. This may be due to methodological limitations. In some

instances the negative events reported in the present study involved a close relative, and negative

events may thereby have been less serious than lung disease. This finding would support the theory

of terror management, namely, that reminders of one’s own personal mortality are more likely to

trigger religiosity than more mundane life events.

Religious, spiritual, and existential concerns among lung disease patients

Question 3 aimed at examining the existential, spiritual, and religious concerns and needs among

LDPs, and it was found that patients expressed relatively low levels of increased religious, spiritual,

and existential concerns following their diagnosis. Between 10.2% and 16.2% of the patients

responded positively that they had more thoughts on existential, spiritual, and religious issues. This

finding came as a surprise given the relative severity of the patients’ diagnosis and the time of

measurement. Studies among lung cancer patients and mixed groups of cancer patients have found

existential and spiritual concerns to be elevated at the time of diagnosis and at the point in time

when death is perceived as unavoidable (Ausker, la Cour, Busch, Nabe-Nielsen, & Pedersen, 2008;

Moadel et al. 1999; Murray, Kendall, Boyd, Worth, & Benton, 2004). The point of measurement

(immediately after diagnosis) was chosen because it was hypothesized that existential, religious,

and spiritual concerns would be elevated and thereby relatively prevalent. As found in Study 2, it

was suggested that almost two thirds of the LDPs sought positive religious meaning-making, which

makes the low prevalence of existential, spiritual, and religious concerns puzzling. One explanation

may be that the questions were not differentiated enough. The question about existential concerns

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30

was clustered and covered “thoughts about finding peace, meaning, and purpose”. Existential

concerns may also cover fears of death and dying, fear of losing control, feelings of loneliness, and

concerns about relationships (Moadel et al., 1999; Murray et al, 2004; Yalom, 1980), and more

differentiated and comprehensive measures of existential concerns could have revealed a more

nuanced picture. It may also be argued that a single question about elevated thoughts about

existential matters is too abstract, and a formulation such as “Behind all this I think God has a

meaning after all”, which was used in Study 2, could have induced more concrete reflections among

the patients. Conversely, it is suggested that secular worldviews may be associated with existential

indifference characterized as a state of low meaningfulness and yet not a crisis of meaning (Schnell,

2010). Thus, due to secularization Danes may be less concerned about existential issues in general,

and findings from the World Value Surveys (1997) give tentative support for this hypothesis, as it

was found that only 29% of Danes report to reflect much upon the meaning of life compared to 34%

in the United Kingdom, 37% in Finland, and 48% in the U.S (la Cour, 2005). The lack of

engagement in existential, spiritual, and religious issues can be positive in the sense that Danes may

be less vulnerable to crisis of meaning. However the present study only measured religious,

spiritual, and existential concerns at the time of diagnosis, and future studies may reveal if levels of

concerns increase with the severity and stage of illness.

Addressing religious, spiritual, and existential concerns

Study 1 also found that only a minor group of LDPs reported a need to discuss spiritual (0.9%) and

existential considerations (3.9%) with a health care professional and none wanted to discuss their

religious concerns. These results indicate that Danes are very private about their existential and

spiritual considerations, and that religion may be a non-topic as suggested by Zuckerman (2008) –

at least in the conversation with health care professionals. A study from the U.S. including ethnic

diverse samples suggests that between 28% and 43% of cancer patients report a need to talk to

someone about existential concerns like finding peace of mind and meaning in life (Moadel et al.

1999), and another U.S. study found that 62% of severely ill patients find it important that the

physician attends to the spiritual concerns of the patient. However, the same study also found that

62% did not think that is was the physician’s job to talk with patients about spiritual concerns

(Holmes, Rabow, & Dibble, 2006). The same attitude may be present among Danes. As suggested

in the study of Danes’ expectations towards the Danish health care system’s ability to provide

palliative care, it was found that: whereas 96% expected to receive medical care, only 16% reported

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31

that they expected to receive spiritual care at the end-of-life (PAVI 2013). Thus, Danes may not

perceive the discussion of religious, spiritual, and existential concerns with health care personnel as

necessary, appropriate, or something to be demanded. Rather, it may be the hospital chaplain who is

expected to take care of the patients’ spiritual and existential needs. However in everyday life some

patients are reluctant to talk to a pastor, particularly if they do not consider themselves very

religious or have another spiritual orientation than Christianity. Therefore it may be crucial that the

physicians and nurses are attentive to the potential existential, spiritual, and religious concerns of

the patient, especially as results from this thesis suggest that religious concerns and struggles can

affect the patient’s QoL.

Associations between religious coping and QoL

Negative religious coping

Question 4 aimed at investigating the possible associations between religious coping and the QoL

among LDPs and Danes reporting negative life events. Although less prevalent than positive

religious coping, Study 1 suggested that negative religious coping had a significant negative impact

on QoL among LDPs, while Study 2 found this to be true among LDPs only. Negative religious

coping among the negative events group and the healthy control group was not associated with

QoL. Several studies have suggested that the associations between religious coping and measures of

well-being and QoL are stronger when coping with major life stressors such as medical illness

(Cummings & Pargament, 2010), and frequency of pain and poorer physical functioning have been

associated with greater levels of negative religious coping among cancer patients (Cole, 2005; Hills

et al. 2005; Sherman et al. 2005). Thus, the severity of the LDPs’ situation is likely to have resulted

in the links between religious struggles and lower QoL. However, due to the cross-sectional design

it is not possible to conclude whether low QoL resulted in religious struggles or vice versa. It may

also be argued that due to less integrated and fragmentized religious beliefs the LDPs experienced

frustration instead of comfort when trying to mobilize religious resources. According to Pargament

(2007) less integrated religious world views may more easily be shattered when the individual is

exposed to turmoil and distress, and could result in religious struggles. If personal beliefs in secular

societies are actualized ad hoc as suggested by Rosen (2009), Danes may not be able to actualize

these beliefs effectively during major life stressors as the cognitive content of these beliefs is not

sufficiently explicated and developed before a crisis strikes. According to Dull & Skokan (1995)

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32

one of the mechanisms behind the positive link between religious coping and stress is that religious

beliefs engender a sense of optimism, control, and meaning, that effect whether a given negative

event is appraised as stressful at all. The question is whether Danes in general are poorly equipped

to profit by their beliefs when struck by major events?

Positive religious coping

The hypothesis that Danes lack fully functioning religious beliefs that are able to function as a

buffer against distress may be supported by the finding that positive religious coping was not

associated with QoL or existential well-being among LDPs or the negative events group. According

to Pargament and colleagues (2001), lack of associations between positive religious coping and

measures like QoL can be explained by the argument that: “religion has more significant effects for

those whose roles and identities are more closely tied to religion” (p. 510), and this has been

confirmed in empirical studies since (Jonas & Fischer, 2006). In a study among deeply religious

participants from the Netherlands, which is also a society characterized by secularization, positive

religious coping was found to be associated with higher levels of existential well-being and less

anxiety (Pieper, de Vries-Schot, & van Uden, 2012). Future studies among deeply religious Danes

may reveal whether religious beliefs function as a resource affecting health and well-being, or

whether secularization has impacted the ability of religious beliefs to offer comfort, meaning, and

hope even among the most religiously oriented during major life events. The non-significant links

between positive religious coping and QoL could also be explained by the religious coping

mobilization effect (Pargament, 1997). Religious coping could have been mobilized during severe

distress. However, severe distress may also have caused low QoL, and the two effects could

hypothetically have neutralized each other. Longitudinal studies are needed to clear up this

hypothesis.

Whereas no associations were found between positive religious coping and QoL, Study 1 suggested

that LDPs reporting to believe in God only, or God and a spiritual power, reported higher levels of

QoL than patients believing in a spiritual power only. Analyses suggested that patients believing in

a spiritual power only reported less public and private religious activity and low support from

fellow believers, indicating a non-traditional belief without organized social engagement in

religious communities. Study 2 suggested that congregational support was associated with higher

levels of QoL and existential well-being in the control group only. These independent findings

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33

suggest that Danes holding religious beliefs that involve a social engagement in a church or another

religious fellowship may more likely benefit from their religious orientations in terms of social

support, which is suggested to function as a buffer against stress (Cohen & Wills, 1985), affect QoL

among cancer patients (Allart, Soubeyran, & Cousson-Gélie, 2013), and ultimately result in

decreased mortality (la Cour, Avlund, & Schultz-Larsen, 2006; McCullough, Hoyt, Larson, Koenig,

& Thoreson, 2000).

Individual characteristics associated with religious struggles

Question 5 aimed at studying different psycho-social factors and their associations to religious

struggles in a group of participants reporting negative events, and is described in Paper 3. Results

revealed remarkably few significant associations between religious struggles and socio-

demographic factors, personality dispositions, religious factors, social factors, and situational

factors. In fact, only two variables, neuroticism and congregational support, were statistically

significant when testing the final logistic regression model, including all variables associated with

religious struggles in a series of initial analyses. A couple of explanations for this finding are

suggested.

Negative events

Initial analyses suggested that participants rating the negative event as having little or no negative

impact on QoL were less likely to report religious struggles, indicating that the gravity of negative

events is important to consider in predicting religious struggle. This has also been found in studies

from the U.S. (Exline, Park, Smyth, & Carey, 2011; Ano & Pargament, 2012) and a recent Danish

twin study suggest that traumatic events like losing a child or a spouse are more likely to elicit

negative religious coping responses than more mundane events (Hvidtjørn, Hjelmborg, Skytthe,

Christensen, & Hvidt, 2013). This may be explained by the theory of core assumptions put forward

by Janoff-Bulman (1992), that humans live with the assumption that the world is good and

meaningful. When faced with traumatic events this assumption is easily shattered and the individual

may experience great confusion and despair trying to reconstruct his assumptions about the world.

Under these circumstances, religious struggles are likely to occur. The theory of religious coping

also suggests that more severe events are likely to elicit religious coping responses. However,

nearly half of the sample in this present study did not rate the impact of events on QoL and did not

specify the nature of the event when responding to the negative subscale of Brief RCOPE. Thus, it

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34

was not possible to determine whether the gravity of negative events was significantly associated

with the presence of religious struggles in the final regression model, and a type 2 error is likely to

have occurred. That is when an effect is truly present but not found statistically significant due to

lack of power (Field, 2009). Future studies should be careful to register the nature of negative

events and the subjectively perceived gravity of these events. Furthermore, it may also be argued

that situational factors could potentially have mediated or moderated the associations between

individual differences and religious struggles. Hence, future studies could benefit by applying more

sophisticated models of analyses like structural equation modeling to investigate possible mediators

and moderators of religious struggles, situational factors, and individual differences.

The impact of individual differences

An explanation for the relatively few significant results may be based on the finding that

neuroticism was relatively highly correlated with negative religious coping. Personality traits as

measured by the Big Five have in general been found to be strong predictors of a wide range of

individual, interpersonal, and social outcomes (Ozer & Benet-Martinéz, 2006). Neuroticism in

particular has been found to be the strongest predictor compared to other personality dispositions on

psychological outcomes like negative affect and QoL (Steel, Smith, & Shulz, 2008). Furthermore,

personality traits have been associated with certain patterns of coping behaviour, suggesting that

personality traits to a great extent determine how the individual adjusts to different circumstances

(Costa, Somerfield, and McCray, 1996), and some even argue that “coping is personality in action

under stress” (Bolger 1990, p. 525). For example, neuroticism has been associated with the

tendency to blame oneself and others (Costa, Somerfield, and McCray, 1996), which is also

represented in the negative subscale of Brief RCOPE covering thoughts of being punished by God.

According to the general transactional coping theory it is assumed that the individual has a high

degree of freedom to choose his appraisal of a stressor and how to adjust, and little attention is paid

to the influence of individual differences possibly influencing the coping process. Pargament (1997)

implements the concept of an orienting system in his theory on religious coping, consisting of

personality dispositions, religious dispositions, and social dispositions, and thereby acknowledging

that the freedom to choose one’s coping strategies is to some degree limited by basic dispositions

and previous experiences. However, this point has not been clearly underscored in the earliest

studies on religious coping. Recent studies seem to investigate the influence of basic personality

dispositions to a higher degree and have also found neuroticism to be associated with negative

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35

religious coping styles (Ano & Pargament, 2012; Wood et al. 2010). Yet, longitudinal studies

including personality traits as predictors of religious struggles are lacking. It may be suggested that

continuous religious struggles highly correlated with neuroticism represent a trait-like rather than

state- like construct. If this is the case, it may also explain why religious struggles have been found

to have a devastating impact on health over time (Exline, Park, Smyth, & Carey, 2011; Pargament,

Koenig, Tarekeshwar, & Hahn, 2001), as studies have found neuroticism to be associated with

increased mortality (Shipley, Weiss, Der, Taylor, & Deary, 2007). Furthermore, if the tendency to

engage in negative religious coping is determined by neuroticism, this may also explain why

relatively few studies have found negative religious coping to be associated with spiritual growth

(Exline, 2013). Neuroticism has been found to be negatively associated with open, mature

spirituality (Saroglou, 2002), and is therefore likely to complicate the possibilities for spiritual

growth. Future studies should pay closer attention to the influence of individual differences like

personality traits in adjustment to major negative life events, and more longitudinal studies are

needed to clarify whether continuous religious struggles are more trait-like than state- like.

Furthermore, it was expected that insecure attachment would be significantly associated with

religious struggle. Studies have found insecure attachment style to be associated with negative

religious coping (Schottenbauer et al. 2006b), and especially disorganized attachment style is

suggested to be associated with viewing God as aberrant and frightening (Granqvist, Hagekull, &

Ivarsson, 2012). However, this association could not be confirmed in the final regression model,

and could be ascribed to the type of attachment measure applied. It is argued that the individual’s

relationship to God “bears striking resemblance to the child’s attachment to caregivers, and seems

to meet important criteria for defining attachment relationships” (Granqvist, 2005:36; Kirkpatrick,

1999). Therefore a measure of parental attachment style may be more appropriate to apply when

studying attachment in relation to religious coping.

Religious characteristics

No clear conclusions could be drawn regarding the association between religious beliefs, religious

activity, and religious struggles. Previous studies have found that religious struggles are also

prevalent among atheists and agnostics (Exline, Park, Smyth, & Carey, 2011), but religious beliefs

did not turn out to be significant in the final regression model, although the initial analyses

suggested secular believers to report less religious struggles. Instead, congregational support was

found to be associated with religious struggles, and it was hypothesized that individuals facing

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36

stressful events turned to their congregation for social support. However it may also be argued that

congregational support is an indicator of traditional religiousness, since very few Danes are engaged

in their church or congregation. Future studies should apply more precise measures of religious and

spiritual engagement as well as different religious, spiritual, and secular-existential orientations to

better predict whether religious struggles occur among the religiously oriented only. The hypothesis

that individuals living in secular societies are more prone to struggles of a religious, spiritual or

existential character during traumatic events because they lack coherent worldviews (DeMarinis,

2008) could not be confirmed since the only measure of struggle or negative coping style was

religious in nature. This means, therefore, that future studies should apply measures of existential

and spiritual struggles and this point leads on to methodological reflections on the validity of theory

and measures used in this thesis.

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Methodological considerations and limitations

In proposing models and methods for investigating how religion affects the coping process and

well-being of the individual during crisis, the theory of religious coping has contributed greatly to

the field of psychology of religion. As such, Kenneth I. Pargament deserves acknowledgement for

his seminal work giving insights as to how religion functions during crisis. In this present thesis the

theory and methods developed by Pargament (1997; 2007) and colleagues (1998; 2000) was

adopted and applied in a Danish context to test the generalizability of findings from a U.S. context

in a far more secular society. However, taking a critical stance, the coping perspective of religion

and the mainly quantitative methodology used in this research field has its limitations and will be

discussed in this section on methodological considerations.

The validity of Brief RCOPE in a secular society

As presented in Study 4, much is up for discussion regarding the applicability and validity of the

chosen religious coping measure, Brief RCOPE. Three themes in relation to the validity of

measuring religious and spiritual coping in a secular society emerged. First of all it was found that

the religious and/or spiritual language and concepts available to the individual determined to which

degree the participants were able to decode and respond adequately to the questionnaires. A

potential problem was detected among non-believers and non-theists of whom some refused to

respond because the language and underlying conception of religious beliefs were perceived to

reflect old-fashioned and traditional Christianity. Especially non-believers missed other response

options such as “Not relevant”, and in its absence some chose to mark negative religious coping on

items like “Questioned the power of God” with “Very much” to express their disbeliefs. As a

consequence this particular item was omitted from the analyses in Studies 1-3; and in Studies 1 and

2 non-believers were omitted from the regression analyses testing associations between religious

coping and QoL. However, even though the individual responding to the questionnaire held the

appropriate religious concepts and language to decode the different religious coping items,

participants with a theistic belief pinpointed that the language offered to them was too limited to

describe their experience of beliefs. The second theme highlighted the importance of the concrete

situation of the individual when measuring religious coping. Participants who were asked to recall a

negative event had great difficulty responding to the questions retrospectively if the negative was

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not severe enough or fresh in memory. Being situated in a stressful circumstance like having lung

cancer or being able to recall a recent negative life event was more likely to give rise to religious

interpretations of the event, even among participants who did not view themselves as very religious.

As such the questionnaire of Brief RCOPE did tap into ways of applying religious beliefs in coping

during major negative life events, although with varying precision. However, the third theme

questioned whether religious and spiritual phenomena can and should be measured as a universal or

a context-specific phenomenon. One of the underlying assumptions in the Brief RCOPE is that the

individual engages with a personal and active God. However, theistic beliefs (beliefs in a personal

and active God) have decreased in Denmark, and changed into more ill-defined and vague concepts

of an impersonal transcendent being (Lüchau, 2005). A new scale on spiritual coping which had

been developed for this project was found to be an important contribution – especially to

participants who did not believe in God. However, results suggested that the underlying construct

came too close to the Brief RCOPE’s conception of an active and involved spiritual being.

Furthermore the negative formulated items in the spiritual scale were not found adequate, since

participants believing in a spiritual power rather than God, described this spiritual being as solely

positive in nature. Thus, as a consequence it was determined only to include the Brief RCOPE in

the analyses conducted in study 1 to 3. Furthermore, fragments of what could be characterized as

religious and spiritual meaning-making strategies in adjusting to major negative events were found

among patients and healthy participants, however not presented in the Brief RCOPE neither the new

spiritual scale, because they did not necessary include the concept of a personal and active God.

Therefore, the results from Studies 1 to 3 are most likely to have ignored other religious, spiritual

and existential coping and meaning-making processes during adjustment that are important for

people living in secularized societies. Ganzevoort (2004) states it very clearly: “If religion is taking

new shapes (as is the case in Scandinavia), we need new concepts and measures as well” (p. 119),

and this is the natural conclusion of Study 4. Hall, Meador and Koenig (2008) elaborate on ways to

use questionnaires of religiosity in general and still ensure context-sensitivity. They recommend

using measures that enable the individual to read his own religious or spiritual view of life into the

questionnaires. Furthermore, it would be worthwhile studying religious or spiritual homogenous

groups, or, if studying mixed groups, employing ways of distinguishing groups that share

theologically similar perspectives to obtain more meaningful findings. However, this method still

requires shared understandings of faith traditions, and this may be problematic in societies like

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Scandinavia where religion is highly individualized and fragmentized. Furthermore, this approach

assumes that religious beliefs have universal, context-free characteristics that are stable and can be

measured objectively. Although very prevalent in the psychology of religion this assumption is to

opt for critique as it has far-reaching consequences for how we are able to understand religious and

spiritual phenomena. This leads on to critical reflections on the theoretical and empirical work of

religious coping.

A critical comment on the theoretical and empirical work on religious coping

In a recent paper on the history of the Western psychology of religion, Nelson (2012) describes the

development of the discipline with regard to three scientific paradigms: the hermeneutical-

phenomenological, positivistic naturalism, and religious integration, highlighting the underlying

research assumptions and preferred methods, and discussing their advantages and disadvantages. In

line with the tradition of critical psychology as represented by Wulff (1997), Nelson criticizes the

dominance of the positivistic naturalism paradigm in the psychology of religion, although it has

helped the discipline to be established as a legitimate part of mainstream psychology (Emmons &

Paloutzian, 2003; Pargament, Mahoney, Exline, Jones, & Shafranske, 2013). The positivistic

naturalism paradigm relies on the methodological assumptions that “operationalization is the key to

methodology”, and often “reliability in measurement has some degree of priority over validity”,

and “quantitative methods are assumed to be the best way of testing the operationalised

propositions”. Furthermore, the epistemology of the positivistic naturalism assumes true knowledge

to “consist of abstract propositions about universal causal laws”, and regarding ethical assumptions

“simplicity is privileged over completeness in models and explanations”. Finally, the ontology of

positivistic naturalism assumes the human person as “essentially a self-contained individual and any

cultural or relational context is secondary to this individual essence” (Nelson, 2012, pp. 693-694).

When applied in research disciplines like natural science this paradigm has its many advantages, but

in the psychology of religion some disadvantages are inevitable. With regard to the theoretical and

empirical work on religious coping a couple of disadvantages will be presented:

First of all, in religious coping theory it is assumed that crisis is likely to evoke religious responses

and therefore, Pargament (1997) states that there is no better place to study religion than in “the

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laboratory of times of crisis and coping” (p. 5). However as in all “experimental” research, it is

important to consider the ecological validity of the design (Bronfenbrenner, 1979) and the

generalizability of results. Taking a crisis coping perspective on religion, focus is directed at the

individual and is at risk of arriving at a one-dimensional “here and now” image of how religion

functions under unusual circumstances, not taking into account a range of potential dimensions

inflicted before, during, and after a crisis. Past experiences, individual differences, social relations,

and the surrounding milieu plays a great role in how religious beliefs are shaped and expressed

(Ganzevoort, 1998), and whether they become involved during crisis or not. The concept of the

orienting system as introduced by Pargament (1997) attempts at accounting for individual and

social factors in a multidimensional model of religion. However the orienting system and its

different elements are diffusely described, and according to Ganzevoort (1998) seen as “external

independent variables rather than influencing and being influenced by the coping process and

religion of the individual” (p. 262). Furthermore, even though Pargament (1997; 2007) makes an

effort to describe religiosity and spirituality as multidimensional and continuous process, the

applied quantitative measures makes it difficult to uncover this complex picture, and unfortunately

often end up by portraying religion and coping in a simplistic manner. For example in the measure

Brief RCOPE, religious and spiritual beliefs are operationalised as if they were a stable and fixed

part of the orienting system, almost like a tool that functions in more or less desirable ways when

applied in individual problem solving (Ausker, 2012). As mentioned by some of the participants in

Study 4, the questionnaire was perceived as rigid and not applicable in all situations. Furthermore,

several participants protested against either single items or the whole idea of measuring religious

belief by paper and pencil, because they could not read their own experience of religious beliefs

into the questionnaire. Thus, as a consequence of the underlying positivistic approach in the theory

and measure of religious coping, religious beliefs are easily understood as simple, static, universal,

and context-free phenomena that can be measured objectively and replicated in other settings.

However, religious and spiritual beliefs may rather be seen as changeable and situational, which

develop and unfold ad hoc as suggested by Rosen (2009) and closely connected to the language,

narratives, and characteristics of the individual and his surroundings.

According to recent sociological studies (European Value Survey, 2008) religion and spirituality do

not seem to disappear, but are changing, in secular societies, and recent studies from a Danish

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41

context suggest that medical illness is likely to increase religious, spiritual, and existential concerns,

beliefs and practices (Ausker, la Cour, Busch, Nabe-Nielsen, & Pedersen, 2008). However, it is

questionable to what degree the coping perspective is successful at uncovering the influence and

impact of religion during adjustment to illness and other major negative life events. Being a part of

the cognitive tradition in psychology, general coping theory relies on the assumption that coping is

a mainly conscious process in which the individual more or less rationally appraises the nature of a

given stressor and which coping resources to apply. But as found in Study 4, the nature of religion

appeared undefined and tacit to many participants, and very difficult to access at a solely cognitive

level when trying to explain how it became important during negative events in meaning-making

and adjustment. Furthermore, given the private nature of religion to individuals in secular societies,

a questionnaire may not be the appropriate way to access this sensitive topic. The majority of Danes

may not be used to expressing themselves in very manifest ways about religion and their personal

beliefs. Some of the interviewees even stated that they became suspicious as to whether the research

team had a hidden agenda to missionize through the Brief RCOPE because it was so explicit about

religious matters. As such, religious coping as operationalized in the Brief RCOPE must be

understood as a contextual phenomenon in the U.S. but not very central to individuals in secular

societies. It is likely that the Brief RCOPE may cause trouble for some individuals in the U.S. too,

as individualization and privatization of beliefs is becoming more commonplace there as well.

Finally, the theory of coping emphasizes the importance of the individual being active in problem

solving. However, in some incidents it may be de-motivating to engage in active problem solving

like suffering from chronic pain, grieving over the loss of a child, or being terminally ill, because

the problem cannot be solved! It may be impossible to gain control or there may be little meaning to

make. In these incidences the individual is likely to score high on “religious struggles”. Thus, the

coping functions of religious coping presumes the individual will succeed if he engages actively in

positive coping strategies of meaning-making, gaining control, seeking support and intimacy or

transforms spiritually. But, he copes negatively if he bargains with God, cannot make sense of his

situation or does not grow spiritually. As such, the theory of religious coping could be perceived as

normative prescribing the ‘good way’ of coping. Sometimes, however, ‘none’-coping may be the

best strategy, like accepting the lack of control or ceasing to try to make sense of a trauma are not

necessarily negative in nature. As suggested by Schottenbauer, Rodgriguez, Glass, and Arnkoff

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(2006) in situations with a high amount of control it may indeed be viewed as maladaptive to

engage in passive religious deferral (handing over the control to God), but in situations with low

control it may just be the exact right thing to do for people whose beliefs rely on God. The

dichotomized way of describing religious coping functions (good versus bad coping) may result

from an interest in evaluating the effect of coping in terms of outcome, rather than revealing the

process of religious coping. Revealing the process of religious coping, however, calls for an

increased focus on the social and cultural context in which the individual is situated. As such the

theory on religious coping must also be understood as a “child of its time” developed in the

cognitive wave of the psychology in which social and cultural influence was mainly seen as an

external influence on internal processes (Klaassen, Graham, & Young, 2009). As stated by Belzen

(2010): “Ideas never come out of the blue…different cultures lead to different theories, and so do

different periods of time within the same culture” (p. 18). Although the religious coping theory

provides a useful framework for studying religion, it is one perspective of many on how religion

may become involved during major negative life events.

Integrating a hermeneutical approach to religious coping?

There is much more to say and learn about the complex processes of religious beliefs, individual

differences, social relations, adjustment, and well-being than can be revealed by taking a positivistic

perspective applying mainly quantitative methods. As stated by Gorsuch, measurement has been

both a “boon and a bane” to the psychology of religion, because it has helped the discipline to

become more legitimate in mainstream psychology, but at the expense of a true explanation of

religion (Gorsuch, 1984; Hood, 1999). Historically the psychology of religion has been separated

into functional and substantive approaches to religion (Wulff, 1997; Nelson, 2012). That is,

researchers have distinguished between “what religion is” (the substance) and “what religion does”

(the function) resulting in very different approaches and methodologies applied. The substantive

approach has mainly relied on qualitative, hermeneutical methodology, whereas the functional

approach has mainly applied quantitative methodology (Hood, 1999). However, this distinction is

counter-productive as it overlooks potential causal explanations of how and why religion becomes

involved and potentially helpful or harmful under certain circumstances to different individuals. It

seems as fairly reasonable to assume that the substance of religious and spiritual beliefs is crucial

for the function in terms of adjustment and well-being, and that the substance of religious and

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spiritual beliefs is affected by the individual’s dispositions, social relations, and surrounding

narratives and language available in the culture. Future empirical and theoretical work could benefit

from taking a hermeneutical-phenomenological approach applying narrative, qualitative methods in

investigating religion and coping as multifaceted processes unfolding in the concrete life story of

the individual and his surroundings (Ganzevoort, 1998; Nelson, 2012). McGuire (2008) proposes to

examine and understand religion as much more than pure cognitive content, but the daily practices

of body, mind, emotion, and spirit, a so-called “lived religion”, and calls for anthropological

methodology to come closer to the content and importance of religious experience. Others have

called for a cultural psychology of religion aiming at highlighting the cultural embedment of

religion even more and moving away from an individual focus (Belzen, 2010; Hood, 2010).

Contextual action theory has also been proposed as an integrative framework for studying religion

and spirituality taking into account human emotional, cognitive, behavioral, and relational processes

and drawing on hermeneutics, phenomenology, and narrative studies (Klaassen, Graham, & Young,

2009). Although this kind of research has limited generalizability in a positivistic manner, the

psychology of religion may generate more genuine and useful theories and empirical work for the

involved individuals, and may also benefit from integrating perspectives from theology, philosophy

and the sociology of religion. However, acknowledging the favor of quantitative methodology in

the psychology of religion, future studies should aim at developing context-specific measures

reflecting the language, narratives, and concepts available to the population one wants to study.

This could be done by applying qualitative methodology to generate concepts and categories of

religious and spiritual beliefs and functions in a particular setting. Moreover, the most important

point in research is to acknowledge that, what can be said about a specific phenomenon is limited to

the perspective and methodology used, and that a specific operationalization of a given phenomena

is just one aspect of the complexity of the real world that may be inflicted by the researcher’s pre-

assumptions and biases.

Generalizabilty

As such, the scope of the results presented in this thesis is admittedly also limited due to the

methodology and instruments applied. With regard to the “knowing” dimension, the Brief RCOPE

does not totally cover the often tacit content of religious orientations among Danes and needs to be

extended or reformulated to cover new forms of religious and spiritual beliefs. In relation to “doing”

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and “being”, the measure of Brief RCOPE is likely to draw a skewed picture of how religiosity is

involved in coping when asking people to reflect on a rather complex issue on command, and

because it does not take into account the process of religious coping. Although longitudinal studies

may come closer to revealing the process of religious coping, other methodologies could be applied

too. Furthermore, the coping perspective operationalised through questionnaires is considered too

narrow a focus to take if one wants to explore how and why religion becomes involved during

major life events, because these processes are often unconscious and not directly accessible to the

individual. Moreover, due to the socio-demographic characteristics of the samples included in this

present thesis the generalizability of the results is limited to elderly, relative low-SES individuals

living in secularized societies. Since this present thesis only included lung disease patients results

may not apply to other patient groups. The relative low response rate of especially the lung disease

sample calls for caution when interpreting the results, as selection bias may have occurred; it is

likely that mainly lung patients in better physical condition did participate. The focus on religious

issues is likely to have caused some patients and control participants to decline from participating,

and the samples may have an overrepresentation of religiously oriented Danes. Finally, due to the

cross-sectional design it was not possible to examine any causal associations between religious

coping, individual characteristics, negative events, or QoL.

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Conclusion: A soda-analogy?

This summer (2013) a soda- company is running a campaign, selling their product with different,

individual names tagged on the front of each soda. It is therefore possible to go into any given shop

and find a product directed personally to you almost anywhere in the world. Funny idea – and

certainly successful in obtaining what the company wants – to sell more of their products. In

quantitative research we as researchers are successful if we gain a high respondent rate and are able

establish evidence to support (or reject) our hypotheses. To obtain that goal we do our best to direct

the form of our product to our target group. In studying religion and health we should, as suggested

by Hall, Koenig, and Meador (2008), make scales on religion in such a way that the individual is

able to read his own religious beliefs into the questionnaire (the personal label). As with the soda,

we assume the product to contain the same key features (sugar, carbon dioxide, water and some

kind of flavor additive) making it comparable all over the world. Likewise with religious coping

scales, we expect them to contain some kind of relationship to the sacred. Furthermore, we assume

that certain circumstances, for example hot weather or social gatherings make people more likely to

buy a soda. In the analogy with religious coping, we assume that highly stressful, challenging,

and/or life- threatening situations make people turn to religion as a coping resource. Finally, we

assume that the product is able to serve different purposes under different circumstances – the soda

is able to quench thirst, add “a little something” to the social gathering, make the individual look

prestigious when choosing this particular brand etc. In the analogy with religious coping, we

assume religious coping to serve the functions of gaining control, finding meaning, feeling intimacy

and support, and obtaining spiritual transcendence during negative events. However, we are only

successful in selling our product if we address it towards individuals living in societies where

buying a soda is legitimate, makes sense, and fulfills the needs of the individual. But what if the

society does not approve of this given product? Or what if the consumer does not prefer exactly this

product – what if he buys another product? Or he would like to mix it himself? Maybe some of the

key features are the same – but the relationship between them differs. What can we then say about

the content? Or why he prefers this taste? Or what function it serves? And what about the

experience? Or the effect of the product? If the “homemade” version contains less sugar maybe the

costumer gains less weight, but due to the amount of caffeine it may have some other side effects?

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Are we able to detect these differences in experience or effect if we assume the form, the content,

and the function of our product to be the same all over the world?

In this present study, a “product” (Brief RCOPE), which was developed in the U.S. was applied

with a couple of changes to direct it more personally to the target group with the assumption that

people in need would “consume” or respond positively to the form (the questionnaire) reflecting the

given content (religion as coping strategy). Results suggested that some consumed the product and

that some effects were detectable. Positive religious coping, although not as prevalent as found in

U.S studies, was more prevalent than negative religious coping. Furthermore, LDPs were found to

report more positive religious coping than participants dealing with less severe negative life events,

partially supporting the hypothesis that people in need may turn to religion. No effects were found

between positive religious coping and QoL, whereas negative religious coping was found to have a

negative impact on QoL among LDPs only. Moreover, it was detected that reporting negative

religious coping was associated with higher levels of neuroticism and congregational support.

However, a qualitative study suggested that the form and content of the Brief RCOPE was not a

perfect match to the target group. Some chose not to respond because it was not perceived as

directed to them, others tried to communicate their non-belief or dissatisfaction with the

questionnaire by responding in an inadequate way. A few were able to answer adequately, while

others were unable to explain why they had responded as they had because their beliefs were not

very explicit. Ways of engaging in religious and spiritual beliefs that were not covered by the Brief

RCOPE were found, suggesting that the phenomenon of religious coping as found in the United

States is context specific and not comparable with more secular societies when applying the Brief

RCOPE. Furthermore, it is questionable whether the theory of coping operationalized through

quantitative methods is the appropriate way of investigating how beliefs become important and

potentially protective or harmful to the individual facing major life challenges in general – and in

secular societies in particular. The theory of coping assumes a rather conscious way of relating to

beliefs and adjustment during crisis. However, as suggested by Rosen (2009) and found in Study 4,

in a society dominated by privatization and individualization of experience, personal beliefs are

often tacit and applied and developed ad hoc. Therefore it may be difficult to measure beliefs and

detect true effects at a solely cognitive level by questionnaires. Furthermore, few individuals in

secular societies may think they involve religion actively in coping, as is the underlying assumption

of Brief RCOPE. Religion could be approached as “lived” as suggested by McGuire (2008).

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Therefore, narrative methodology is relevant as a way to detect patterns of functions and

dysfunctions in meaning-making and ascertain how it becomes important to the individual in terms

of adjustment, and could potentially give rise to new context-specific measures of religion and

spirituality in secular society.

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Perspectives and future studies

Clinical implications

Although many things are up for discussion regarding methods and measures chosen in this present

thesis, it was found that some forms of religious coping were negatively associated with QoL

among medically ill LDPs. This finding is in line with a range of international studies, and must be

taken seriously, because something is at stake for patients experiencing religious struggles, and

most likely also struggles of a spiritual and existential kind. The results are relevant to health care

personnel, especially nurses, who are obligated to provide spiritual care among patients. An

ongoing but quiet debate about spiritual care among Danish nurses indicates that many nurses

express uncertainty about how to provide this, although it is recognized as an important topic

(www.aandeligomsorg.dk). International as well as Danish studies suggest that this may be due to

lack of time and skills, lack of vocabulary, personal issues surrounding death and dying, as well as a

misunderstood consideration of the patient’s privacy (Abbas & Dein, 2011; Christensen & Turner,

2008; Dam, Johansen, Jørgensen, & Winck, 2006). However, international studies suggest that it is

important to approach the individual’s relation to spirituality or religion in order to be in a better

position to prevent or intervene on potential spiritual struggles. A growing body of intervention

studies is emerging (see Pargament, Mahoney, & Shafranske, 2013 for a comprehensible overview

of the field). The relevance of examining the question: “For whom do religious and spiritual beliefs

become a potential burden?” should be taken seriously by Scandinavian health care systems too,

and methods for discovering the “red flags” of potential spiritual distress are needed. However,

results from this present thesis should be interpreted as preliminary regarding the ability for

deducing clinical implications. More research on religious, spiritual, and existential needs and

resources among different medical samples are needed from secular societies, and it is too early to

suggest specific screening tools for religious or spiritual struggles or applying spirituality-integrated

interventions in Denmark. The question about who is best suited to approach the religious, spiritual,

and/or existential needs remains unanswered. The bio-medical model of health care seems to

dominate the Danish health care system as very few Danes expect to receive spiritual care during

end-of-life care (PAVI, 2013). As suggested in Study 1, only a minority called for the opportunity

to talk to a health care professional about existential and spiritual concerns. This finding is

supported by a study conducted by Ausker, la Cour, Busch, Nabe-Nielsen, & Pedersen (2008)

among 480 hospitalized Danes, where only 1% of the patients indicated that they would like to talk

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to a doctor and 11% would like to talk to a nurse about existential or religious concerns. However,

according to the study conducted by PAVI (2013) younger Danes are more likely to expect the

Danish health care system to address spiritual needs, and in the future patients may place higher

demands on a holistic approach to the individual. Ausker, la Cour, Busch, Nabe-Nielsen, &

Pedersen (2008) also found that younger patients (<36 years) were more likely to have had a

conversation about existential or religious topics after their hospitalization (34%) compared to 13%

of the oldest (>56 years) patients. This may of course reflect that more existential issues are at stake

for younger patients. However, the study also found younger patients to report more religious

activity and religious/spiritual beliefs than older patients, indicating that future generations may be

in need of increased focus on existential health. Furthermore, a qualitative study conducted among

12 terminally ill patients receiving end-of-life care at hospice suggested that especially patients

having difficulties expressing themselves about religious or spiritual matters experienced a need for

the nurse to attend to spiritual issues to come to terms with unresolved conflicts of personal beliefs

(Nielsen, 2005). Courses directed at nurses and doctors on communication skills and touching

difficult existential issues are becoming more commonplace in Denmark and represent one way to

enable health personnel to better detect possible religious, spiritual, and existential needs and

struggles. However, there may be a particular need to work with the reluctance to touch spiritual or

religious issues among nurses and doctors. Often local or hospital chaplains, rabbis or imams are

referred to if the question at stake exceeds the competence and resources of the health care

personnel and, as such, represents an important resource in the health care system. Given the

changing religious and spiritual beliefs among people in secular societies, however, it is important

to have other competences to refer to, like a conversational partner with a philosophic or secular

humanistic background, a spiritual coach, or psychologists to accommodate individuals with secular

or spiritual views of life.

Research implications

The findings of this thesis touches the surface of how religious and spiritual orientations become

involved in and affect adjustment and well-being among Danes facing lung disease and other major

life events. However, much more waits to be explored! Hopefully this thesis it gives rise to other

studies aiming at revealing more of the complex picture of how religious, spiritual, and secular-

existential worldviews are involved in and impact the lives of individuals facing major and minor

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life events. Future studies should include younger participants to investigate whether religious,

spiritual, and existential struggles are becoming more commonplace, affecting health and well-

being in line with the hypothesis that due to increased secularization coherent worldviews are

lacking and may affect the ability to adjust adequately to major life events (DeMarinis, 2008; la

Cour, 2008). Furthermore, studies should develop and apply measures that are sensitive to the

specific worldview of the individual and be careful not to enforce certain ideas and concepts of

religious, spiritual, and secular existential orientation on the research participant (la Cour & Hvidt,

2010). Qualitative methods or mixed methods design are called for, since they may reveal more in-

depth information about the complicated processes of meaning-making, adjustment, and well-being

during major negative events and prevent simplistic conclusions on the associations between life

orientation and health. Furthermore, studies should take into account the impact of individual

differences in the adjustment to major negative life events, and apply more sophisticated statistical

analyses to test possible moderators and mediators of religious and spiritual coping. Finally, studies

in Denmark should investigate different medical samples, at different stages of illness progression,

and follow them over time to generate more genuine results of the impact of religious, spiritual, and

existential concerns among people living in secular societies during illness.

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64

Appendix

Measures included in the questionnaire packages and measures used in the four studies

Dimension Measures Lung

patients

Control

group

Qualita-

tive

study

Study 1 Study 2 Study 3 Study 4

Da

te

ID number X X X

Date of answering the

questionnaire

X X

So

cio

-dem

ograp

hic

in

form

ati

on

Gender X X X X X X

Age X X X X

Education

Primary School

Lower secondary school

Vocational school

High school, upper.

Sec.school etc.

Further education medium

lengt

Further education extended length

X X X X X

Marital status

Married or living together

Single (divorced or

separated)

Single (widow)

Single (never married)

X X X X X

Kids (boys and girls) X X X X

___________________________________________

65

Dimension Measures Lung

patients

Control

group

Qualita-

tive

study

Study 1 Study 2 Study 3 Study 4

Kids living at home (boys

and girls)

X X

Work situation before

illness

Self-employed

Full-time

Part-time

Umemployed (involuntary)

Umemployed (voluntary)

Pensioned/early retirement

Sick leave

X

Current work situation

Self-employed

Full-time

Part-time

Umemployed (involuntary)

Umemployed (voluntary)

Pensioned/early retirement

Sick leave

X X X X X

Annual income (household

and your own)

<200.000

2-300.000

3-400.000

4-500.000

5-600.000

X X X X X

___________________________________________

66

Dimension Measures Lung

patients

Control

group

Qualita-

tive

study

Study 1 Study 2 Study 3 Study 4

6-700.000

Volunteer work during the

last 12 months (relief work,

member of boards etc.)

X (2

items)

X (1

item)

X X

Dairy over the course of the

illness

X

Smoking X

Dela

y

Patient-delay og system-

delay (9 items)

X

Illn

ess

an

d c

o

morb

idit

y

Type of lung disease (COPD; cancer, other)

X X X

Treatment (Operation, chemo, other, don’t know)

X

Purpose of the treatment

(improve QOL, healing, life-sustaining)

X

CCI (Physical co morbidity) (Charlson et al., 1987)

X X X X

Qu

ali

ty o

f li

fe

FACT-G, 30 items

(physically, social, emotional, functional well-being) 21

items in control version

(Cella et al., 1993)

X X X X

FACIT Sp, 12 items

(Existential well-being) 10

items in control version (Peterman et al., 2002)

X X X X

Co

pin

g CBI-14 items (self-efficacy)

10 items in control version

(Merluzzi et al. 2001)

X X

___________________________________________

67

Dimension Measures Lung

patients

Control

group

Qualita-

tive

study

Study 1 Study 2 Study 3 Study 4

Benefit-finding, 17 items

(Tomich & Helgeson, 2004)

X X

Positive subscale Brief

RCOPE, 9 items (Pargament

et al. 1998)

X X X X X X

Negative subscale Brief

RCOPE, 7 items (Pargament et al, 1998)

X X X X X X X

Positive subscale Brief

SCOPE, 9 items

X X X X

Negative subscale Brief

SCOPE, 7 items

X X X X

Other religious coping

strategies (free to write)

X

Co

mp

lem

en

tary

an

d A

ltern

ati

ve

Treatm

en

t (C

AM

)

Definition of CAM (what is

seen as CAM)

X X

Attitude towards the different CAM types

X X

Attitude towards CAM in general, 14 items

X X

Consumption of CAM X X

Consumption before and after lung diagnosis

X

Consumption frequency X X

Satisfaction with CAM X X

Experienced effect of CAM

on QOL

X X

Experienced effect of CAM on illness

X X

Motives for use of CAM (10 X X

___________________________________________

68

Dimension Measures Lung

patients

Control

group

Qualita-

tive

study

Study 1 Study 2 Study 3 Study 4

items)

Fait

h a

nd

sp

irit

uali

ty

Beliefs:

(1) A believer – beliefs in

God

(2) A believer – beliefs in a

spiritual power

(3) A believer – does not

believe in God/spiritual but

in shared cultural/historical

community

(4) A non-believer

(5) An atheist

X X X X X

Church affiliation X X

Beliefs:

Believing person

A non-believing person

A convinced atheist

A spiritual person

X X

Assurance of conviction X X

Religious or spiritual

experiences (yes-no) X (2

items)

X (1

item)

Denomination (Christian,

Muslim, Jew, Hindu, Buddhist, Atheist, Other,

Don’t know)

X X X X

Member of the Evangelical Lutheran Chuch

X X X

Member of another faith community

X X

Church attendance or other

religious meetings

X X X X X

Frequency - other religious

practices (prayer, meditation,

scripture reading)

X X X X X

___________________________________________

69

Dimension Measures Lung

patients

Control

group

Qualita-

tive

study

Study 1 Study 2 Study 3 Study 4

Social support from members

of a congregation

X X X X X

Intercessory prayer since

diagnosis/within the last 12

months

X X

Religious/spiritual or

existential concerns since diagnosis/within the last 12

months

X X

Need to talk to a doctor/nurse about religious, spiritual or

existential concerns

X X

Faith in God or a spiritual

force (2 items)

X X X

Experienced importance of faith on QOL

X X

Experienced importance of

faith on illness

X

God concepts - 11 items

(Schaefer & Gorsuch, 1992)

X X

Experienced importance of

faith in coping with major

challenges

X

Intrinsic religious motivation

10 items (Hoge, 1972)

X X

Em

oti

on

s PSS (perceived stress) 10

items (Cohen &

Williamson, 1988)

X

BDI (depression) 21 items

(Beck et al., 1996)

X

Perso

na

-

lity

sca

les Absorbtion - 15 items

(Tellegen & Atkinson, 1974)

X

Alexithymi – 20 items

(Parker et al., 2003)

X

___________________________________________

70

Dimension Measures Lung

patients

Control

group

Qualita-

tive

study

Study 1 Study 2 Study 3 Study 4

RAAS (Attachment) – 18

items (Fraley et al., 2000)

X X X

Social desirability – 12 items

(Crowne & Marlowe, 1964)

X

NEO-FFI (personality traits)

62 items (Costa & McCray,

1992)

X X X

Lif

e e

ven

ts LRE (stressful life events) 8

items (Henderson et al.,

1981)

X X X

Influence of negative life

events on QOL

X X X

Paper 1

The International Journal for the Psychology of Religion, 23:188–203, 2013

Copyright © Taylor & Francis Group, LLC

ISSN: 1050-8619 print/1532-7582 online

DOI: 10.1080/10508619.2012.728068

Religious Coping and Quality of Life AmongSeverely Ill Lung Patients in a Secular Society

Heidi F. PedersenDepartment of Psychology

Aarhus University, Denmark

Kenneth I. PargamentDepartment of Psychology

Bowling Green State University

Christina G. PedersenDepartment of Psychology

Aarhus University, Denmark

Robert ZachariaeDepartment of Oncology

Aarhus University Hospital, Denmark

This survey study investigated the prevalence of religious beliefs and religious coping and possible

associations between religious factors and quality of life (QoL) among a group of severely ill lung

patients (lung cancer and chronic obstructive pulmonary disease) in Denmark (N D 111). Almost

two thirds (64.8%) reported having some belief in God and/or a spiritual power. Patients who

reported believing in God and patients who believed in God and a spiritual power reported better

QoL than patients who reported that they believed in a spiritual power only. Religious coping was

prevalent; for positive religious coping strategies, those used from least to most often, respectively,

were invoked 15% to 37% of the time; for negative religious coping strategies the percentages

were 3% to 16%. Negative religious coping was associated with lower QoL (ˇ D �0.320, p <

.006), whereas no associations were found between positive religious coping and QoL. Results are

discussed in relation to the cultural context of secularized societies like the Scandinavian countries.

Spirituality and religion have received increased attention in health research (Cobb, Puchalski,

& Rumbold, 2012; Masters & Hooker, 2013). A number of studies have linked religion andspirituality with the development and course of a variety of diseases (Koenig, King, & Carson,

Correspondence should be sent to Heidi Frølund Pedersen, Department of Psychology, Aarhus University, 8000

Aarhus C, Denmark. E-mail: hefpe@psy.au.dk

188

COPING AND QUALITY OF LIFE FOR LUNG PATIENTS 189

2012). In addition, indices of religiousness have been found associated with lower mortality

(McCullough, Hoyt, Larson, Koenig, & Thoresen, 2000) as well as with various measuresof well-being and quality of life (QoL) (Krupski et al., 2006; Mytko & Knight, 1999). In

general, religion and spirituality appear to be associated with improved health, although some

studies have found ambiguous results indicating at least some negative effects of religion and

spirituality on well-being and health (for a comprehensive review, see Cobb et al., 2012).

Research in this domain has so far been limited in some important respects. Perhaps mostimportant, there are problems of measurement. Religion and spirituality have most often been

assessed with global one-dimensional constructs, for example, frequency of church attendance

(Hill, 2013; Hill & Pargament, 2003). Such measures are unable to pinpoint the possible “active

ingredients” in religion and spirituality that promote or impair health and well-being, because

religion is multidimensional (Stefanek, McDonald, & Hess, 2005).

Researchers have therefore called for more specific, theory-based approaches to investigatingand measuring religiousness and spirituality (Paloutzian & Park, 2013; Park & Paloutzian,

2013). Some advances have been made, particularly in the area of religious coping research.

Growing out of the transactional coping theory of Lazarus and Folkman (1984), studies of

religious coping focus on the variety of ways in which religion and spirituality are expressed

in the efforts of people to understand and deal with major life stressors. Pargament (1997) de-scribed religious coping as multidimensional (e.g., cognitive, behavioural, affective, relational),

multipurpose (e.g., meaning making, intimacy, control, comfort, closeness with God), and

multivalent (i.e., potentially helpful or harmful). Research on religious coping attempts to take a

focused, differentiated look at religious coping strategies, which include both positive religious

coping (e.g., seeking spiritual support) and negative religious coping or religious struggles(e.g., anger at God). Empirical studies have shown that positive religious coping methods are

generally related to more favourable health outcomes among patients with severe illnesses, such

as cancer, heart disease, and HIV/AIDS (Ano & Vasconcelles, 2005), although there have been

some exceptions to this pattern of findings (Hills, Paice, Cameron, & Shott, 2005). Conversely,

negative religious coping have been found associated with increased distress, lower well-being,

and higher mortality among severely ill patients (Pargament, Koenig, Tarakeswar, & Hahn,2001; Sherman, Simonton, Latif, Spohn, & Tricot, 2005; Zwingmann, Wirtz, Müller, Körber,

& Murken, 2006).

A key limitation to these studies is that the majority of research has been conducted within

the theistic context of North America and with largely Christian participants. It is unclear how

well the research paradigms and methods developed in research with North American Christiansapply to other, less religious contexts. Some researchers have, for example, argued that this type

of research cannot be generalized to secularized countries (e.g., European societies; Salander,

2006). The present study examined the prevalence of religiousness among people dealing

with significant medical illness in Denmark and considers the degree to which indices of

religiousness and religious coping are predictive of the patients’ QoL.

SECULARIZATION?

Sociologists continue to debate whether “secularization” adequately describes the changing role

of religion in Europe, as religion in European countries displays different patterns of change.

190 PEDERSEN ET AL.

Furthermore, empirical studies suggest that about 42% of the European population may fall

into the category of “fuzzy fidelity,” that is, people who are neither traditionally religious norcompletely secularized (Voas, 2009). Denmark has been named one of the most secularized

countries in the world (Zuckerman, 2008). Approximately 51.8% of Danes are estimated to

be “fuzzies,” 28.7% secular, and only 19.5% very religious (Storm, 2009). This finding is

supported by other sociological studies suggesting that although more than 80% of Danes are

members of the National Church, only 2% attend church services regularly (Højsgaard & RavnIversen, 2005). Through interviews with 150 Danes and Swedes, Zuckerman (2008) arrived at

a picture of Danes as Cultural Christians, who attend church for social events a few times a

year and fail to hold or practice any traditional Christian beliefs. In fact, Zuckerman suggested

that religion is simply a nonissue to Danes.

RELIGIOSITY AND HEALTH IN DENMARK

But is religiousness largely irrelevant to Danes? A few studies have provided indirect evidence

to suggest that this may not be the case, especially when illness strikes. In a survey of

a cohort of 3,128 Danish women treated for primary breast cancer, 83% reported havingeither unambiguous or at least a little faith in “God or a higher spiritual being,” which

is somewhat larger than what one finds in the general Danish population (65%) (Pedersen,

2009). In another study of 480 hospitalized Danish patients, those with severe illnesses also

reported more existential, spiritual, and religious practice activity; this tendency was higher for

younger patients (<36 years) (la Cour, 2008). These results suggest that a medical crisis mayelicit religious and spiritual beliefs and practices even among people in the most secularized

societies. Such findings have been explained by the “religious coping mobilization” effect

(Koenig, Pargament, & Nielsen, 1998; Pargament, 1997). That is, the crisis of illness prompts

greater reliance on religious resources or greater religious struggle as individuals are faced with

new challenges.

Elaborating on this process of religious coping mobilization, Pargament (1997) noted thatpeople appear to have different orienting systems, that is, cognitive schematas shaped by

previous experiences that help them navigate and make sense of the world. Major life crises,

such as severe illness, may be more likely to activate religious beliefs and practices as a way of

coping with stressful events, even if religion makes up only a minor part of the orienting system.

This theoretical perspective may also apply to Danes who, although not very religious, are nottotally removed from religious expression. Studies describing the prevalence and influence of

belief in God in Denmark indicate that the number of Danes believing in a deity is similar to

the level reported 50 years ago, although it has been argued that beliefs have shifted from a

traditional view of an active and involved God to more ill-defined images of a distant, divine

entity (Lüchau, 2005). It is important to recognize, however, that people who are either nottraditionally religious or totally secular (i.e., fuzzies) may also find it more difficult to mobilize

religious or spiritual beliefs and practices because they lack the foundation of a strong religious

belief system or context to support these beliefs.

Religious orienting systems that lack integration and coherence may also be more easily

shaken by major crises, leading to religious struggles and poorer adjustment in turn (Exline

& Rose, 2013; Gall, Kristjansson, Charbonneau, & Florrack, 2009; Pargament, 2007). Among

COPING AND QUALITY OF LIFE FOR LUNG PATIENTS 191

Danes manifesting lower levels of consistent, integrated religious and spiritual beliefs, illness

could therefore be particularly likely to trigger existential, spiritual, and religious strugglesand subsequent distress. On the other hand, it could also be argued that groups not bound to

specific religious systems of belief and practice (i.e., “fuzzies”) may be able to adapt more

flexibly than religious individuals to stressful situations (la Cour, 2005).

OBJECTIVES

The present study was designed to explore the assertion that religiousness is largely irrelevant to

the lives of people in secularized societies. More specifically, we investigated the prevalence ofreligiousness and positive and negative religious coping among a group of patients from a highly

secularized country (Denmark) with severe, chronic lung diseases (i.e., lung cancer and chronic

obstructive pulmonary disease [COPD]). We hypothesized that because of the serious nature

of these lung diseases, a substantial proportion of patients with lung disease would manifest

signs of religiousness and make use of religious coping methods. We also hypothesized thatthe outcomes on measures of religiosity, spirituality, and religious coping would be associated

with QoL. It was predicted that positive religious coping would be associated with better QoL

and that negative religious coping would be associated with poorer QoL.

METHODS

Participants

The sample included 62 men and 49 women between the ages 26 and 105 years (M D 65.2,SD D 10.2) newly diagnosed with chronic lung diseases, that is, lung cancer (39.1%) and

COPD/other lung diseases like bronchiecstasia (60.9%). More than two thirds (68.5%) of the

patients had less than 11 years of education, 72.7% were married, 67% were retired, and

39.4% reported an annual income below USD$35,700, which according to the Organisation

for Economic Co-operation and Development (OECD) standards is perceived as relative povertyin Denmark (OECD, 2009). Thus, this sample was considered relatively low socioeconomic

status (SES).1

Procedure

Five respiratory medicine clinics (four on the main peninsula of Jutland and one at an island inthe eastern part of Denmark) participated in the project. From October 2008 to October 2010,

patients being diagnosed with a severe chronic lung disease were informed about the study by

the medical staff and asked to give their informed consent to participate. Patients were asked

to complete the questionnaire shortly after their diagnosis and return it to the research team by

mail. Those who did not return the questionnaire within 2 weeks received a single reminder. In

1Detailed sociodemographic data were collected and are available from the author, but analyses indicated that these

data did not affect the outcomes on the key dependent measures and are therefore not subsequently referred to.

192 PEDERSEN ET AL.

all, 514 received the questionnaire and 120 responded (response rate D 23.4%). Nine patients

were excluded because of insufficient data, resulting in a final sample of 111 patients. Theproject was evaluated by the Committee on Biomedical Research Ethics in Denmark.

Measures

The present study was part of a larger study on QoL, complementary alternative treatment,

and religiosity among severely ill chronic lung disease patients in Denmark, and measures

in the questionnaire package included medical information, information on psychosocial vari-

ables such as self-efficacy, QoL, personality traits, religious measures, and information about

complementary and alternative treatment. In the present study, the following measures wereused.

Sociodemographic information. Sociodemographic information included age, gender,

marital status (dichotomized into married/cohabiting and widowed/divorced/single), number

of children, highest education level (dichotomized into “Low education” D 7–10 years and

“High education” >10 years), current work situation (dummy coded into “Part-time/sick leave,”

“Retired,” and “Full time”) and SES.

Medical information. Information about the patients’ medical condition was retrievedfrom the Danish Lung Cancer Registry and from the records of the participating respiratory

medical clinics. The variables included diagnosis and date of diagnosis. Self-reported comor-

bidity was assessed with an adapted version of the Charlson Co-morbidity Index (Charlson,

Pompei, Ales, & MacKenzie, 1987; Christensen et al., 2009).

Health-related QoL and existential well-being. A Danish version of the Functional

Assessment of Cancer Therapy Scale (Cella et al., 1993) was used to measure overall QoL.This scale is a standardized questionnaire developed for cancer research and contains 30 items

covering the patients’ physical, emotional, social, and functional well-being. Responses are

given on a 5-point Likert scale ranging from not at all to a lot. In addition, existential well-

being was measured using the FACIT-Sp (Peterman, Fitchett, Brady, Pharm, & Cella, 2002), a

12-item questionnaire covering the patients’ sense of meaning, purpose and peace in life, andability to find comfort in spiritual convictions during illness. In the present sample, the internal

consistency (Cronbach’s alpha) of the total QoL score was 0.95 and ranged from 0.77 to 0.90

for the subscales.

Beliefs and religious identifiers. Patients were asked two questions concerning their

religious beliefs: whether they believed in “God” and whether they believed in a “Spiritual

power,” each with the response options of “yes, “maybe,” or “no.” Participants with no belief ineither God or a spiritual power were coded as “Non-believers.” Participants having unambiguous

or little faith (Yes C Maybe) in a spiritual power only were coded as “spiritual believers.”

Participants having unambiguous or a little faith (Yes C Maybe) in God only C God and a

spiritual power were coded as “God-believers.” Patients were also asked to identify themselves

as either “a believing person,” “a spiritual person,” “a nonbelieving person,” and “a convinced

atheist.” “Nonbelieving” patients and “Atheists” were coded as “nonbelieving patients.”

COPING AND QUALITY OF LIFE FOR LUNG PATIENTS 193

Religious behavior, thoughts and needs. Public religious behavior was measured by

a single item about church attendance and/or attendance at other religious meetings. Privatereligious behavior was measured by a single item about the frequency of prayer, meditation,

and/or scripture readings. Response options to these measures were 5-point Likert scales

ranging from never to every day. Participants were also asked if they since their diagnosis

had experienced more frequent religious thoughts (e.g., thoughts about the existence of God),

spiritual thoughts (e.g., thoughts about the existence of a spiritual power), and/or existentialthoughts (e.g., thoughts about finding meaning, purpose and peace), and whether they had

experienced the need to consult a professional about these religious, spiritual, and/or existential

thoughts. Response options to these measures were “yes” or “no.”

Congregational support. This construct was measured by a single item: “To what degree

do you receive support from your fellow believers” on a 5-point Likert scale with response

options ranging from not at all to a great deal.

Religious coping. Positive and negative religious coping was measured by the Brief

RCOPE (Pargament, Smith, Koenig, & Perez, 1998), a 14-item measure with two subscales:

Positive Religious Coping and Negative Religious Coping. Positive Religious Coping measures

the degree to which the patients cope with illness by looking to God for comfort and support,

and Negative Religious Coping measures to which degree the patients interpret their illness asa punishment or abandonment by God. The response format is a 4-point Likert scale ranging

0 (not at all), 1 (to some degree), 2 (a lot), and 3 (a great deal). The questionnaire was

translated into Danish by three independent translators, and the translations were discussed until

agreement was obtained. A preliminary qualitative pilot study conducted by the research team

(unpublished) revealed potential problems with using the scales among Danish nonbelievers.

Results indicated that nonbelievers may score higher on negative religious coping as a way toexpress their disbelief rather than religious struggle. For example, an item like “Questioned the

power of God” may be answered with “a great deal” by a nonbeliever, not because he or she

has religious doubts but simply because the person does not believe in God’s powers. Thus,

the item “Questioned the power of God” was omitted, and furthermore nonbelievers were

left out of the analyses concerning associations between religious coping on QoL. Internalconsistencies (Cronbach’s alpha) were 0.93 for the Positive Religious Coping subscale and

0.60 for the Negative Religious Coping subscale in the present sample. Among “believing”

and “spiritual” patients, Cronbach’s alphas were 0.92 for Positive Religious Coping and 0.71

for Negative Religious Coping.

Statistical Analysis

Mean substitution was used to handle missing data on continuous variables in accordance withSchafer and Graham (2002). This procedure is adequate and preferable to procedures such

as listwise deleting or scale mean substitution. Means and standard deviations of religious

coping were explored. Religious coping was positively skewed, and nonparametric as well

as parametric tests were applied when appropriate. Kruskal–Wallis tests were conducted to

determine possible differences in religious coping between “believing,” “spiritual,” and “non-

believing” patients. Bivariate, unadjusted regressions and one-way analyses of variance were

194 PEDERSEN ET AL.

conducted to explore associations between demographic factors, medical factors, religiousness,

religious coping, and overall QoL. Finally, hierarchal regression analyses were conducted todetermine the associations between religious coping and QoL while adjusting for demographic,

medical, and religious factors. Prior to testing a final model, three independent regression

models were conducted to determine which variables should be included in the final regression

in order to prevent overfitting. The first model consisted of demographic variables: marital

status, education, annual house income, and current work situation. To prevent underfitting,the significance level in the first three independent regression models was set at p < .10, and

variables that were significant at this level were carried forward to the next model testing the

medical factors: Diagnosis and Charlson Co-morbidity Index scores. The statistically significant

variables in the second model were carried forward to the third model testing religious factors:

congregational support, religious coping, and church attendance. In the final model, all variables

that were significant at level p < .10 in the previous three independent models were included.The level of significance for the final model was set at p < .05.

RESULTS

Prevalence of Religiousness and Existential Needs

The sample consisted of 83.6% Christians, and 54.9% reported unambiguous faith or a little

faith in God, 9.9% had unambiguous faith or a little faith in a spiritual power only, and 35.1%

reported no belief in either God or a spiritual power. A total of 14.6% reported that they

attended church regularly (more than once a month) and 23.1% reported praying more than

once during the week. Since the time of diagnosis, between 10.2% and 16.2% reported havingmore religious, spiritual, or existential thoughts. Although none reported having a need to

discuss religious thoughts with a professional, a minor proportion (0.9–3.6%) reported having

experienced a need to talk about spiritual or existential thoughts with a professional.

Prevalence of Religious and Spiritual Coping

Table 1 displays means and standard deviations on the religious coping subscales and the

percentages of patients indicating that they use the respective coping strategies to some extent

or more. The most frequently reported positive religious coping strategies were “Seeking God’slove and care” (seeking spiritual support), “Trying to see how God might strengthen me in this

situation” (religious transformation), and “Asking forgiveness for my sins (religious purifica-

tion).” Negative strategies like “Deciding the devil made this happen (demonic reappraisal)”

and “Wondering whether my religious community had abandoned me” (interpersonal religious

discontent) were less frequent.Kruskal–Wallis tests were used to test possible significant differences in religious coping

between patients considering themselves to be “a believing person,” “a spiritual person,” and “a

nonbelieving person.” The difference was statistically significant for Positive Religious Coping

�2(90) D 14.37, p D .001, and no statistical differences were found for Negative Religious

Coping. Mann–Whitney tests were used to run post hoc analyses applying a Bonferroni

correction of the alpha value (p < .017). Results indicated that “believers” scored significantly

COPING AND QUALITY OF LIFE FOR LUNG PATIENTS 195

TABLE 1

Percentages of Patients Indicating That They Use Religious Coping to ‘‘Some Degree’’ or More

Type of Patient

Total

% (N)a

Believing

% (N)b

Spiritual

% (N)c

Nonbelieving

% (N)d P

Positive religious coping (“Some degree” or more)

1. Looking for a stronger connection with God 26.1 (96) 40.3 (62) 36.4 (11) 0.0 (18) .005

2. Seek Gods love and care 36.9 (96) 54.8 (62) 36.4 (11) 11.1 (18) .004

3. Seek Gods help to let go of my anger 19.8 (96) 29.0 (62) 18.2 (11) 5.6 (18) .105

4. Try to put my plans into action together with God 22.5 (96) 32.3 (62) 27.3 (11) 5.6 (18) .077

5. Try to see how God might try to strengthen me

in this situation

32.2 (97) 50.8 (63) 18.2 (11) 5.6 (18) .001

6. Ask forgiveness for my sins 28.8 (97) 41.3 (63) 36.4 (11) 5.6 (18) .018

7. Focus on my religion to stop worrying about my

problems

15.3 (97) 22.2 (63) 18.2 (11) 5.6 (18) .275

Positive religious coping MEAN and

(standard deviation)

3.1 (4.5) 4.1 (4.8) 2.9 (4.6) 0.04 (1.4) .001

Negative religious coping (“Some degree”–“A great deal”)

8. Feel that God has abandoned me 6.3 (17) 8.2 (61) 0.0 (10) 11.1 (18) .570

9. Feel that I am being punished by God 5.4 (95) 8.1 (62) 0.0 (10) 5.6 (18) .624

10. Wonder what I did since God is punishing me 9.9 (96) 12.9 (62) 0.0 (11) 11.0 (18) .451

11. Questioned Gods love for me 16.2 (97) 15.9 (63) 9.1 (11) 27.8 (18) .372

12. Wonder whether my religious community has

abandoned me

1.8(101) 3.2 (63) 0.0 (15) 0.0 (18) .586

13. Decided that an evil power (like the Devil) made

this happen

2.7 (97) 4.8 (63) 0.0 (11) 0.0 (18) .490

Negative religious coping MEAN and

(standard deviation)

1.5 (2.1) 1.2 (2) 0.7 (1.6) 2.8 (2.3) .343

aN D 111. bN D 68. cN D 17. dN D 19.

higher on Positive Religious Coping (z D �3.764, p D .001) than nonbelievers. “Spiritual”

patients scored significantly higher than nonbelievers on positive religious coping (z D �2.186,

p D .029). There were no significant differences between believers and spiritual patients onthe Positive Religious Coping scale.

Religious and Spiritual Beliefs Associated QoL

One-way analyses of variance were conducted to test the associations between overall QoLand beliefs in God and/or a spiritual power. The results suggested that “God-believing” pa-

tients (patients believing in God and patients believing in God and a spiritual power) had

a higher overall QoL compared to patients having no belief or belief in a spiritual power

only, F(2, 102) D 4.451, p D .014. Post hoc analyses (Bonferroni tests, adjusting for multiple

comparisons) indicated that “spiritual believing” patients (believing in a spiritual power only),

had a significantly (p < .05) lower QoL than God-believing patients. The difference between

196 PEDERSEN ET AL.

nonbelieving patients and God-believing patients did not reach statistical significance (p D

.184).

Predictors of Religious Coping and QoL Among ‘‘Believing’’ and

‘‘Spiritual’’ Patients

Table 2 displays the unadjusted and adjusted hierarchical regressions. The unadjusted analyses

suggested higher education and higher annual household income to be associated with higherQoL, whereas working part time or being on sick leave were associated with lower QoL. Marital

TABLE 2

Sociodemographic, Medical, and Religious Predictors of Quality of Life

Unadjusted Analyses Adjusted Analyses

ˇ p ˇ p

Model 1: Sociodemographic factors

1. Age �0.033 0.770 �0.101 0.509

2. Sex 0.018 0.887 0.024 0.849

3. Marital status (married–single) 0.173 0.124 0.074 0.578

4. Education (high–low) 0.259 0.020 0.208 0.080

5. Full timea�0.010 0.931 �0.300 0.060

6. Part timea�0.234 0.045 �0.320 0.023

7. Annual house income 0.305 0.011 0.392 0.008

R2D 0.267***

F(7, 60) D 3.119

Adjusted for 4, 5, 6, and 7

(sign: p < 1.0 in Step 1)

Model 2: Medical factors

8. Diagnosis 0.109 0.965 0.007 0.952

9. Comorbidity �0.164 0.147 �0.154 0.167

R2D 0.279***

F(6, 62) D 4.001

�R2D 0.024

Adjusted for 4, 6 and 7

(sign: p < 1.0 in Step 1)

Model 3: Religious factors

10. Church attendance 0.165 0.143 �0.108 0.458

11. Congregational support 0.224 0.059 0.150 0.280

12. Positive religious coping 0.065 0.596 �0.060 0.688

13. Negative religious coping �0.391 0.0001 �0.301 0.014

R2D 0.370***

F(8, 52) D 3.812

�R2D 0.114

(Continued)

COPING AND QUALITY OF LIFE FOR LUNG PATIENTS 197

TABLE 2

(Continued)

All variables

(sign: p < 1.0 in Steps 1 and 3)

Final Model ˇ P

Step 1

1. Education 0.231 0.055

2. Full timea�0.257 0.062

3. Part timea�0.310 0.013

4. Annual house income 0.438 0.002

Step 2

1. Education 0.160 0.164

2. Full timea�0.233 0.072

3. Part timea�0.275 0.021

4. Annual house income 0.417 0.002

5. Negative religious coping �0.320 0.006

R2D 0.351***

F(5, 55) D 5.957

�R2D 0.096**

aThe comparison groups were “Retired” patients.

*p < .05. **p < .01. ***p < .001.

status, age, and sex were unrelated to QoL. In the first adjusted model, associations between

demographic variables and overall QoL were explored. Age, sex, marital status, education,

current work situation, and annual household income were entered into the first model and

explained 26.7% of the variance in overall QoL. To prevent underfitting of the model, the

significance level was set at p < .10, and the model indicated that higher annual householdincome and higher education were significantly associated with higher QoL, whereas working

part time and being on sick leave were associated with lower QoL. These variables were

carried forward to be entered in the second model. In the second set of unadjusted regressions,

associations between QoL and medical factors were explored, but none of the variables reached

statistical significance at p < .10. In the second adjusted model, the disease-related variablesof diagnosis and comorbidity were entered but did not reach statistical significance at p <

.10, when controlling for education, annual household income, and work status. Therefore,

these variables were not carried forward to the third model. The third set of unadjusted

regressions showed greater church attendance to be significantly associated with higher QoL,

and congregational support was unrelated to QoL. Negative religious coping, but not positivereligious coping, was significantly associated with QoL. In the third adjusted model, church

attendance, congregational support, and positive and negative religious coping were entered

as predictors. Congregational support, church attendance, and positive religious coping were

unassociated with overall QoL, whereas negative religious coping was found associated with

worse overall QoL. After entering religious variables, the third model explained 35.1% of the

total variance in overall QoL.

198 PEDERSEN ET AL.

The final model included variables significant at p < .10 in the previous adjusted regressions.

The significance level in the final model was set at p < .05. In the final model, threevariables reached statistical significance, with working part time/being on sick leave, annual

household income, and using negative religious all being significantly associated with poorer

QoL.

DISCUSSION

It has been argued that religiousness may be largely irrelevant to people in secular societies

like Denmark (Zuckerman, 2008). However, religiosity has so far been assessed in very generalterms and has not been studied in detail, such as in terms of specific coping strategies.

Our findings among a sample of low-SES Danish patients who had recently been diagnosed

with chronic lung disease suggest, contrary to the findings from sociological studies, that

religiosity and spirituality is a relevant factor to Danes facing a serious health-related problem.

Beliefs in God or a spiritual power were prevalent in the present sample of patients and were

shown to be associated with QoL. Furthermore, religious coping strategies were prevalent,with negative religious coping being significantly associated with lower QoL after controlling

for sociodemographic variables associated with QoL. A small group reported having more

existential, spiritual, and religious thoughts after diagnosis, but very few were interested in

discussing existential or spiritual thoughts with a professional, and none were interested in

talking about religious thoughts with a professional. This result suggests the private characterof religion to Danes (Andersen & Riis, 2002). In the remaining part of the discussion, we

consider these findings in more detail.

Religious Beliefs

Beliefs in a transcendent power were prevalent, with more than half of the patients reportingbelief in God or a spiritual power. The present study differs from several previous studies by

distinguishing between belief in a personal God and belief in a spiritual power, showing that

whereas approximately one tenth of the patients reported a belief in a spiritual power only, more

patients (31.5%) reported a belief in a personal God. Some patients reported beliefs in both a

personal God and a spiritual power (23.4%). In the World Value Surveys 1999–2001, more thanone third (38.1%) of Danes reported to believe in a “spirit or life force” and 24.9% believed in a

“personal God.” One reason for the difference found between these results and the results from

our sample could be related to the age of the present sample. The mean age of our sample was

65 years compared to 45.8 years in the Value Surveys, and traditional theistic beliefs (beliefs

in an active, involved God) may be more prevalent among elderly people (Andersen, Ausker,& la Cour, 2011). Another reason could be that the concepts of “a personal God” and “spiritual

power” are not mutually exclusive. In contrast to the Value Surveys, patients in our study were

not forced to choose between the two constructs, and a significant group reported belief in

both. This finding suggests that Danes may hold more fuzzy concepts of the transcendent than

previously (Lüchau, 2005).

COPING AND QUALITY OF LIFE FOR LUNG PATIENTS 199

Existential Needs

The finding that only a minor proportion reported having a need to discuss existential and

spiritual thoughts with a professional, and none reported a need to discuss religious thoughts

with a professional, suggests that religion is considered a private matter among Danes. In

contrast, studies show that between 25% and 51% of Americans are willing to talk about reli-

gious, spiritual, and existential thoughts (Miller, Pittman, & Strong, 2003; Moadel et al., 1999)

and find it helpful to share their thoughts and feelings with professionals such as physicians(Kristeller, Rhodes, Cripe, & Sheets, 2005). The private nature of Danish religiousness may

leave those experiencing religious, spiritual, or existential struggles isolated with their thoughts.

Although the nature of our study did not allow for exploring this aspect further, it would be

interesting in future studies to investigate whether this has any bearing on patients’ illness

adjustment and QoL.

Religious Coping

The relatively high percentage of patients that reportedly used religious coping at least to some

degree challenges the assertion that religious beliefs are not salient among people from secular

societies and is more consistent with the hypothesis that crisis may “mobilize” religious coping

strategies. Although less prevalent than positive religious coping, the key question here is why

Danes express religious struggles, if religion is a nonissue for them as suggested by Zuckerman(2008). We suggest, given the age of the present sample, that a large proportion could have

experienced some kind of religious socialization through baptism and confirmation as children

and that they therefore hold some traditional religious beliefs. However, these beliefs may

not have been differentiated, elaborated, and refined over their lifespan, partly because of the

secularization taking place in Danish society. Faced with a life-threatening crisis, these patientsmay have tried to mobilize religious resources that remained undeveloped. As a result, their

religion may have become a source of struggle rather than a source of support and comfort. In

any case, it appears that religious issues are not irrelevant in this secular society; in contrast

they appear to remain salient to Danes in times of great urgency.

Religious Coping and Quality of Life

Previous studies have shown that elderly people, women, and people who lack secular resourcessuch as money and education are especially likely to use religious coping and gain benefits from

it (Pargament, 1997). Consistent with these findings, we hypothesized that positive religious

coping would be associated with better QoL in this sample of elderly, low-SES patients.

However, positive religious coping did not explain any of the variance in QoL. There are a few

possible explanations for this finding. First, the level of positive religious coping in this samplewas lower than that of medical patients in the United States (Pargament, Koenig, Tarakeshwar,

& Hahn, 2004). Danish patients may not rely on religious resources to the same extent that

Americans do, perhaps because most Danes enjoy a relatively high living standard. Second, as

previously noted, it is also possible that the positive religious coping methods are less effective

because they are less deeply grounded in the individual’s repertoire of resources and orientation

200 PEDERSEN ET AL.

to the world. Finally, the lack of links between positive religious coping and QoL could reflect

the religious coping mobilization effect (Pargament, 1997). That is, in cross-sectional studies,the positive effect of religion on QoL could be counterbalanced and washed out by mobilization

of religious coping by the distress associated with a poorer QoL. Longitudinal studies are

needed to identify whether religious coping mobilization is taking place.

In contrast to the findings involving positive religious coping, negative religious coping was,

as predicted, associated with lower QoL. The findings suggest that religious struggles, thoughnot as prevalent as positive religious coping, may still have implications for well-being even

among people in highly secularized societies. Multiple comparison analyses suggested that

especially patients believing only in a spiritual power scored significantly lower on QoL than

people believing in God. Furthermore, there was a tendency for this group to score higher on

negative religious coping than God-believing patients. We do not know the nature of the beliefs

of those who believed only in a spiritual power, but apparently these beliefs are associatedwith nontraditional spiritual beliefs and behaviors as this group showed lower levels of private

religious activity (such as prayer), showed lower levels of public religious activity (such as

church attendance), and received little support from fellow believers (congregational members)

when compared to patients with belief in God. It is likely that when crisis strikes, these beliefs

are challenged, resulting in spiritual struggles that may be causing lower QoL. People holdingnontraditional spiritual beliefs and not receiving social support from fellow believers may be

left to fend for themselves in their efforts to resolve their existential and spiritual struggles.

If Danish society does indeed become more secularized, it is possible that spiritual struggles

will increasingly become commonplace among patients dealing with life-threatening diseases as

their religious belief systems becomes more fragmentized, less integrated, and less helpful. Asreligious upbringing becomes less common among younger generations (Ausker & Mørk, 2007)

younger patients in secular societies may become more vulnerable to spiritual struggles because

they lack concepts and language to deal with existential, religious, and spiritual questions

(la Cour, 2008) and as a result grasp for whatever existential, spiritual, or religious meaning-

making systems (Park, 2005) they believe may help them cope. The question is whether they

will succeed in constructing a new system of religious or spiritual meaning or whether theirstruggles will lead to frustration, confusion, and despair. The topic of spiritual struggles seems

ripe for further empirical study. Health professionals should also consider how they might assist

in the prevention and resolution of existential, spiritual or religious struggles.

Limitations

This study is one of the first to explore religious coping among medical samples in Denmark.

However, a number of limitations should be noted. First, the sample represents elderly, low-SES

lung disease patients from Denmark. It is unclear whether the findings will generalize to other

patient groups, Danish or otherwise. Second, the study had a low response rate, likely due atleast in part to the severity of the illness these patients were experiencing. Unfortunately, it was

not possible to explore this further, as information about the health condition of nonresponders

was not available to us. The low response rate could also reflect the reluctance among many

Danes to discuss religious issues. Therefore, the sample might have an overrepresentation

of religiously oriented patients. Third, the study used a cross-sectional design. As a result,

important questions about causal relationships cannot be determined. Fourth, the Brief RCOPE

COPING AND QUALITY OF LIFE FOR LUNG PATIENTS 201

seemed to apply to subgroups of patients identifying themselves as “believing” and “spiritual.”

However, it is likely that other spiritual and existential coping strategies are also prevalentamong Danish patients. It could be important, especially among younger patient groups, to

consider other scales or develop new items covering more spiritual and existential ways of

coping (Ahmadi, 2006).

Conclusions

Despite the limitations noted previously, the results of the present study challenge the notionthat religion and spirituality are unimportant to patients in secular societies. The sample

reported widespread beliefs in God or a spiritual power, which in turn were associated with

QoL. Furthermore, religious coping appeared to be prevalent. Negative religious coping, in

particular, was found associated with poorer QoL. These findings underscore the potential

risk of religious struggles for the QoL of patients, particularly those holding nontraditionalspiritual beliefs. Although the majority of patients were not interested in talking about reli-

gious, spiritual, or existential thoughts with professionals, patients—especially those undergoing

religious struggles—could perhaps benefit from increased attention to these matters from health

professionals.

ACKNOWLEDGMENTS

The project was supported by the Danish Knowledge and Research Centre of Complementary

and Alternative Medicine (ViFAB) in collaboration with Center for Cross-Scientific Evaluation

Studies on Complementary and Alternative Medicine (CCESCAM) at University of SouthernDenmark and Aarhus University as well as a stipend from Aarhus University.

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Paper 2

© 2013 Koninklijke Brill NV ISBN 978-90-04-25205-9

Research in the SocialScientifijic Study of Religion

Volume 24

Edited by

Ralph L. PiedmontLoyola University Maryland

andAndrew Village

York St. John University, UK

LEIDEN •• BOSTON2013

© 2013 Koninklijke Brill NV ISBN 978-90-04-25205-9

CONTENTS

Preface  ................................................................................................................ viiAcknowledgements  ........................................................................................ ixManuscript Invitation  .................................................................................... xi

The Revised Faith Development Scale: An Option for a More Reliable Self-Report Measurement of Postconventional Religious Reasoning   ................................................................................. 1

 J. Irene Harris and Gary K. Leak

Spirituality’s Unique Role in Positive Afffect, Satisfaction with Life, and Forgiveness over and above Personality and Individualism-Collectivism  ............................................................. 15

 Inna Reddy Edara

SPECIAL SECTION

RESTORING THE TEMPLE: RELIGIOUSNESS, SPIRITUALITY, AND HEALTH

Restoring the Temple: Religiousness, Spirituality, and Health  .......... 45 Gina Magyar-Russell

Forgiveness, Religiousness, Spirituality, and Health in People with Physical Challenges: A Review and a Model  ........................... 53

 Caroline R. Lavelock, Brandon J. Grifffijin, and Everett L. Worthington, Jr.

Religious and Spiritual Appraisals and Coping Strategies among Patients in Medical Rehabilitation  ....................................................... 93

 Gina Magyar-Russell, Kenneth I. Pargament, Kelly M. Trevino, and Jack E. Sherman

The Relationship of Spirituality, Benefijit Finding, and Other Psychosocial Variables to the Hormone Oxytocin in HIV/AIDS  ................................................................................................. 137

 Courtney B. Kelsch, Gail Ironson, Angela Szeto, Heidemarie Kremer, Neil Schneiderman, and Armando J. Mendez

© 2013 Koninklijke Brill NV ISBN 978-90-04-25205-9

contents iii

Coping Without Religion? Religious Coping, Quality of Life, and Existential Well-Being among Lung Disease Patients and Matched Controls in a Secular Society  ....................................... 163

 Heidi Frølund Pedersen, Christina G. Pedersen, Kenneth I. Pargament, and Robert Zachariae

Magic and Jinn among Bangladeshis in the United Kingdom Sufffering from Physical and Mental Health Problems: Controlling the Uncontrollable  ............................................................. 193

 Simon Dein

Spirituality, Faith, and Mild Alzheimer’s Disease  ................................. 221 Jocelyn Shealy McGee, Dennis R. Myers, Holly Carlson,

Angela Pool Funai, and Paul A. Barclay

Spiritual Struggles, Health-Related Quality of Life, and Mental Health Outcomes in Urban Adolescents with Asthma  .................. 259

 Sian Cotton, Kenneth I. Pargament, Jerren C. Weekes, Meghan E. McGrady, Daniel Grossoehme, Christina M. Luberto, Anthony C. Leonard, and George Fitchett

Testing the Validity of a Protocol to Screen for Spiritual Struggle among Parents of Children with Cystic Fibrosis  .............................. 281

 Daniel H. Grossoehme and George Fitchett

Winding Road: Preliminary Support for a Spiritually Integrated Intervention Addressing College Students’ Spiritual Struggles  ... 309

 Carmen K. Oemig Dworsky, Kenneth I. Pargament, Meryl Reist Gibbel, Elizabeth J. Krumrei, Carol Ann Faigin, Maria R. Gear Haugen, Kavita M. Desai, Shauna K. Lauricella, Quinten Lynn, and Heidi L. Warner

Authors’ Biographies  ...................................................................................... 341Manuscript Reviewers  ................................................................................... 351Subject Index  .................................................................................................... 353Author Index  .................................................................................................... 358

© 2013 Koninklijke Brill NV ISBN 978-90-04-25205-9

Research in the Social Scientifijic Study of Religion, Volume 24© Koninklijke Brill NV, Leiden, 2013

COPING WITHOUT RELIGION? RELIGIOUS COPING, QUALITY OF LIFE, AND EXISTENTIAL WELL-BEING AMONG LUNG DISEASE PATIENTS AND MATCHED CONTROLS IN A SECULAR SOCIETY

Heidi Frølund Pedersen, Christina G. Pedersen, Kenneth I. Pargament, and Robert Zachariae*

Abstract

The present study examined religious coping following negative life events among three groups of participants in Denmark: severely ill lung disease patients (n = 111), individuals facing other negative life events (n = 91), and a healthy control group (n = 246) matched on age, gender, education, and region. The aims of the study were to explore the degree to which major life stressors mobilize greater levels of religiousness in a secular society like Denmark, the types of religious behaviors and coping strategies employed (if any), and the associations between religious coping and well-being among the participant groups. While we found no diffferences in the level of general religious activities between groups, lung disease patients reported greater use of positive religious coping than the control group, especially asking forgiveness and religious meaning-making. Hierarchical regression analy-ses indicated that negative religious coping was signifijicantly associated with poorer overall quality of life (QoL) among lung disease patients (β = .19, p < 0.01), whereas congregational support was associated with better QoL (β = .20, p < 0.01) and existential well-being (β = .19, p < 0.01) in the control group. Positive religious coping was not associated with well-being measures in any of the groups. The results suggest that despite secularization, religion continues to be a relevant factor among Danes, particularly for those facing severe illness. The practical implications of these fijindings for health care are considered.

Keywords: Lung disease, negative life events, religiousness, religious coping, quality of life, existential well-being, secular

* Authors Note: Heidi F. Pedersen, Unit for Psycho-Oncology and Health Psychology, Department of Psychology, Aarhus University; Christina G. Pedersen, Unit for Psycho-Oncology and Health Psychology, Department of Psychology, Aarhus University; Kenneth I. Pargament, Bowling Green State University; Robert Zachariae, Unit for Psycho-Oncology and Health Psychology, and Department of Oncology, Aarhus University Hospital.

The project was supported by the Danish Knowledge and Research Centre of Com-plementary and Alternative Medicine (ViFAB) in collaboration with Center for Cross-Scientifijic Evaluation Studies on Complementary and Alternative Medicine (CCESCAM) at University of Southern Denmark and Aarhus University as well as a stipend from Aarhus University.

Correspondence concerning this article should be addressed to Heidi Frølund Pedersen, Department of Psychology, Aarhus University, 8000 Aarhus C, Denmark. E-mail: hefpe@psy.au.dk

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The idea that negative life events such as life threatening illness, accidents, or bereavement elicit religiosity or faith in something greater than man-kind is well-known and reflected in the famous saying: “There are no athe-ists in foxholes.” Although this maxim may be overstated, studies in the United States (US) have shown higher levels of religiousness among peo-ple facing life and death situations (Pargament, 1997). Life crises appear to mobilize religious and spiritual resources, and psychological theories sug-gest that this phenomenon may stem from a need to reduce death anxiety by afffording a sense of psychological security and the hope of immortal-ity (Vail et al., 2010). Specifijically, according to terror management theory (Greenberg, Pyszczynski, & Solomon, 1986), reminders of human mortal-ity make people engage in their own cultural world views and values to enhance self-esteem and deal with existential concerns. Religious and spiritual ideas are more appealing in this situation because they affford lit-eral immortality, as opposed to secular ideas of symbolic immortality like making major contributions to the cultural society that will persist after one’s demise or, more modestly, living on through the next generation. Experimental psychology has provided some evidence that religion may be more appealing when reminded about death, even among non-religious people. In a study by Jong, Halberstadt, and Bluemke (2012), explicit mea-sures (questionnaires) as well as implicit measures (single-target Implicit Association Test) were applied to test how thoughts of death influence belief in supernatural agents. Participants were instructed to categorize a series of nouns as real or imaginary (including religious concepts as God, Angel, Heaven) as quickly as possible. Hesitations in categorizing religious concepts as imaginary among non-believers in the death priming condi-tion were interpreted as signs of implicit religiosity caused by mortality salience. The study showed that participants explicitly defended their own worldviews; religious participants were more confijident that supernatural beings exist, whereas non-religious participants were more confijident that they do not. However, when measured implicitly, death priming increased beliefs in religious supernatural entities among all participants, regardless of their prior religious or non-religious worldviews.

Religion may serve other important functions in times of stress besides being a bufffer against death anxiety. In this vein, Pargament (1997) sug-gested that religion may serve multiple purposes among people cop-ing with major life events, including fijinding comfort and support from a higher being and obtaining social support from a religious or spiritual community. Religion can also function as a way of gaining control, either

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by attributing the responsibility for a stressful event to a higher being or asking for strength to handle a situation. In addition, religion can func-tion as a source of personal transformation; non-religious people may convert to religion and change their lives, and religious people may refijine and expand their religious beliefs. Finally, religion may offfer a framework for meaning-making. These functions may become especially signifijicant when people confront stressful events that shatter their worldviews and reveal their fundamental frailty, such as loss, serious illness, or accidents (Janofff-Bulman, 1992). Questions remain, however, about the generaliz-ability of this theory and research to other contexts.

Scandinavian societies like Denmark are considered to be among the most secularized in the world (Zuckerman, 2008). Although nearly 80% of Danes are members of the National Lutheran Church (Statistics Denmark, 2012), only 2% attend church on a weekly basis (Højsgaard & Iversen, 2005) as opposed to 43.1% of Americans (Gallup Daily Tracking, 2008–2010), and some have suggested that religion is a non-issue among Danes (Zuckerman, 2008). A few studies have explored the prevalence of religiosity among medically ill patients in Denmark, and their results indi-cate that medical patients are more religiously oriented than the general population (Andersen, Ausker, & la Cour, 2011; Ausker, la Cour, Busch, Nabe-Nielsen, Pedersen, 2008; Pedersen, 2009). The frame of reference in these studies, however, was the general population as a whole; the samples were not specifijically matched with respect to demographic factors such as age and gender, which have been found to be signifijicant predictors of religiosity (The Danish Value Survey, 2008; Pew Research Center, 2008).

Given this background, we explored whether individuals reporting a wide range of major negative events and life-threatened individuals, namely lung disease patients, are more likely to report religious coping when compared to a healthy control group matched on age, gender, and education level reporting no negative events. The aim was to test the hypothesis that negative life events, such as receiving a diagnosis of lung disease or grieving the death of a loved one, are more likely to elicit reli-gious activity and religious coping when compared to the coping activi-ties of individuals not confronted with major life events. Additionally, whether possible links between religion and well-being vary as a function of stressor type; that is, whether possible efffects of religious coping on well-being will be stronger among individuals reporting severe illness or negative events, were also explored.

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Positive and Negative Methods of Religious Coping

Although religion is most often thought of in positive terms as afffording comfort and hope, anthropological studies have also suggested that reli-gion may often be far from comforting. One example is the Calvinist belief that God pre-determines souls to salvation or damnation (Thuesen, 2009). Thus, religion may be a double-edged sword depending on the religious worldviews available to the individual (Schaie, Krause, & Booth, 2004). Accordingly, research has identifijied both positive and negative religious coping strategies (Pargament, Koenig, & Perez, 2000). Positive religious coping can be viewed as reflecting a secure relationship with God, a spir-itual connectedness with others, and a belief in life as being generally meaningful. In contrast, negative religious coping, or religious or spiri-tual struggle, is defijined as an expression of spiritual conflicts and doubts in one’s religious beliefs, relation with the divine, and connections with other people (Pargament, Murray-Swank, Magyar, & Ano, 2005). Studies of negative religious coping suggest that people are more likely to experi-ence anger towards God when their worldview is shattered and when God is held responsible for a negative event (Exline, Park, Smyth, & Carey, 2011). Furthermore, it is argued that religious beliefs that are not coherent and well-integrated in a person’s belief system may be more easily shat-tered and become a potential source of struggle (Pargament, 2007). Much of the research showing that religiousness is mobilized in stressful times has focused on positive forms of religious coping. Less clear is whether stressful situations are more likely to produce negative religious coping or religious struggles.

Religious Coping and Well-Being

Studies of religious coping and health suggest that positive and negative religious coping strategies impact well-being and adjustment diffferently. Positive religious coping has generally been associated with positive out-comes in terms of better quality of life (QoL), existential well-being, and better adjustment among a variety of diseases (Ano & Vasconcelles, 2005). It is here important to note that some studies fijind limited or no associa-tions (Hebert, Zdaniuk, Schulz, & Scheier, 2009; Schreiber & Brockopp, 2012) and others have found negative associations (Hills, Paice, Cameron, & Shott, 2005). Conversely, negative religious coping, although less preva-lent than positive religious coping (Meisenhelder & Marcum, 2004), has

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been robustly tied to poorer physical and mental health in many popula-tions (Ano & Vasconcelles, 2005), including lower levels of quality of life and existential well-being among cancer patients (Delgado-Guay et al., 2011; Tarakeshwar et al., 2006) and poorer emotional regulation among the bereaved (Lee, Roberts, & Gibbons, 2012). Furthermore, longitudinal studies have found associations between chronic religious struggles and increased distress (Hebert et al., 2009; Sherman, Plante, Simonton, Latif, & Anaissie, 2009) and mortality among severely ill patients (Pargament, Koenig, Tarakeshwar, & Hahn, 2001).

Furthermore, several studies have suggested that the relationships between religiousness and indices of well-being and distress are stronger among people dealing with major life stressors, such as medical illness (see Cummings & Pargament, 2010). For example, in a national survey of adults in the US, reports of spiritual struggles were found to be associated with a variety of indicators of psychopathology, and these relationships were signifijicantly stronger among people facing medical illnesses (McCo-nnell, Pargament, Ellison, & Flannelly, 2006).

The Present Study

The studies reviewed above have largely been conducted in societies that are generally thought to be more religiously oriented than the Scandi-navian counties, such as the United States (Zuckerman, 2008). Little is therefore known about associations between religious coping and QoL and existential well-being in more secular societies such as Denmark. Perhaps religion is not a source of spiritual support or a framework for meaning-making in secular societies. On the other hand, religion may continue to be a positive resource, and sometimes a source of existen-tial and religious struggle, when people encounter signifijicant stressors, even in more secularized countries. The present study, therefore, focused on three questions: (a) Do major life stressors mobilize greater levels of religiousness in a secular society like Denmark? (b) What types of reli-gious coping strategies do Danes facing major negative life events employ, if any, and do these strategies difffer from those used by people who do not face negative life challenges? (c) Is religiousness associated with well-being, particularly in times of stress, among people in Denmark?

Specifijically, in the present study, we compared the prevalence of religiosity and religious coping in: (a) a group of lung disease patients, (b) a matched group of participants who reported a negative life event(s)

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during the last 12 months (the negative events group), and (c) a control group of participants who did not report a negative life event during the past 12 months (the control group). We also explored whether the associa-tions between positive and negative religious coping and QoL and exis-tential well-being varied as a function of the stressor.

It was hypothesized that severely ill lung disease patients and the nega-tive events group would report higher levels of public and private religious activity as well as both more positive and negative religious coping than the control group. In addition, based on theory and previous fijindings, we hypothesized that higher levels of positive religious coping would be asso-ciated with higher overall QoL and existential well-being among patients and participants dealing with negative life events, in comparison to those reporting no negative life events. We also hypothesized that higher levels of negative religious coping would be associated with lower levels of over-all QoL and existential well-being.

Methods

Procedure

The lung disease participant group was recruited from fijive respiratory medicine clinics (four on the main peninsula of Jutland and one at an island in the eastern part of Denmark). From October 2008 to Octo-ber 2010, patients diagnosed with severe and chronic lung disease were informed about the study by the medical stafff and asked to give their informed consent to participate. Patients were asked to complete the questionnaire shortly after their diagnosis and return it to the research team by mail. Those who did not return the questionnaire within 2 weeks received a single reminder. In all, 514 received the questionnaire, and 120 responded (response rate: 23.4%). Nine patients were excluded because of insufffijicient data, resulting in a fijinal sample of 111 lung disease patients. The project was evaluated by the Committee on Biomedical Research Ethics in Denmark.

The control group was established by Statistics Denmark, a government agency that has access to a range of national registries such as the Cen-tral Person Registry (CPR). All Danish residents are given a CPR number, enabling retrieval of information for research purposes. In all, 11 individu-als per patient matched on age, gender, education level, and region were selected from the CPR. The resulting group of 1,437 potential participants received a questionnaire during March 2010 and was asked to complete

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and return the questionnaire. Those who did not return the question-naire within 2 weeks were mailed a single reminder. In all, 498 responded (response rate = 34.7%). Of these, 45 were excluded due to insufffijicient data, 116 were excluded due to reporting serious illness such as heart dis-ease, cancer, AIDS, diabetes, liver, and lung diseases, resulting in a fijinal sample of 337 matched control participants.

The present study was part of a larger study focusing on the use of complementary and alternative medicine (CAM) and religiosity among Danish chronically ill lung disease patients.

Measures

Socio-demographic informationSocio-demographic information included: age, gender, marital status (dichotomized into married/cohabiting and widowed/ divorced/ single), number of children, highest education level (dichotomized into Low edu-cation = 7–10 years and High education = > 10 years), current work situ-ation (dummy coded into Unemployed/sick leave, Retired, and Working part- or full-time), and socio-economical status (annual house income).

Medical informationAn adapted version of the Charlson Co-morbidity Index (Charlson, Pom-pei, Ales & MacKenzei, 1987; Christensen et al., 2009) was used to assess self-reported co-morbidity in the patient and control groups. Information on lung disease patients’ diagnosis was retrieved from the Danish Lung Cancer Registry (www.lungecancer.dk) and from the records of the par-ticipating respiratory medical clinics.

Negative life eventsAn adjusted version of the List of Recent Events (LRE) (Henderson, Byrne, & Duncan-Jones, 1981) was used to access the presence and psychological impact of major life events during the last 12 months among control par-ticipants covering: (a) illness, injury, and accident, (b) bereavement, (c) pregnancy or abortion, (d) changes in relationships, (e) living conditions, (f) education, (g) employment, and (h) fijinances and legal difffijiculties. We excluded the category of pregnancy or abortion, as this item did not seem relevant to this sample due to the mean age of the participants. The response format on the question “Have you within the past 12 months experienced [event]?” was Yes or No for each event. For the items “Illness, injury, and accident” and “Bereavement,” the question was formulated:

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“Have you or one of your closest relatives experienced [event]?” For each event, participants were asked to indicate to what degree this event had a negative influence on their QoL on a 5-point Likert scale from 1: (Not at all) to 5: (Very much). Events that were rated higher than 2 were catego-rized as “Negative events.”

Health related quality-of-life (QoL)A Danish version of the Functional Assessment of Cancer Therapy Scale, FACT-G (Cella et al., 1993) was used to measure overall health-related QoL among lung disease patients. The FACT-G is a standardized ques-tionnaire developed for cancer research and consists of 30 items cover-ing the patients’ physical, emotional, social, and functional well-being (“I feel sick,” “I feel nervous,” “I sleep well”). The wording was changed from “cancer” to the broader term “lung disease.” Responses are given on a 5-point Likert scale ranging from 0 (Not at all) to 4 (Very much). The four subscales are computed into one total score. In the present samples, the internal consistency (Cronbach’s alpha) of the overall QoL score among lung disease patients was 0.92 and ranged from 0.77 to 0.90 for the sub-scales. For control participants, the overall QoL score was 0.87 and ranged from 0.74 to 0.86 for the subscales.

Existential well-beingExistential well-being was measured using the FACIT-Sp (Peterman, Fitch-ett, Brady, Pharm, & Cella, 2002), a 12-item questionnaire covering the patients’ sense of meaning, purpose, and peace in life and ability to fijind comfort in spiritual convictions during illness (“I feel peace,” “I fijind com-fort in my spiritual beliefs”). Responses are given on a 5-point Likert scale ranging from 0 (Not at all) to 4 (Very Much). A total score is calculated by summing the scores of each item. The internal consistency for existential well-being was 0.86 among lung disease patients and 0.82 for control par-ticipants. Participants in the control group were given an adjusted version of the FACT-G and the FACIT-Sp without items referring to lung disease, and total scores were calculated in accordance with scoring guidelines from the FACT-G in order to be able to compare the scores of the two independent groups (Brucker, Yost, Cashy, Webster, & Cella, 2005).

Religious behaviorPublic religious behavior was measured by a single item about church attendance and/or attendance at other religious meetings: “How often do you attend church or other religious services?” Private religious behavior

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was measured by a single item about the frequency of prayer, meditation, and/or Scripture readings: “How often do you engage in religious activi-ties like prayer, meditation, or Scripture reading?” Response options to these two measures were 5-point Likert scales ranging from 1 (Never) to 5 (Every day).

Congregational supportCongregational support was measured by a single item: “To what degree do you receive support from your fellow believers” on a 5-point Likert scale with response options ranging from 1 (Not at all) to 5 (A great deal) for lung disease patients, and the format 2 (Yes), 1 (No), or 0 (Not relevant) for control participants. The score was then dichotomized into 1 (Congre-gational support; 2–5 among the lung disease group, and 2 among negative events group and the control group) and 0 (No support; 1 for lung disease group, and 1 and 0 for negative events group and the control group).

Religious copingPositive and negative religious coping was measured by a revised version of the Brief RCOPE (Pargament, Smith, Koenig & Perez, 1998), a 14-item measure with two subscales: Positive religious coping which measures the degree to which the patients cope with illness by looking to God for com-fort and support (“Looked for a stronger connection with God”) and Nega-tive religious coping which measures the degree individuals interpret their illness as a punishment or abandonment by God (“Wondered whether God had abandoned me”). The latter subscale is often referred to as reli-gious or spiritual struggle, because it reflects a religious system in tension or turmoil (Pargament et al., 2005). The response format is a 4-point Likert scale ranging from 0 (Not at all) to 3 (A great deal), and a total score is calculated for each subscale. The original Brief RCOPE assesses religious meaning-making only in the negative subscale (such as “Wonder why God is punishing me”). Thus, a new item was developed covering positive reli-gious meaning-making in the present study: “Thought God had a meaning with my illness/situation after all,” and another variable covering spiritual support was added: “God granted me the strength to handle my illness/situation.” Internal consistencies (Cronbach’s alpha) were 0.94 for the positive and 0.60 for the negative religious coping subscale in the present sample. Deleting the item “Questioned the power of God” resulted in a Cronbach’s alpha of 0.71 for negative religious coping which was done in the following analyses. An unpublished qualitative validation study of the Brief RCOPE conducted by the fijirst author suggested that non-religious

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people and atheists often answer this last item “Questioned the power of God” with “Very much.” Not because they have religious struggles but simply because they want to declare their disbelief in God. On this back-ground, we chose to delete this item, although this particular item has been found to be one of the most commonly endorsed religious strug-gles among cardiac patients with symptoms of acute coronary syndrome (Magyar-Russell et al., submitted for publication) and among diabetic, congestive heart failure, and oncology patients (Fitchett et al., 2004) in the United States.

Thus, the fijinal measure consisted of 15 items covering positive and negative religious coping strategies. When answering the religious cop-ing items, the negative events group and the control group were asked to think of the most negative life event they reported and the lung disease group was asked to think about how their illness afffected them.

Statistical Analysis

Mean substitution was used to handle missing data on continuous vari-ables as suggested by Schafer and Graham (2002). This procedure is adequate and preferable to procedures such as list-wise deleting or scale mean substitution. One-way ANOVAs and Chi-square tests were applied to test any diffferences in socio-demographic information between the lung disease group, negative events group, and control group. Religious coping was positively skewed, and non-parametric as well as parametric tests were applied when appropriate. Kruskal Wallis and Chi-square tests were applied to test diffferences in religious coping between the lung dis-ease group, negative events group, and control group. Finally, hierarchal regression analyses were conducted to determine the associations between religious coping, overall QoL, and existential well-being, while adjusting for demographic, medical, and religious factors. To reduce the risk of over-fijitting, three independent regression models were conducted in order to determine which variables should be included in the fijinal regression. The fijirst model consisted of demographic variables: sex, age, marital status, number of kids, education, annual house income, current work situa-tion, and volunteer work. In order to reduce the risk of under-fijitting, the signifijicance level in the fijirst three independent regression models was set at p < 0.10, and variables statistically signifijicant at this level were car-ried forward to the next model testing influence of the following medi-cal factors: diagnosis and Charlson Co-morbidity Index scores and group membership (i.e., lung disease, negative events, or a control individual reporting no negative events). The statistically signifijicant variables in the

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second model were carried forward to the third model testing the role of religious factors: church attendance, prayer/meditation/Scripture read-ing, congregational support, and positive and negative religious coping. In the fijinal model, all variables that were signifijicant at level p < 0.10 in the previous three independent models were included. Furthermore, an interaction term was added testing possible interactions between group membership and the religious variables by centering the data and multi-plying group membership with the signifijicant religious variables from the previous regression models. The signifijicance level for the fijinal model was set at p < 0.05. All analyses were conducted using SPSS 19.

Results

Sample

The lung disease participant sample included 55.9% males between the ages 26 and 105 years (M = 65.2, SD = 10.2) newly diagnosed with chronic lung diseases; that is, lung cancer (39.1%) and COPD/other lung diseases like bronchiecstasia (60.9%). More than two thirds (68.5%) of the patients had less than 11 years of education, 72.7% were married, 67% were retired, and 39.4% reported an annual income below 35.700 USD, which accord-ing to Organisation for Economic Co-operation and Development (OECD) standards is perceived as relative poverty in Denmark (OECD, 2009).

The matched control sample (N = 337) included 50.7% males. Partici-pants were between 42 and 96 years of age (M = 67.6, SD = 9.7). Almost three quarters (74.2%) of the participants had fewer than 11 years of edu-cation, 78% were married, 70.9% were retired, and 21.5% reported an annual income below 35.700 USD, which according to OECD standards is perceived as relative poverty in Denmark (OECD, 2009). Thus, both sam-ples were considered relatively low socioeconomic status (SES). Detailed socio-demographic data were collected and are available from the author, but analyses indicated that these data did not relate to the outcomes on the key dependent measures and are not described further here.

Ninety-one control participants reported negative events (negative events group), with 47% of these reporting to have experienced seri-ous accidents or illness of a close relative, 17% reporting a loss, and 36% reporting negative events in relations to work, fijinances, close relation-ships, or other events. A total of 246 control participants (control group) reported no negative events. The 111 lung disease patients were therefore compared separately to the 91 participants in the negative events group and the 246 participants in the control group.

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A one-way ANOVA showed a statistically signifijicant diffference in age between lung disease group (M = 65.2, SD = 10.2) and the control group only (M = 68.2, SD = 9.7, F[2, 445] = 4.18), p = .02), with a medium efffect size (partial eta squared = 0.20). Furthermore, a chi-square for indepen-dence indicated a statistically signifijicant diffference between the lung dis-ease group, the negative events group, and the control group regarding current work status (χ² [5, n = 439] = 20.85, p = 0.00, Cramer’s V = .15, p = .00), which is considered a small efffect size. No diffferences were found between the three groups on any other socio-demographic variables. Thus, the groups of lung disease patients, negative events group, and the control group could be considered relatively comparable.

Prevalence of Religious Behavior and Religious Coping

Table 1 displays the prevalence of religious behavior (church attendance, prayer/meditation/Scripture reading, and congregational support) and positive and negative religious coping. A signifijicant number of partici-pants did not respond to the religious coping items (N = 100). One way ANOVAS and Chi-square tests suggested that non-responders were more likely to be categorized as control participants not reporting a negative event before answering the religious coping items, elderly, and had a higher frequency of church attendance.

Table 1. Prevalence of Religiousness and Positive and Negative Religious Coping

Total%

Lunggroup

%N = 96

Negative eventgroup

%N = 84

Controlgroup

%N = 168

Positive religious coping (“Some degree” or more)1. Looking for a stronger

connection with God32.9 30.2 38.8 31.4

2. Seeking God’s love and care 35.7 42.7 36.5 31.43. Seeking God’s help to let go of

my anger19.9 22.9 22.6 16.8

4. God grants me the strength to handle my situation/illness

36.3 41.1 37.6 32.9

5. Trying to put my plans into action together with God

26.0 26.0 25.3 26.3

6. Try to see how God might try to strengthen me in this situation

32.7 37.1 36.1 28.4

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Total%

Lunggroup

%

Negative eventgroup

%

Controlgroup

%

7. Asking forgiveness for my sins

23.1* 33.0* 15.5 21.2

8. Focusing on my religion to stop worrying about my problems

17.9 17.5 13.3 20.4

9. Behind all this, I think God has a meaning after all

40.5*** 60.4* 28.6 35.1

Positive religious coping  MEAN (SD)

4.1 (5.9)* 5.0 (6.2)* 3.6 (5.2) 3.7 (6.0)

Negative religious coping (”Some degree” or more)10. Feeling that God has

abandoned me9.8 7.4 15.3 8.4

11. Feeling that I am being punished by God

5.5 6.3 6.0 4.7

12. Wondering what I did since God is punishing me

10.4 11.5 10.6 9.6

13. Questioning God’s love for me 12.5 18.6 10.8 9.814. Wondering whether my

religious community has abandoned me

1.5 2.0 1.3 1.3

15. Deciding that an evil power (like the Devil) made this happen

3.7 3.1 2.4 4.8

Negative religious coping  MEAN (SD)

0.6 (1.5) 0.8 (1.6) 0.6 (1.4) 0.5 (1.6)

Religious behaviorChurch attendance MEAN (SD)

1.9 (0.7) 1.9 (0.7) 1.9 (0.7) 1.9 (0.7)

Prayer/ meditation/Scripture MEAN (SD)

2.1 (1.5) 2.1 (1.6) 2.4 (1.5) 2.0 (1.5)

Congregational support (Yes-No) %

34.3 28.7 42.2 33.3

Note: Kruskal Wallis tests were applied to test diffferences in mean scores between the three groups. Chi-square tests were applied to test diffferences between groups on the diffferent coping strategies 1–15 and congregational support. ANOVA was applied to test diffferences between the groups in church attendance and prayer/meditation/Scripture reading.* p < .05 ** p < .01 *** p < .001

Table 1 (cont.)

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Chi-square tests showed no signifijicant diffferences between the lung disease group, the negative events group, and control group in church attendance, private religious practice, or congregational support. Overall, positive religious coping strategies were more frequently reported than negative strategies across all three groups. Kruskal Wallis and Chi-square tests showed no statistically signifijicant diffferences in overall negative religious coping and the separate negative religious coping strategies between the three groups. A Kruskal Wallis test indicated that the lung disease group reported more overall positive religious coping than both the negative events group and the control group (χ2 [2, n = 348] = 8.17, p = 0.02). Mann Whitney tests were applied as post hoc tests using a Bonferonni correction of the alpha value to 0.02 and suggested only the lung disease group and the control group difffered signifijicantly in overall positive religious coping, (U = 6470.5, z = –2.82, p = 0.01, r = –0.20), cor-responding to a medium efffect size. Specifijically, Chi square analyses indi-cated a statistically signifijicant diffference in the prevalence of the positive religious coping strategies of religious purifijication (“Asked forgiveness for my sins”) and positive religious meaning-making (“Thought God had a meaning after all”) between the three groups. Post-hoc analyses using the standardized residuals suggested lung disease patients reported greater religious purifijication (z = 2.00, α = 1.96) and religious meaning-making (z = 3.10, α = 1.96) than the negative events group and the control group.

Religious Coping and Overall Quality of Life

Table 2 displays the unadjusted and adjusted hierarchical regressions examining associations between socio-demographic and religious factors, religious coping, and overall quality of life and existential well-being.

The unadjusted analyses showed that higher annual household income was associated with higher overall QoL. In the fijirst adjusted model, asso-ciations between demographic variables and overall QoL were explored. Age, sex, marital status, number of children, education level, current work situation, and annual household income were entered into the fijirst model and explained 5.8% of the variance in overall QoL. In order to reduce the risk of under-fijitting of the model, the signifijicance level was set at p < 0.10, and the model indicated that higher education and higher annual house-hold income were signifijicantly associated with higher QoL. These variables were carried forward to be entered in the second model. In the second set of unadjusted regressions, associations between QoL and medical factors were explored, and the unadjusted analyses indicated that being a patient

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Table 2. Socio-demographic, Medical, and Religious Predictors of Overall Quality of Life and Existential Well-being

OVERALL QUALITY OF LIFE EXISTENTIAL WELL-BEINGUnadjusted

analysesAdjusted analyses

Unadjusted analyses

Adjusted analyses

Beta Beta Beta Beta

Model 1: Socio- demographic factors

1. Age –0.06 –0.02 –0.06 0.002. Sex 0.06 –0.07 –0.05 –0.053. Marital status

(married–single)0.06 0.02 0.06 0.03

4. Children 0.00 –0.02 –0.04 –0.065. Education (high–

low)0.16** 0.13* 0.13** 0.10

6. Work^ 0.07 –0.03 0.13** 0.077. Unemployed/sick

leave^–0.04 –0.06 –0.11* –0.12*

8. Annual house income

0.19*** 0.16* 0.17** 0.11

9. Aid work (hours) 0.02 0.03 0.05 0.06R² = 0.06** R² = 0.07**F (9, 354) = 2.42 F (9, 354) = 2.83

Model 2: Medical  factors

Adjusted for 5 and 8(sign: p < .10 in step 1)

Adjusted for 5, 7 and 8(sign: p < .10 in step 1)

10. Lung disease patients¤

0.51*** 0.51*** 0.29*** 0.33***

11 . Control with negative events¤

–0.06 –0.08 –0.07 –0.08

12. Co morbidity –0.12* –0.18*** –0.13** –0.15**R² = 0.35*** R² = 0.19***

F (6, 371) = 14.89ΔR2 = 0.14***

F (5, 360) = 39.28ΔR2 = 0.30***

Model 3: Religious  factors

Adjusted for 5, 8, 10, 11 and 12 (sign: p < .10 in step 1 and 2)

Adjusted for 5, 7, 8, 10, 11 and 12 (sign: p < .10 in step 1 and 2)

13. Church attendance

0.10* 0.08 0.14** 0.04

14. Prayer 0.03 –0.05 0.11* –0.0215. Congregational

support0.12* 0.15** 0.15** 0.12*

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16. Positive religious coping

0.11* 0.01 0.20*** 0.11

17. Negative religious coping

–0.12* –0.14** –0.06 –0.06

R² = 0.40*** R² = 0.24***F (10, 286) = 18.94 F (11, 285) = 8.05ΔR2 = 0.05** ΔR2 = 0.04**

Final modelStep 1

All variables (sign: p < .10 in step 1, 2, and 3)

Final modelStep 1

All variables (sign: p < .10 in step 1, 2, and 3)

Beta Beta1. Education 0.12* 1. Education 0.08

2. Unemployed/sick leave

–0.20***

2. Annual house income

0.13* 3. Annual house income

0.14**

3. Co morbidity –0.18*** 4. Co morbidity –0.15**4. Patient¤ 0.51*** 5. Patient 0.33***5. Control with

negative events¤–0.08 6. Control with

negative events¤–0.08

R² = 0.35*** R² = 0.19***F(5, 291) = 31.75 F(6, 352) = 14.13

Step 2 Step 21. Education 0.06 1. Education 0.08

2. Unemployed/sick leave

–0.20***

2. Annual house income

0.12 3. Annual house income

0.14**

3. Co morbidity –0.17*** 4. Co morbidity –0.15**4. Patient¤ 0.53*** 5. Patient¤ 0.34***5. Control with

negative events¤–0.09 6. Control without

negative events¤–0.09

6. Congregational support

0.17*** 7. Congregational support

0.17***

7. Negative religious coping

–0.14**

R² = 0.39*** R² = 0.22***F(7, 289) = 26.84 F(7, 351) = 14.34ΔR2 = 0.04*** ΔR2 = 0.03***

Table 2 (cont.)

OVERALL QUALITY OF LIFE EXISTENTIAL WELL-BEINGUnadjusted

analysesAdjusted analyses

Unadjusted analyses

Adjusted analyses

Beta Beta Beta Beta

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Table 2 (cont.)

OVERALL QUALITY OF LIFE EXISTENTIAL WELL-BEINGUnadjusted

analysesAdjusted analyses

Unadjusted analyses

Adjusted analyses

Beta Beta Beta Beta

Step 31. Education 0.09 1. Education 0.082. Annual house

income0.14** 2. Unemployed/

sick leave–0.19***

3. Co morbidity –0.17*** 3. Annual house income

0.14**

4. Patient¤ –0.53*** 4. Co morbidity –0.15**5. Control with

negative events¤–0.09 5. Patient¤ 0.34***

6. Congregational support

0.22** 6. Control without negative events¤

–0.08

7. Negative religious coping

–0.02 7. Congregational support

0.22**

8. Patient X congregational support¤

–0.09 8. Patient X congregational support¤

–0.03

9. Control with negative events X congregational support¤

–0.07 9. Control with negative events X congregational support¤

–0.07

10. Patient X negative religious coping¤

–0.19**

11. Control with negative events X negative religious coping¤

–0.05

R² = 0.42*** R² = 0.23***F(9,349) = 11.34ΔR2 = 0.00

F(11, 285) = 18.85ΔR2 = 0.03**

Note. Predictors, signifijicant at p < .10, were carried forward to the next models. P-value was set at .05 in the fijinal model^ The comparison groups were “Retired” participants¤ The comparison was controls without negative events* p < .05 ** p < .01 *** p < .001 ΔR2 = R square change

was associated with higher overall QoL, whereas comorbidity was associ-ated with lower overall QoL. In the second adjusted model, the disease-related variables of comorbidity and group membership were entered, and the analyses showed that the lung disease group reported a signifiji-cantly higher overall QoL than the negative events group and the control group, and comorbidity was signifijicantly associated with lower overall QoL, when controlling education level and annual household incomes.

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After entering medical variables, the second model explained 35.3% of the total variance in overall QoL. The variables reaching signifijicance at level p < 0.10 were carried forward to the third model. According to the third set of unadjusted regressions, church attendance, congregational support, and positive religious coping were associated with higher overall QoL, whereas negative religious coping was associated with poorer overall QoL. In the third adjusted model, church attendance, prayer/meditation/Scripture reading, and positive religious coping were unassociated with overall QoL when controlling for demographic and medical variables, whereas congregational support was tied to better overall QoL, and nega-tive religious coping was linked with poorer overall QoL. After entering religious variables, the third model explained 39.8% of the total variance in overall QoL.

The fijinal model included variables signifijicant at p < 0.10 in the pre-vious adjusted regressions and four interaction terms testing possible interactions between group membership and congregational support and group membership and negative religious coping. The signifijicance level in the fijinal model was set at p < 0.05. In the fijinal model, fijive variables reached statistical signifijicance: Annual household income, being a lung disease patient, and receiving congregational support were signifijicantly associated with higher overall QoL, whereas comorbidity was signifijicantly associated with poorer QoL. The interaction term indicated that negative religious coping was signifijicantly associated with lower QoL among the lung disease group only and that congregational support was benefijicial for the control group only. The fijinal model accounted for 42.1% of the variance, the religious variables added 4.1% to the model over and above the demographic and medical factors, and the interaction terms added 2.7%, p < 0.01.

Religious Coping and Existential Well-Being

Exploring associations between existential well-being and diffferent pre-dictors, the fijirst set of unadjusted analyses showed that higher education, working full time or part time, and annual house income was associated with higher level of existential well-being, while being unemployed or at sick leave were associated with lower level of existential well-being. According to the fijirst set of adjusted analyses, being unemployed or on sick leave were associated with lower existential well-being, whereas higher annual house income was associated with better existential well-

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being. In the second set of unadjusted analyses, being a lung disease patient was associated with higher levels of existential well-being, while reporting co morbidity was associated with lower level of existential well-being. In the second set of adjusted analyses, controlling for demographic variables that were signifijicant in the fijirst adjusted model at p < 0.10, con-trols reporting negative events and participants reporting co-morbidity had lower level of existential well-being, while the lung disease group reported higher level of existential well-being. In the third set of unad-justed analyses, exploring associations between existential well-being and religious factors, church attendance, prayer/meditation/Scripture reading, congregational support, and positive religious coping were all associated with higher levels of existential well-being, while negative religious coping was not associated with existential well-being. In the third adjusted model controlling for demographic and medical factors that were signifijicant in model 1 and 2, congregational support reached statistical signifijicance and was carried forward to the last model.

The fijinal model included variables signifijicant at p < 0.10 in the previous adjusted regressions. Furthermore, interactions terms testing the possible interaction between group membership and congregational support were added. The signifijicance level in the fijinal model was set at p < 0.05. In the fijinal model, fijive variables reached statistical signifijicance: higher annual household income, being a lung disease patient, and reporting congrega-tional support were signifijicantly associated with higher levels of overall existential well-being, while comorbidity and being unemployed or on sick leave were signifijicantly associated with poorer existential well-being. The interaction efffect revealed that only the control group benefijitted from congregational support, but the interaction term did not add signifijicantly to the model over and above demographic, medical, and religious factors. The fijinal model accounted for 22.6 % of the variance, with congregational support adding 2.5% over and above demographic and medical factors.

Discussion

The present study was designed to test the generalizability of two fijindings that have emerged from research conducted in the US: (a) Reminders of mortality and human frailty, such as life threatening disease or negative life events, are associated with greater religiousness and religious coping when compared to individuals reporting no negative events, and (b) the

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associations between religiousness and well-being are stronger among people facing major life events. More specifijically, higher levels of positive religious coping are tied to greater QoL and existential well-being among those dealing with negative life events, and higher levels of negative religious coping are tied to lower QoL and existential well-being among people facing major life events. The results of the present study offfered partial support for these predictions. Religious activities did not difffer between people facing life threatening illness and other negative events when compared to a healthy control group, but some forms of positive religious coping were more prevalent among life threatened individuals (lung disease patients) than those who were not dealing with negative life events (control group). Furthermore, negative religious coping was associ-ated with lower QoL among lung disease patients only. In contrast to our predictions, social support from one’s congregation was associated with better overall QoL and existential well-being only for the control group.

Religiosity and Prevalence of Religious Coping

The samples did not difffer signifijicantly in terms of religious behavior such as church attendance and prayer/meditation/Scripture reading, indicating that negative life events did not afffect either public or private religious behaviors signifijicantly. Our samples reported more frequent church atten-dance than usually reported for the general Danish population. Only 7% reportedly attend church monthly in the general population (The Danish Value Survey, 2008) in contrast to almost 15% in the present study. One reason for this diffference could be the relatively high mean age of our participants, which is supported by previous studies showing that elderly generations are more religiously oriented than younger ones. A Danish study by Andersen et al. (2011) using data from the Danish Value Survey 1990–2008 found that levels of religiosity were associated with the cohort the individuals belonged to; that is, elderly people were in general more religiously oriented than younger generations. However, the study did not support the idea that a person becomes more religious with age. The diffference between generations was mainly explained by declines in reli-gious socialization during childhood among the younger generations.

Religious coping strategies in the present study were prevalent among all three groups. Positive religious coping was reported more frequently than negative religious coping strategies, which is in accordance with results from previous studies (Bjorck & Thurman, 2007). The results suggest that lung disease patients report more overall positive religious

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coping when compared to the control group, but signifijicant diffferences were not found between lung disease patients and the negative events group or between the negative events group and the control group. The strategies of asking for forgiveness and positive religious meaning-making were especially prevalent in the lung disease group. Earlier studies have found that, due to life style-related factors like smoking in the etiol-ogy of lung disease, lung disease patients often report greater self-blame (Chapple, Ziebland, & McPherson, 2004). It could be that the lung disease patients in our study may have experienced a need to ask forgiveness for an unhealthy life style and could be seeking reconciliation with family or friends (and ultimately God) while there was still time (De Guzman et al., 2010). Furthermore, receiving a life threatening diagnosis like lung cancer or COPD may increase the need for fijinding meaning in the midst of major life challenges. In a study of the existential and spiritual needs among cancer patients, Moadel and colleagues (1999) found that 40% reported to have a need for fijinding meaning. In our sample, almost two thirds of the lung disease group (60%) reported using religious meaning-making to some degree or more, compared to approximately one third of both the negative events group and the control group. Patients may benefijit from increased focus on (religious) meaning-making, and health professionals or hospital chaplains may be able to support this positively. Caution is called for here, however. It may be premature to suggest specifijic inter-vention programs because research in this area in Denmark is only in its infancy, and more studies on religious, spiritual, and existential needs and practices during severe illness are needed.

Contrary to expectations, we found no diffferences in religious coping between the negative events group and the control group. Reasons for this fijinding may be that the negative events reported in the present study were less serious than lung disease and in some instances involved a close relative versus oneself. Therefore, it seems religion was not widely mobi-lized as a coping strategy by this group. This fijinding would support the theory of terror management, namely, that reminders of one’s own per-sonal mortality are more likely to trigger religiosity than more mundane life events.

Religious Coping and Overall QoL

While the unadjusted analyses suggested a positive association between positive religious coping and QoL, the adjusted model did not support the hypothesis that positive religious coping afffects well-being. It has been

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suggested that due to the relatively high standard of living among Danes, religious coping strategies may not contribute signifijicantly to adjustment among Danes (Pedersen, Pedersen, Pargament, & Zachariae, in press) as seen in American studies among individuals with fewer economic and secular resources (Pargament, 1997). Another explanation could be that our results reflect the efffect of secularization. From this perspective, reli-gion no longer provides a framework for meaning, comfort, and control; it is only mobilized during times of distress but has little efffect on adjust-ment. Finally, the non-signifijicant associations between positive religious coping and QoL could be the result of what has been called a religious cop-ing mobilization efffect (Pargament, 1997). This efffect occurs in cross-sec-tional studies and involves two offfsetting or counterbalancing forces: (a) the positive efffect of religious coping on distress or well-being (i.e., QoL); and (b) the mobilizing efffect of distress or lower well-being (i.e., QoL) on religious coping. While the fijirst efffect would create a positive correla-tion between religious coping and QoL, the second efffect would create a negative correlation between religious coping and QoL. In theory, the two efffects could wash each other out, resulting in a non-signifijicant correla-tion between positive religious coping and distress/well-being. Longitu-dinal designs are needed to tease out these efffects.

In contrast, congregational support was found to be signifijicantly asso-ciated with better overall QoL. The control group benefijitted most by this type of support. Receiving social support from the members of one’s con-gregation or fellow believers may be perceived as interpersonal religious coping, which is represented in the Brief RCOPE by only one item (Ano & Pargament, 2012). A meta-analysis of 38 studies found that social sup-port from members of religious communities is one of the most-reported predictors of mental health (Larson et al., 1992) and appears to influence well-being more than private aspects of religiosity, such as prayer (Lim & Putnam, 2010). Social support in general has been found to be a stress-bufffering factor (Antonovsky, 1979). The present study, however, did not include specifijic measures of other types of non-religious social support (family, friends, neighbors, colleagues, self-help groups, or others). Thus, we do not know whether congregational support contributed to better QoL among Danes above and beyond the efffects of other forms of social support. It may, however, be argued that people engaged in religious communities may have easier access to social networks and therefore a fijirmer background of social support. This could also apply to Danes who are involved in religious communities.

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Although not as prevalent as positive religious coping, negative reli-gious coping was associated with lower overall QoL among lung disease patients, thereby confijirming previous results from a range of studies (Ano & Vasconcelles, 2005). Our results contribute to the literature by demon-strating that negative religious coping seems to afffect QoL in a negative direction even in a highly secularized society such as Denmark, in con-trast to the idea that religious beliefs are irrelevant to Danes (Zuckerman, 2008). There could be several possible explanations for this fijinding. First, lung disease patients report more internal causal illness attributions (e.g. smoking), which, in turn, have been associated with poorer adjustment in terms of higher anxiety and more depressive symptoms (Else-Quest, LoConte, Schiller, & Hyde, 2009). Thus, blaming oneself for an unhealthy life style leading to the development of illness may also be tied to religious struggles, such as thoughts of “getting what you deserve” as a punishment from God. One study by Webb (1995) found that self-blame among people who reported abuse experiences was tied to beliefs in a punitive God. Such fijindings may be explained by the just-world-theory (Lerner & Miller, 1978), which states that people are motivated to maintain their beliefs that the world is just (Hafer & Bégue, 2005). Patients facing severe illness may also pose the question “Why me?” and feel that their just world views have been violated (Janofff-Bulman, 1992). This could potentially lead to strategies of holding God responsible for an event, seeing oneself as a vic-tim (Exline et al., 2011), or perceiving an event as unfair and uncontrol-lable (Ano & Pargament, 2012), thereby resulting in religious struggles and poorer well-being.

Second, it is possible that other factors that were not measured are responsible for the associations between religious struggle and lower QoL. In a recent study of 309 undergraduate students coping with negative events, Ano and Pargament (2012) found that personality factors such as neuroticism and ambivalent attachment to God were signifijicant predic-tors of religious struggles. Due to the cross-sectional design of the pres-ent study, we are unable to determine whether negative religious coping caused low QoL or vice versa, and additional unknown variables could be contributing to both. Longitudinal studies that assess possible moderating or mediating factors are needed to explore such causal explanations.

Finally, in line with terror management theory, some studies have found that only well-developed religious beliefs function as a bufffer against death anxiety and result in higher well-being (Jonas & Fischer, 2006). As we have argued previously (Pedersen et al., in press), it is therefore possible

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that religious struggle was prevalent among the lung disease group because their religious beliefs were not fully functioning and integrated due to secularization. When trying to mobilize their religious beliefs, lung disease patients may have experienced that their religious beliefs repre-sented a source of doubts and frustration instead of a source of comfort and hope, thereby resulting in poorer QoL. The present study found that lung disease patients may be especially vulnerable to the efffects of nega-tive religious coping on well-being, perhaps because of the profound and disturbing struggles that may be tied to lung disease as compared to other major life events.

Religious Coping and Existential Well-Being

Associations between existential well-being and positive and negative reli-gious coping did not reach statistical signifijicance in the adjusted regres-sions. Existential well-being represents the extent to which an individual experiences meaning and purpose in life and fijinds comfort in religious and spiritual beliefs. It has been suggested that one of the core functions of religion is meaning-making (Park, 2005). While previous studies have found positive associations between positive religious coping and exis-tential well-being (Arnette, Mascaro, Santana, Davis, & Kaslow, 2007; Holt et al., 2011), the present study failed to reveal associations between posi-tive religious coping strategies and existential well-being in the adjusted model. Negative religious coping was not associated with existential well-being either, which is somewhat surprising given the links between nega-tive religious coping and overall QoL.

The lack of statistically signifijicant associations between positive reli-gious coping and QoL and existential well-being in the adjusted regressions could also be explained by another fijinding. The hierarchical regressions indicated that the lung disease group scored signifijicantly higher on all subscales of overall QoL and existential well-being than the negative events group and the control group, which by itself was an unexpected fijinding. This fijinding could be due to several factors. First, normative data on the FACT-G comparing cancer patients with healthy controls suggest that patients may score higher on social well-being than the general popu-lation perhaps because they receive high levels of social support for their illness (Brucker et al., 2005). It may be argued that higher social support is associated with better emotional well-being, thereby causing a higher score in overall QoL as reported in the present study. Second, the dif-ferences in scores on well-being measures between patients and healthy

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controls may reflect avoidant coping strategies among the lung disease group; that is, patients may report higher levels of well-being as a way of minimizing the gravity of their situation. Finally, the fijinding could be influenced by selection bias in recruiting the patient sample. Due to the severity of lung disease, only the higher functioning patients may have participated. Thus, diffferences in QoL and existential well-being scores between the lung disease group, the negative events group, and the con-trol group could explain why no associations were found between posi-tive religious coping and QoL and existential well-being in the adjusted regression model. More studies investigating diffferent patient groups are needed to clarify the impact of religiosity among severely ill patients in secular societies like Denmark.

Limitations and Future Directions

The present study is among the fijirst to investigate the prevalence of reli-gious coping and associations to QoL and existential well-being in a secu-lar country such as Denmark. Some limitations of the study should be noted. Among the key limitations is the issue of the low response rate among lung disease patients and the subsequent limited representative-ness of this sample with respect to the population of lung disease patients as a whole. In general, the samples represented elderly individuals, and religious issues may be perceived very diffferently among younger gen-erations. One previous Danish study found that religious, spiritual, and existential concerns were signifijicantly more prevalent among younger (< 36 years) hospitalized patients (Ausker et al., 2008). Because religious upbringing has become less common over time in Denmark, it is important to identify those resources that become important in coping and mean-ing-making during challenging life events among younger Danes. Second, the cross-sectional design of the present study limits our ability to draw conclusions about causality. Although more recent longitudinal studies have yielded valuable insights into the mechanisms of religious coping in association with well-being, studies are needed in secular societies too. One area of potential interest is the question of possible associations between negative religious coping and post-traumatic growth, which so far has only been scantily explored in the literature (Pargament, Desai, & McConnell, 2006). Questions about this issue may be present in secular societies where existential and religious struggles may develop diffferently than in religious societies such as the US. It has been argued that ben-efijit fijinding or positive thinking may be more commonplace as a cultural

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construction in the US than in European countries (Ehrenreich, 2009), but whether this has any influence on how negative events are dealt with in terms of religious coping among Europeans is unclear. Finally, the cop-ing and support assessments used in the present study were limited to religious coping and support. The rather large amount of non- responders on the religious coping items calls for reflection. Analyses suggested that especially control participants did not answer the religious coping items. This fijinding may be due to methodological issues. Control participants may have misinterpreted the instruction (that they were to think of how they usually cope with major challenges when answering the Brief RCOPE), and instead skipped the whole questionnaire, because they did not specify a negative event. Another explanation could be that the religious coping items did not apply to the non-responders. It could be important to exam-ine other secular and spiritual existential coping strategies of meaning-making and social support in further research (la Cour & Hvidt, 2010).

Despite these limitations, the present study yields relevant insights into the prevalence of religious coping and associations with well-being among Danes. Support was found for the hypothesis that life threatening situations like a lung disease may be tied to religious coping, even among individuals from societies who in general are not thought to be very religious. Support was also found for the hypothesis that negative religious coping (religious struggle) is associated with lower QoL among lung disease patients. These results indicate that although religion may not play a central role in the lives of the majority of the Danes, religious coping strategies may become relevant in life threatening situations such as severe illness. Health profes-sionals, as well as hospital chaplains, imams, and rabbis should consider a detailed religious or spiritual assessment (see Grossoehme & Fitchett, 2013 [this volume]) for patients who may be at risk of developing religious struggles, as this may be tied to poorer adjustment among Danes.

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Paper 3

1

Psycho-social factors associated with religious struggles during

negative life events in a secular society

Heidi F. Pedersen, Christina G. Pedersen, & Robert Zachariae

Unit for Psycho-Oncology and Health Psychology, Department of Psychology, Aarhus University

and Department of Oncology, Aarhus University Hospital, Aarhus, Denmark

Submitted for Psychology of Religion and Spirituality (Spring 2013)

Author note

Heidi F. Pedersen, Unit for Psycho-Oncology and Health Psychology, Department of Psychology,

Aarhus University; Christina G. Pedersen, Unit for Psycho-Oncology and Health Psychology,

Department of Psychology, Aarhus University; Robert Zachariae, Unit for Psycho-Oncology and

Health Psychology, and Department of Oncology, Aarhus University Hospital

The project was supported by the Danish Knowledge and Research Centre of Complementary and

Alternative Medicine (ViFAB) in collaboration with Center for Cross-Scientific Evaluation Studies

on Complementary and Alternative Medicine (CCESCAM) at University of Southern Denmark and

Aarhus University as well as a stipend from Aarhus University.

Correspondence concerning this article should be addressed to Heidi Frølund Pedersen, Department

of Psychology, Aarhus University, 8000 Aarhus C, Denmark. E-mail: hefpe@psy.au.dk

2

Abstract

Negative religious coping, e.g. religious struggles, has been associated with deleterious effects on

health and well-being. Yet, few studies have examined the possible psycho-social factors associated

with religious struggles. In this present study we examined the associations between the presence of

religious struggle and personal dispositions (personality traits and adult attachment style), religious

factors (religious beliefs, church attendance, and private religious activities), social factors (social

support and congregational support), situational factors (negative events and impact of event on

quality of life), and socio-demographic factors (age, gender, education, marital status, and income)

in a group of middle-aged and elderly community dwelling Danes exposed to major negative life

events. Results suggested that between 9% and 24% of the total sample reported religious struggle

to some degree. Multiple logistic regressions indicated that the presence of religious struggle was

associated with: higher levels of neuroticism (OR: 1.08, 95% CI: 1.04-1.12, p < 0.01) and reporting

higher levels of congregational support (OR: 2.7, 95% CI: 1.45-6.02, p < 0.01). The results are

discussed in relation to the secular culture of Denmark.

Keywords: Religious struggle, negative life event, neuroticism, god concept, secular

3

Several studies have explored the associations between spirituality and health, and in general the

results indicate beneficial effects of spirituality on physical and mental health (Koenig, King, and

Carson, 2012). However, spirituality may also be a source of problems. In recent years, measures of

spirituality have been refined especially in the area of religious coping (Pargament, Smith, Koenig,

& Perez, 1998), and several studies across diverse populations have revealed potential harmful

effects of engaging in negative religious coping, e.g. religious or spiritual struggles (hereafter

referred to as religious struggles) (Exline, 2013). Religious struggles are defined as questions,

tensions, and conflict about religious and spiritual issues concerning one’s God, interpersonal

relationships, and oneself (Pargament, Murray-Swank, Magyar, & Ano, 2005). The construct of

religious struggles has been examined using the negative subscale of the Brief RCOPE, a religious

coping measure developed by Pargament and collegues (1998), which mainly covers divine

struggles such as thoughts of being punished by God and feelings of abandonment, but also

interpersonal struggles covering concerns about abandonment from one’s congregation. Overall, it

has been found that religious struggles are negatively associated with physical and mental health. In

a meta analysis on 49 studies, modest but significant associations (effect size of 0.22) were found

between religious struggles and higher levels of psychological distress during negative events (Ano

& Vasconcelles, 2005). Literature reviews of studies among cancer patients also suggest measures

of negative religious coping to be associated with lower levels of quality of life (QoL) and greater

emotional distress (Lavera & O’Hea, 2010; Thuné-Boyle, Stygall, Keshtar, & Newman, 2006). It

has been argued that religious struggles is not harmful per se, but can also be a source of post

traumatic and spiritual growth (Gerber, Boals, & Schuettler, 2011), but studies are few and results

are contradicting (Exline, 2013). Furthermore, studies suggests that prolonged religious struggles

are at risk of turning chronic and have even more devastating impact on health in terms of poorer

adjustment to cancer over time (Exline, Park, Smyth, Carey, 2011) and increased mortality among

4

medically ill patients (Pargament, Koenig, Tarakeshwar, & Hahn, 2001). Thus, it is important to

look into which factors are associated with the development and presence of religious struggles in

order to better understand the phenomenon and possible prevent the struggles to grow into a more

chronic states.

Predictors of religious struggles

A growing number of studies encompass potential risk factors for developing religious

struggles, and theoretical models have been developed and tested to better understand which factors

may be associated with religious struggles. According to Pargament (1997), particular coping

strategies are chosen if they are available and compelling to the individual. Our general orienting

system, which covers personal elements (such as personality traits and attachment style), religious

elements (such as religiousness and perceptions of the Sacred), and social elements (such as

interpersonal relationships and access to social support), determines to which degree coping

strategies are available and compelling to us. Religious struggles may stem from an orienting

system characterized by conflict, strain and weakness, but could also be activated during severe

negative life events threatening core beliefs (Ano & Pargament, 2012; Bjorck & Thurman, 2007;

Pargament, 1997). It is suggested that religious struggle should be viewed as a multidimensional

phenomenon including personality, religious factors, social factors, situational factors, and socio-

demographic factors. Studies have found religious struggles to be associated with several different

sources like individual characteristics such as neuroticism (Ano & Pargament, 2012), and insecure

attachment style (Belavich & Pargament, 2002; Schottenbauer et al., 2006). It is argued that the

individual’s relationship to God “bears striking resemblance to the child’s attachment to caregivers”

(Granqvist, 2005: 36; Kirkpatrick, 1999), and insecure attachment style may therefore be a crucial

predictor of maladaptive adjustment such as religious struggles during negative life events. In terms

5

of social predictors, religious struggle has been found among people with poor social support

(McConnell et al. 2006). Furthermore situational factors such as negative events and evaluating this

life event as uncontrollable and shaking up an individual’s life have also been linked with religious

struggles (Ano & Pargament, 2012; Exline, Park, Smyth, Carey, 2011; Schottenbauer et al. 2006).

Finally, studies including socio-demographic factors suggest that being young (Exline et al., 2011),

male (Hvidtjørn, Hjelmborg, Skytthe, Christensen, & Hvidt, 2013), and unmarried (McConnell,

Pargament, & Ellison, 2006) is associated with greater religious struggles. However, relatively few

studies are currently available on psycho-social factors associated with religious struggles in more

secular contexts.

A universal or culture-specific phenomenon?

So far, the majority of studies on spirituality and health have been conducted in North

America, which has been characterized as being far more religiously oriented than, for instance,

Denmark (Zuckerman, 2008). In Denmark, religion is characterized as fragmentized and highly

individualized (Iversen, 2006), but it is unclear whether religious struggles are prevalent among

Danes. It is argued that secular individuals may to a higher degree be challenged when adjusting to

stressful life events because they lack coherent and functional world views (Stålhandske, Ekstrand,

& Tyden, 2011). On the other hand, they may not experience struggles in relation to religious issues

if they do not embrace religion as important in everyday life (la Cour, 2005). Researchers have

argued that aspects of religious struggles such as feeling abandoned by God or a higher power may

represent a universal existential void occurring during deep crisis and depression (Braam, et al.,

2010). In their study of a multi-ethnical sample (including Muslims and more secular Dutch

citizens), Braam and colleagues found that the strongest predictor of depression, independently of

the participants’ religious background, was the negative coping strategy of “feeling abandoned by

6

God”. Studies from the U.S. indicate that religious struggle may also appear among less religious

individuals (Exline, Park, Smyth, Carey, 2011) and recent research on spirituality and health in

Denmark (Pedersen, Pargament, Pedersen, Zachariae, 2013; Pedersen, Pedersen, Pargament, &

Zachariae, 2013), suggests that religious struggles are prevalent among Danes when dealing with

negative life events such as severe lung disease or bereavement, and that religious struggles may

pose a threat to well-being as negative religious coping was associated with lower quality of life

among lung disease patients. Due to increased individualization and fragmentation of religion in

Western world (Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985; Pargament, Mahoney, Exline,

Jones, & Shafranske, 2013) information about what predicts religious struggles in a more secular

society like Denmark may add important information to international research on the phenomenon

of religious struggles.

In the present study we wanted to test the model suggested by Ano & Pargament (2012),

adding socio-demographic factors to the model, and explore which factors are associated with

religious struggles among people living in secular societies. The aim of the present study was to

explore the association between different psycho-social factors and religious struggles (negative

religious coping) during times of distress in a sample of middle-aged and elderly Danes. It was

hypothesized that a negative religious coping style would be associated with religious factors, i.e.

general religiousness, personality factors, i.e. insecure adult attachment style and neuroticism, social

factors, i.e. low social and congregational support, and situational factors, i.e. negative events and

the impact of negative events on QoL.

Method

Procedure

The present study was part of a larger study focusing on the use of complementary and

alternative medicine (CAM) and religiosity among Danish chronically ill lung disease patients. The

7

sample used in the present study was established as a control group socio-demographically matched

with a sample of chronically ill lung patients. The sample was established by Statistics Denmark, a

government agency with access to a wide range of national registries, including the Central Person

Registry (CPR). All Danish residents are given a CPR number, enabling retrieval of information

for research purposes. In all, 11 individuals per patient in the original study matched on age,

gender, education level, and region were selected from the CPR-registry. The resulting 1.437

potential participants were mailed a questionnaire during March 2010 and asked to complete and

return the questionnaire. Those who did not return the questionnaire within 2 weeks were mailed a

single reminder. In all, 498 responded (response rate = 34.7%). Of these, 45 were excluded due to

insufficient data, resulting in a total sample of 453 respondents.

Measures

Negative life events. An adjusted version of the List of Recent Events (LRE) (Henderson,

Byrne, & Duncan-Jones, 1981) was used to access the presence and psychological impact of major

life events during the last 12 months among the participants. The listed events included: (a) illness,

injury, and accident, (b) bereavement, (c) pregnancy or abortion, (d) changes in relationships, (e)

living conditions, (f) education, (g) employment, and (h) finances and legal difficulties. The

category of pregnancy or abortion was excluded, as this item did not seem relevant to the present

sample due to their mean age (mean 67.9, SD 9.7). The response format of the question “Have you

within the past 12 months experienced [event]?” was Yes or No for each event. For the items

“Illness, injury, and accident” and “Bereavement,” the questions were worded: “Have you or one of

your closest relatives experienced [event]?” For each event, participants were asked to indicate to

what degree this event had a negative influence on their QoL on a 5-point Likert scale from 1: (Not

at all) to 5: (Very much), resulting in an impact of event score. A categorical variable called

8

“negative events group” was created to distinguish between participants reporting a negative event

with high negative impact on QoL, participants reporting a negative event with low negative impact

on QoL, and participants not specifying a negative event: Participants scoring above 2 on the impact

of events score were categorized as the high impact group (value=3), participants scoring below 3

on the impact of event scores were categorized as the low impact group (value = 2), and participants

not specifying an event was categorized as the non-specified event group (value=1).

Religious struggles. Negative religious coping was measured using the negative subscale

of the Brief RCOPE (Pargament, Smith, Koenig & Perez, 1998), a 7-item measure of the degree to

which individuals interpret their situation as a punishment or abandonment by God (“Wondered

whether God had abandoned me”). This scale is often referred to as a religious or spiritual struggle

scale, because it is taken to reflect a religious system in tension or turmoil (Pargament et al., 2005).

The response format is a 4-point Likert scale ranging from 0 (Not at all) to 3 (A great deal), and a

total score is calculated. Internal consistency (Cronbach’s alpha) was 0.60 for the negative religious

coping scale in the present sample. Omitting item 7“Questioned the power of God” increased

Cronbach’s alpha to 0.71. An unpublished qualitative validation study of the Brief RCOPE

conducted by the first author suggested that non-religious people and atheists often answer this last

item “Questioned the power of God” with “Very much.” Not because they have religious struggles,

but simply because they want to declare their disbelief in God. On this background, we chose to

omit this item from the analysis, although this particular item has previously been found to be one

of the most commonly endorsed religious struggles among cardiac patients with symptoms of acute

coronary syndrome (Magyar-Russell et al., submitted for publication) and among diabetic,

congestive heart failure, and oncology patients (Fitchett et al., 2004) in the United States.

Thus, the final measure consisted of 6 items covering negative religious coping strategies.

When answering the religious coping items, participants were asked to think of the most negative

9

life event they reported. Those who did not specify a negative event were asked to answer how they

usually cope with major challenges. The data were positively skewed and we therefore chose to

dichotomize the scale into: 1: Religious struggle = all values above 0, and 0: No religious struggle

= 0.

Socio-demographic factors.

Socio-demographic information included: age, gender, marital status (dichotomized into

married/cohabiting and widowed/ divorced/ single), highest education level (dichotomized into Low

education = 7-10 years and High education = > 10 years), and socio-economical status (annual

house income).

Personality factors

Personality traits. Personality traits were measured by the NEO Five Factor Inventory including 62

items (NEO-FFI, Costa & MaCray, 1992), which covers the five-factor model of personality traits.

The NEO FFI consists of 5 subscales covering: Conscientiousness (“I am well known for my

judgment and common sense”), Agreeableness (“I would rather corporate than compete”),

Openness to experience (“I like to concentrate on a fantasy or daydream and let it grow and

develop”), Extroversion (“I am a happy and cheerful person”), and Neuroticism (“I often feel tense

and jittery”). Respondents indicated the degree to which they agreed with each statement on a five-

point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. A total score was

calculated for each subscale by summing the responses. In the present sample, the internal

consistency (Cronbach’s alpha) was: 0.74 for conscientiousness, 0.72 for agreeableness, 0.67 for

openness to experience, 0.81 for extroversion, and 0.84 for neuroticism respectively.

Adult attachment. Adult attachment was measured by a Danish version of the Revised

Adult Attachment Scale (RAAS), an 18-item self-report scale measuring how the participants

function and feel in a relationship with a partner, someone close, and people in general, (“I feel

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good being dependent by others”, “I think it is difficult to trust others fully”). Each statement is

rated in a five-point Likert scale from 1 (not at all characteristic) to 5 (very characteristic). The

scale is two-dimensional: 1) items assessing closeness and dependency are merged into one

dimension (α= 0.65) (O’Connor & Elklit, 2008) and 2) an anxious attachment dimension (α= 0.76).

Based on the RAAS, attachment styles corresponding to Ainsworth’s three original attachment

patterns (secure, anxious-ambivalent, and avoidant) can be generated (Collins & Read, 1990; Stein,

Jacobs, Ferguson, Allen, & Fonagy, 1998; O’Connor & Elklit, 2008). A fourth attachment pattern

corresponding to a fearful style was also calculated (Collins & Feeney, 2004). The categorical

attachment styles are categorized using the values on the dimensions of “close-dependency” and

anxious attachment; e.g., secure attached are defined as scoring high on the close-dependency

dimension and low on the anxious dimension. High is defined as being above the midpoint on the 5-

point scale, and low as below the midpoint. Thus, cut off values for the respective attachments

styles were as follow: Secure attachment style = total close-dependency > 36 + total anxious

attachment style < 18. Preoccuppied attachment style = total close-dependency > 36 + total anxious

attachment style > 18. Dismissive attachment style = total close-dependency < 36 + total anxious

attachment style < 18. Fearful attachment style = total close-dependency < 36 + total anxious

attachment style > 18. In the present study 78.6% (n= 312) were determined as exhibiting a secure

attachment style, 4% (n= 16) a preoccupied attachment style, 14.1% (n=56) a dismissive attachment

style, and 3.3% (n=13) a fearful attachment style. Due to small numbers in two of the groups, we

chose to collapse the insecure attachment styles (preoccupied, dismissive, and fearful) into one

category (0 = Insecure) to be compared with the securely attached (1= Secure).

Religious factors

General religiousness. Public religious activity was assessed by a single item asking about

church attendance and/or attendance at other religious meetings: “How often do you attend church

11

or other religious services?” Private religious activity was measured by a single item about the

frequency of prayer, meditation, and/or scripture readings: “How often do you engage in religious

activities like prayer, meditation, or scripture reading?” Response options to both measures were

5-point Likert scales ranging from 1 (Never), 2 (A couple of times year), 3 (A couple of times a

month), 4 (Weekly), and 5 (Every day).

Religious beliefs. According to the European Value Survey (2008) seven out of ten Danes

characterize themselves as a believing person, however only 22% believe in a personal God and

35% believe in a higher spiritual power. We therefore developed five distinct items in the attempt of

accommodating people who neither believe in God or spiritual power. Participants were asked to

categorize themselves into one of five categories: 1) “I consider myself a believer. I believe in

God”, 2) “I consider myself a believer. I believe in a higher, spiritual being”, 3) “I consider myself

a believer. My beliefs concerns being part of a cultural/historical community, and I do not believe

in God or a higher, spiritual being”, 4) “I consider myself a non-believer, but would not reject the

possibility that a god or a higher, spiritual being exists”, and finally 5) “I consider myself an

atheist”.

Social factors. Social support. Social support was measured by the Social Well-being

subscale from a revised version of the FACT-G (Cella, Tulsky, Gray, Sarafian, Linn, Bonomi,

Silberman, Yellen, Winicour, Brannon et al., 1993) (“I feel close to my friends”, “I get emotional

support from my family/my nearest”, “I get support from my friends”, and “I feel close to my

partner (or the person that is my best support)”. Responses are given on a 5-point Likert scale

ranging from 1 = Not at all to 5 = Very much.

Congregational support. Congregational support was measured by a single item: “To what

degree do you receive support from your fellow believers” using the format: 2 = Yes, 1 = No, or 0 =

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Not relevant. The score was then dichotomized into 1 = Congregational support and 0 = No

support.

Statistical analysis

Mean substitution was used to handle missing data on continuous variables as suggested by

Schafer and Graham (2002). This procedure is adequate and preferable to procedures such as list-

wise deleting or scale mean substitution. Chi square tests were conducted for the categorical

variables (gender, education, marital status, attachment, religious beliefs, congregational support,

and negative life events) possibly associated with the dependent variable: negative religious coping.

Spearman correlations were run for continuous variables (age, income, the five personality factors,

church attendance, private religious activity, and social support) possibly associated with negative

religious coping. The variables that were significant in the initial Chi-square tests and correlation

analyses were tested in five independent unadjusted regressions testing socio-demographic factors,

personality factors, religious factors, social factors, and situational factors. Variables that were

statistical significant at p < 0.1 in the five independent regression models were tested in a final

logistic regression, and the significance level was set at p < 0.05.

Results

Sample

Of the 453 participants, 113 did not answer the religious coping items and were excluded

from the analyses. One-way ANOVAS and chi square tests suggested non-responders to be mostly

people who did not specify a negative event, were older, had lower income, and went to church

more often than responders. A total of 340 participants were included in the analyses. The majority

was male (53.8%), and the mean age of the participants was 67.8 years (range 42 – 90 years, SD

13

9.6). The majority were married (79.5%), had fewer than 11 years of education (72.4%), and the

average annual house income was $52.000-$70.000. In terms of religious factors most (87.8%)

identified themselves as Christians and 91.8% were members of the National Church. When asked

about their beliefs, 52.1% of the sample considered themselves to believe in God (theists), 12.4%

considered themselves to believe in a higher, spiritual being (spiritual), 8.5% considered themselves

believers, but not believing in God or a higher, spiritual being (secular believer), 20.3% considered

themselves to be non-believers (non-believers), and 5.3% considered themselves to be atheists

(atheists), while the remaining 1.5% did not specify their belief. Only 3% attended church weekly,

10.9% attended church once or more a month, 60.1% a couple of times a year, while 26% of the

sample answered that they never attended church.

Negative events and religious struggles

In all, 174 referred to a specific negative event when answering the religious coping items

with 51.7% reporting this event to be an illness or accident, 15.5% bereavement, and 32.6% other

negative events, e.g. divorce or financial problems. Of the 174 reporting a specific event, 119

characterized the specified negative event to have a high negative impact on their quality of life and

is referred to as the high impact group, whereas 55 reported the event to have low or no impact on

their quality of life and is referred to as the low impact group. A total of 166 did not specify any

negative event or the impact of event, when answering the religious coping items and is referred to

as the non-specified event group. In the high impact group, 24.4% reported to experience religious

struggle in relation to the event to some degree (mean=0.75, SD=1.78). In the low impact group,

9.1% expressed religious struggles in relation to the event to some degree (mean=0.13, SD=0.47),

and in the non specified event group, 22.9% reported religious struggles to some degree

(mean=0.69, SD=1.67).

14

Chi-square analyses

Chi-square tests were run for the categorical variables possible associated with religious struggles.

The analyses suggested that, marital status χ² ((3, n = 331) = 7.87, p = .05, phi = .05), attachment

style χ² ((1, n = 306) = 3.83, p = .05, phi = .03), religious beliefs χ² ((3, n = 331) = 7.87, p = .05, phi

= .05), congregational support χ² ((1, n = 340) = 14.11, p = .00, phi = .00), and negative event

groups χ² ((1, n = 340) = 14.11, p = .00, phi = .00), were associated with reporting religious

struggles. No significant differences were found in relation to gender, χ² ((1, n = 340) = 0.36, p =

.46, phi = .04), or education level, χ² ((1, n = 340) = 2.57, p = .11, phi = .08).

Correlational analyses

Table 1 displays the correlation matrix of the continuous variables possible associated with

religious struggles. As for the socio-demographic variables, it was suggested that lower income was

positively associated with religious struggles, whereas age was not significantly associated with

religious struggles. Testing personality variables, higher agreeableness was negatively associated

with religious struggle, and neuroticism was positively associated with religious struggles.

Furthermore, analyses suggested 2 religious variables to be associated with religious struggles:

church attendance and private religious activities were positively correlated with religious struggles.

The social factor, social support, did not turn out significant.

INSERT TABLE 1 AROUND HERE

Regression analyses

The significant variables from the Chi-square tests and correlation analyses were tested in

5 independent logistic regression models to decide which variables to include in a final full model

(see table 2). The first independent regression model tested socio-demographic factors associated

15

with religious struggles in the initial analyses and included income and marital status. It was

suggested that lower income was statistically significant (OR: 0.8, CI 95%: 0.68-0.96, p < 0.03),

whereas marital status was insignificant. In the second independent regression model, personality

factors that were significant in the initial analyses were tested, and included agreeableness,

neuroticism, and attachment style. Neuroticism was found to be significantly associated with

religious struggles (OR: 1.08, CI 95%: 1.04-1.12, p < 0.01) whereas agreeableness and attachment

style were not. The third independent regression model tested religious factors and included

religious beliefs, church attendance, and private religious activities, but only higher church

attendance was associated with religious struggles (OR: 1.83, CI 95%: 1.23-2.7, p < 0.01). The

fourth model tested social factors and included congregational support, which was suggested to be

significantly associated with religious struggles (OR: 2.82, CI 95%: 1.80-4.42, p < 0.00). The fifth

model testing situational factors included the three groups reporting negative events (high impact

group, low impact group, and non-specified event group), and the analyses found that a

significantly lower amount of participants in the low impact group reported religious struggles (OR:

0.33, CI 95%; 0.14-0.77, p < 0.03), whereas a marginally larger amount of participants in the high

impact group reported religious struggles (p <0.07)

A final logistic regression model including all variables statistical significant at level p <

0.1 in the five independent regression models analyses was conducted. The final analysis found

higher levels of neuroticism to be associated with religious struggles (OR: 1.08, CI 95%: 1.04-1.12,

p < 0.02). Furthermore, congregational support was associated with religious struggles (OR: 2.7, CI

95%: 1.45-6.02, p < 0.01), whereas lower income was marginally significantly associated with

religious struggles (p < 0.08). No other variables were statistically significant in this final model at

p < 0.05.

INSERT TABLE 2 AROUND HERE

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Discussion

This present study explored the prevalence of religious struggles in a group of middle-aged

and elderly community-dwelling people living in a secular society, and tested a multidimensional

model of possible psycho-social factors associated with religious struggles, which included socio-

demographic variables, personality variables, religious variables, social variables, and situational

variables. The results suggested that the question of religious struggles is not trivial, even among

people who live in what has been characterized as the most secular society in the world

(Zuckerman, 2008). Between 9% and 24% of the sample reported that they engaged in one or more

of the negative religious coping styles, e.i. religious struggles. In addition, the model established by

Ano & Pargament (2012) appeared useful as a framework for exploring different psycho-social

factors associated with religious struggles, although remarkably few variables stood out as

predictors of religious struggles in the final multidimensional model. In the initial analyses it

appeared that participants having fewer secular resources (low income), fewer psychological

resources (neuroticism and insecure attachment style), being more religious active (high frequency

of church attendance and private religious practice), receiving support from their congregation, and

experiencing highly negative events expressed more religious struggles. In the final model only

neuroticism and receiving congregational support significantly predicted religious struggles,

whereas lower income was marginally significant. Several explanations may be suggested for the

role of lower income, neuroticism, and congregational support.

Socio-demographic factors

The only socio-demographic predictor that reached marginal significance in the final model

was lower income, and it may tentatively be suggested in line with other studies (McConnell,

Pargament, Ellison, & Flannelly, 2006) that people having fewer secular resources are more

vulnerable when faced with major life events and prone to religious struggles. However, no other

17

socio-demographic factors were associated with religious struggles. A Danish study suggests

religiously oriented men to report more negative religious coping (Hvidtjørn et al, 2013), whereas

another study suggests women to lose interest in religion when illness grow worse, which could

indicate religious struggles (la Cour, 2008). Neither of these contradictory patterns were confirmed

in this present study and more studies are needed to clear out possible gender differences during

different circumstances.

Personality characteristics

Neuroticism was one of two significant predictors of religious struggles in the final model

and suggests that religious struggles reflect an orienting system in tension and strain. Neuroticism

may affect how ones religiosity is expressed; that is the neurotic disposition may cause one’s

religious beliefs to become a source of religious struggle instead of a source of comfort and support,

and a previous meta-analysis (Saroglou, 2002) found neuroticism to be associated with lower levels

of open, mature spirituality. Neuroticism was also found to be a predictor of religious struggles in

the study of Ano & Pargament (2012) among college students dealing with negative life events, and

another study found that neuroticism was associated with greater disappointment and anger at God

(Wood et al. 2010). Thus, several studies link neuroticism to negative forms of religiosity during

distress and suggest that personality traits is a crucial factor to include when examining the

efficiency of religious beliefs in adjustment. In fact, researchers in trait psychology criticize

researchers engaging in studies on stress and coping for not taking individual differences more into

account when explaining associations between stressors and different coping strategies (Costa,

Somerfield, & McCrae, 1996). It is argued that personality traits affect thoughts, feelings, and

actions far more than any other personality disposition and according to Bolger’s (1990) “coping is

personality in action under stress” (p. 525). A study by Costa, Somerfield, & McCrae (1996) found

people high in neuroticism to react badly to stress and engage in blaming themselves and others.

18

This may also be the case among people engaging in religious struggles who interpret a negative

event as God’s punishment. Furthermore, a review of meta-analyses on personality traits studies

suggests that personality traits like neuroticism are far stronger predictors of psychological

outcomes than any other individual characteristics (Steel, Smith, & Shulz, 2008). This may explain

the few significant associations tested in regression model. Furthermore, since the negative subscale

of Brief RCOPE reflects a mainly insecure relationship to God, it was expected that attachment

style would be a fairly strong predictor of religious struggles. Other studies have found the insecure

attachment style to be associated with negative religious coping (Schottenbauer et al. 2006), and

recently Granqvist, Hagekull, and Ivarsson (2012) suggested that especially disorganized

attachment style may be associated with viewing God as aberrant and frightening. However, the

applied measure of attachment relied on adult attachment style, and it may be argued that a measure

of parental attachment style is more appropriate to apply when studying attachment in relation to

religious coping as was the case in a study by Granqvist (2005).

Religious and social predictors

In the initial analyses religious beliefs, church attendance, and prayer were associated with

religious struggles, indicating that the more religiously oriented engage in these coping strategies.

In the final regression none of the religious identifiers were associated with religious struggles,

However, the final model also included congregational support, which was significantly associated

with religious struggles, and may to a high degree be correlated by church attendance; a variable

included in the final model but did not turn out significant. This finding suggests that the

participants experiencing religious struggles turned to their fellow believers for support during

times of distress. However, since relatively few Danes engage themselves in church attendance and

their congregation, congregational support could also be interpreted as a religious indicator. More

studies are needed to clarify this.

19

Situational factors

It was predicted that perceiving a negative event as having a highly negative impact on

QoL would be associated with religious struggles. Studies have found that the more an event is

perceived as shaking up one’s world, the more likely it is that struggle occurs (Ano & Pargament,

2012), and a recent Danish study suggests that more traumatic events such as losing a child or a

spouse is associated with higher levels of negative religious coping (Hvidtjørn, Hjelmborg,

Skytthe, Christensen, & Hvidt, 2013). The initial analyses suggested this to be somewhat true, as

the low impact event group was less likely to report religious struggles. However, nearly half of

the sample (N=166) did not choose a specific event when responding to the negative religious

coping questionnaire, and thereby they did not rate the impact of event. Thus, it was not possible

to determine the gravity of the non-specified negative events. It is likely that the participants in the

non-specified event group thought of events that did not lie within the frame of the last 12 months

as instructed. These events may have been perceived as having a highly negative impact on QoL,

but yet not rated in the questionnaire. To be able to use the information on the impact of event

among the participants who specified a negative event, and include the participants not specifying

an event, it was decided to create a category that distinguished between high impact events, low

impact events, and non-specified events. Thus, a lot of information was missing for the non-

specified event group and a type 2 error is possible to have occurred – that is, had they specified

an event, an effect might truly be present, but is not found significant in the statistical analysis due

to the missing information. It may also be argued, that the non-specified event group did not pick

a severe event but thought of how they usually handle major challenges when responding to the

items about religious coping. Thus, they may not have experienced religious struggles when

thinking about everyday challenges. However, the mean value of negative religious coping was

relative close to the high impact group, indicating that they did not differ significantly. Future

20

studies should be careful to measure more precisely the negative events that are recalled and use

indicators of the subjectively perceived gravidity of the event to decide whether the severity of

events predicts religious struggles. Furthermore, it may also be argued that situational factors

could potentially have mediated or moderated the associations between individual differences and

religious struggles: For example it is likely that the perceived impact of event on QoL could have

mediated the association between personality dispositions such as neuroticism or attachment style

and religious struggles (Schottenbauer et al, 2006a), and future studies could benefit by applying

more sophisticated models of analyses like structural equation modeling to investigate possible

mediators and moderators of religious struggles.

Limitations

This present study was conducted among a group of middle-aged and elderly Danes, and

the question of generalizability of results to younger generations is relevant. It has been argued that

especially elderly people are more likely to be more religious (Andersen, Ausker & la Cour, 2011)

and religious beliefs may also be more traditionalistic among elderly people. Thus, we do not know

whether major negative life events evoke religious struggles among younger individuals where

religious upbringing becomes more seldom (Mørk & Ausker, 2007). It may be argued that lack of

religious concepts and language leave the individual to fend for himself to find meaning and way

through crisis (DeMarinis, 2008). On the other hand, if religion is not a part of one’s orienting

system, it may not suddenly turn up during crisis and become the object of doubt and struggle.

Future studies will explore these topics. Furthermore, this present study used a cross-sectional

design and thereby causal relationships cannot be explored, and longitudinal studies are called for.

Despite limitations this present study adds to the empirical research about the psycho-social factors

21

associated with religious struggles with information from a more secular region and suggests that

especially personality factors are important to pay attention to in future studies.

22

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29

Table 1: Correlations between psycho-social variables and religious struggles

Variables 2 3 4 5 6 7 8 9 10 11

Socio-demographic factors

1. Age -.50** -.18** -.03 -.04 -0.7 -.08 .14* .18** 0.01 0.7

2. Income - .21** -.03 .25** -.16** .14* -.02 -.12* .07 -.14*

Personality factors

3. Contentiousness - .33* .09 -.62 .44 .01 -.04 .21** -.04

4. Agreeableness - -.09 -.33** .04 -.02 .10 .22** -.11*

5. Openness - -.11* .33** .05 .12* .12* -.06

6. Neuroticism - -.45** .10 .11 -.23** .26**

7. Extroversion - .04 -.04 .29** -.09

Religious factors

8. Church attendance - .51** .14* .20**

9. Private religious

activities

- .13* .15**

Social factors

10. Social support - -.08

Criterion variable

11. Negative religious

coping

-

Notes: *p < 0.05; **p < 0.01

30

Note: Factors that were significant at level p < 0.1 in the initial regression analyses were included in the final regression model. Final model fit statistics: R2 = 0.14 (Hosmer & Lemeshow), .014 (Cox & Snell), 0.22

(Nagelkerke). Model χ² (6) 41.62, p < 0.001.

Table 2: Logistic regression on psycho-social factors associated with religious struggles

Predictors Adjusted OR (95% CI) P values

Equation 1: Socio-demographic factors

Income 0.8 (0.68, 0.96) 0.03

Marital status

Married/cohabiting 0.51

Widowed 1.2 (0.39, 3.82) 0.78

Divorced 2.2 (0.93, 5.17) 0.13

Single 0.0 (0.00, - ) 0.99

Equation 2: Personality factors

Agreeableness 0.99 (0.95, 1.03) 0.72

Neuroticism 1.08 (1.04, 1.12) 0.01

Attachment 0.81 (0.45, 1.43) 0.54

Equation 3: Religious factors

Religious beliefs

Theist 3.86 (0.66, 22.45) 0.21

Spiritual 4.41 (0.72, 26.99) 0.19

Cultural Christian 0.00 (0.00, - ) 0.10

Non-believer 1.95 (0.32, 11.86) 0.54

Atheist 0.37

Church attendance 1.83 (1.23, 2.7) 0.01

Private religious activity 0.95 (0.80, 1.13) 0.64

Equation 4: Social factors

Congregational support 2.82 (1.80, 4.42) 0.00

Equation 5: Situational factors

Negative events

High impact group 0.07

Low impact group 0.33 (0.14, 0.77) 0.03

Non-specified event group 1.09 (0.68, 1.72) 0.77

Final model

Income 0.83 (0.70, 0.10) 0.08

Neuroticism 1.08 (1.04, 1.12) 0.00

Church attendance 1.5 (0.97, 2.33) 0.13

Congregational support 2.7 (1.45, 6.02) 0.01

Negative events

High impact group 0.40

Low impact group 0.48 (0.20, 1.18) 0.18

Non-specified event group 0.96 (0.54, 1.71) 0.90

31

Paper 4

1

Studying religious and spiritual coping in a secular culture: A question of validity

Heidi Frølund Pedersen & Jan Tønnesvang

Department of Psychology, Aarhus University, Denmark

Submitted for Mental Health, Religion, and Culture (Summer 2013)

Author note

Heidi F. Pedersen (corresponding author), Department of Psychology, Aarhus University,

Bartholins Allé 9, 8000 Aarhus Denmark, e-mail: hefpe@psy.au.dk, telephone: 0045-87165307;

Jan Tønnesvang, Department of Psychology, Aarhus University, Bartholins Allé 9, 8000 Aarhus,

Denmark, e-mail: jan@psy.au.dk, telephone: 0045-87165795

2

Abstract

The present paper discuss methodological challenges when investigating religious and spiritual

phenomena like religious/spiritual coping in secular society like Denmark and adopting theoretical

concepts and measures developed in more religiously oriented societies like the U.S. The study is

based on 3 focus groups interviews (n=14) with healthy Danes and individual interviews with

Danish lung cancer patients (n=10) responding to the religious coping questionnaire, Brief RCOPE,

and a newly developed scale on spiritual coping, Brief SCOPE, and through an exploratory thematic

analysis three themes in relation to validity was found: The importance of language and the

“religious capital” of the participant when responding to measures about religiousness in secular

society, the influence of the situation-specific context when asked about religious coping, and the

question of universality versus context-specificity in the measurement of religious and spiritual

phenomena such as religious coping.

Keywords: Religious coping, secular, questionnaire, validity, qualitative

3

Historically, psychology as a scientific discipline has had an ambivalent relationship to religion.

Striving to cut loose the strings to philosophy and theology with which it shared the interest of

describing human experience, the young discipline of psychology distanced itself from these

disciplines during the first half of the 20th century (Paloutzian, 1996). Adopting a positivistic

approach to the study of the human experience, the objective methods of quantitative research let

psychology to be established as a legitimate science while distancing itself further to religion

(Emmons & Paloutzian, 2003). The psychology of religion had difficult times until the late 1960s,

because it was perceived as “unscientific” to be associated with religion, other than offering

reductive naturalistic explanations of its claim (Coon, 1992; Spilka & McIntosh, 1999), and as an

example psychology textbooks hardly included “religion” in their indexes until the 1970es (Spilka,

1981). During the last 40 years the psychology of religion has expanded, although Hood (1999)

argued that psychology of religion would never be a fully integrated part of mainstream psychology

in America, because only a few key researchers sustained the field. Furthermore, he argued that it

had little application to other cultures outside America. However, in 2003 APA published a special

issue on the psychology of religion (see for example Miller & Thoreson, 2003), which among other

things marked the turning point for the psychology of religion in America to become an integrated

part of the mainstream psychology, which uses the theoretical framework and methodology of

mainstream psychology to examine religious sentiment and behaviour (Selvam, 2011). In 2013

APA launched two handbooks on the psychology of religion (Pargament, 2013 vol. I and II)

cementing the legitimacy of the field. Part of this success may be caused by the dominating

quantitative approach for both models and methods in the psychology of religion (Gorsuch, 1984).

Especially studies on links between spirituality, religion, health, and well-being have increased

since the beginning of this century (Miller & Thoreson, 2003) and expanded to other cultures such

4

as Northern Europe (see www.faith-health.org). The area of religious and spiritual coping has

received great attention in faith and health research since Kenneth I. Pargament (1997) formulated

his transactional theory of religious coping. Studies on religious coping are almost solely

quantitatively founded, and the measure of Brief RCOPE (Pargament, Smith, Koenig & Perez,

1998) has become the religious coping measure of choice. It has a strong theoretical base, strong

psychometric properties, it links with a variety of adjustment indexes, and has been used among a

variety of samples representing different groups of medically ill patients, college students coping

with different negative life events, and different minorities (Hill & Edwards, 2013). Furthermore, it

has been revised into Jewish, Hindu, and Muslim versions and translated into different languages

such as Polish, Spanish, German, and Urdu, thereby also making this field open to cross-cultural

comparisons. Despite the apparent validity and psychometric solid base of this questionnaire,

cultural aspects of spiritual and religious experiences need to be considered carefully when adopting

measures from one culture to another (Belzen, 2010; Hood, 2010). In this present paper we discuss

the validity of measures on religion and spirituality when adapted from one culture to another based

on a qualitative study on spiritual and religious coping measured by Brief RCOPE among Danes

suffering from lung cancer and a control group of healthy Danes.

Preparing a study on religious coping – the case of learning by doing

This present study is a case of learning by doing in research humbly acknowledging that the scope

of research results is limited to the knowledge and measures available of a given time as well as the

assumptions and biases of the researcher. In 2007 a study on alternative and complementary

treatment and faith among newly diagnosed Danish lung patients (mainly lung cancer and chronic

obstructive pulmonary disease, COPD) was being prepared. At that time no validated measures of

religious coping was available in Danish. Relying on a quantitative approach, the literature was

5

reviewed systematically focusing on studies using questionnaires to investigate the associations

between religion, coping, well-being and quality of life among cancer patients. The literature

flooded with studies using all kinds of different instruments and studying all kinds of associations

between spirituality, religion, coping, and health among cancer patients. Reviews at that time

(Plante & Sherman, 2001; Thuné-Boyle, Stygall, Keshtar, & Newman, 2006) recommended using

multi-dimensional and problem specific measures to capture the research topic at hand. It became

evident that the theoretical framework developed by Pargament (1997) and the measure Brief

Religious Coping (Brief RCOPE) was widely used and recognized measure. Studies suggest that

religious coping is most likely to be prevalent and have a positive effect on well-being among

people in which religious belief is an integrated part of their living (Krageloh, Chai, Shepherd, &

Billington, 2010; Maynard, Gorsuch, & Bjorck, 2001), but it is also suggested that religious beliefs

may become important during stressful events even among people who do not characterize

themselves as very religious (Pargament, 1997; Vail et al., 2010). Denmark is characterized as a

secular society (Zuckerman, 2008), however 80% are members of the National Church, 72%

characterize themselves as believers, and only 7% characterize themselves as atheists (Danish

Value Survey, 2008). Although the majority of Danes cannot be characterized as traditionally

religious going to church regularly (only 10 % attend church once a month or more) they may not

be totally removed from religious expressions. Furthermore, studies suggest that the elderly

generations in Denmark are more religiously oriented than the younger generations (Andersen,

Ausker & la Cour, 2011), and given that the target group of the study was primarily middleaged-

and elderly patients, we expected them to be more religiously than the normal population. Thus, it

was decided to apply the Brief RCOPE in a Danish context with minor changes guided by the

example of a German and Swedish study that had applied the RCOPE among cancer patients

(Ahmadi, 2006; Zwingmann, Wirtz, Müller, Körber, & Murken, 2006).

6

Measures

Religious coping, Brief RCOPE. The Brief RCOPE is a shortened version of the Religious Coping

Scale (RCOPE) developed by Pargament, Koenig, and Perez (2000), which covers five core

functions of religion in coping: meaning (positive and negative religious reappraisal), control

(active and passive ways of gaining mastery), comfort (spiritual connection, support, spiritual

discontent), intimacy (seeking religious support from others, interpersonal spiritual discontent), and

life transformation (religious direction, conversion). These core functions has served as the

theoretical underpinning of the measure, and 21 different coping strategies has been developed

resulting in a 105 item questionnaire in the original RCOPE. The Brief RCOPE consists of two

subscales with 7 items each measuring positive religious coping (seeking spiritual support and

control) and negative religious coping (religious struggle such as anger at God or feelings of

abandonment). The response format is 0 = “Not at all” to 3 “A great deal”. The questionnaire was

translated into Danish by 3 independent researchers, and discussed until agreement was obtained.

The item about demonic reappraisal was modified into the formulation “a negative power (like the

Devil)”, and 2 items more were developed, one about spiritual support (“God granted me the

strength to handle my illness/situation”), and one about positive religious meaning-making

(“Thought God had a meaning with my illness/situation after all”) as the original Brief RCOPE only

taps into negative religious meaning-making (like interpreting a negative event as Gods

punishment).

Spiritual coping, Brief SCOPE

Sociological studies suggests that only 24.9% of Danes believes in a personal God whereas 38.1%

believes in “a spirit or life force” (Inglehardt et al., 2004), and in order to accommodate participants

who did not believe in God, we developed a scale called Brief SCOPE in which the concept “God”

7

was replaced with “Spiritual power” or “my spiritual faith/conviction”. In the introduction we asked

participants to answer the scale which used the concept they preferred (either RCOPE or SCOPE).

Furthermore, according to the study by Ahmadi (2006), Swedish cancer patients have more

individualized and spiritually oriented ways of coping with illness than Americans, like feeling an

inner spiritual strength and seeking meaning related to the spiritual. Therefore we added two new

strategies of “finding inner spiritual power and strength to help me cope with my illness/situation”

and “finding spiritual meaning with my illness/situation” (see table 1).

The study among lung cancer patients and COPD patients was launched in Fall 2008 and a

study among an age- and gender matched control group of healthy Danes was planned to be

launched when recruitment of the patient group was completed. Unfortunately, recruitment on the

first study went slowly and the response rate was relatively low (23.1%). Some of the returned

questionnaires had a relatively high percentage of missing responses – especially the religious

items. This finding could not solely be explained by the severe diagnosis of our target group. To

investigate this further, the first author conducted a qualitative study among lung cancer patients

and healthy control participants. The purpose of this study was to test the face validity of the

religious and spiritual coping measure among Danish lung cancer patients and healthy Danes.

Method

Participants and procedures

Focus groups

Three focus groups of healthy middle-aged and elderly Danes were established during

October and November 2009. Focus groups were chosen to get a variety of responses and highlight

potential disagreements on the content (Greenbaum, 2000; Halkier, 2006). We aimed at recruiting a

range of people representing different religious and spiritual views, and participants in the first

8

focus group were recruited by a snowball-sampling (Johnson, 1990), and consisted of 3 women and

4 men. They represented mainly non-believers and secular Christians (people who have been

baptized and belong to the state church, but to whom the Christian belief is more about cultural

tradition and not religious belief) and one Christian believer. In order to include people with

religious or spiritual back ground, a second group was recruited from a religious organization called

the Church Association for the Inner Mission in Denmark (Dansk Indre Mission), and consisted of

two women and one man, whom all identified themselves as believing Christians and associated

with the evangelical Lutheran church of Denmark, the state church. A third group was recruited

from a spiritualistic church in Aarhus, and consisted of 2 women and 2 men. They all identified

themselves as spiritualists believing in a spiritual entity or power. Participants were between 40 and

75 years old (mean age: 56.2). The questionnaires were sent to the participants to be completed a

couple of days before the interview, and informed consent was obtained from the participants.

Participants were asked to think of a negative event when answering the questionnaires regarding

religious and spiritual coping. Two of the focus group interviews took place at the Department of

Psychology in Aarhus, and one interview took place in the church facilities of the spiritual group.

The interviews lasted 2 hours, and participants were asked to discuss their understandings of the

terms “God” and “spiritual power”, and interviewed about the relevance and understandings of the

single items in the questionnaires. Interviews were conducted by the first author.

Single interviews

In order to get in-depth information on the content of the questionnaires semi-structured

interviews were conducted (Silverman, 2010) with lung cancer patients recruited from the

respiratory clinic at Aarhus University Hospital in the period of December 2009 to March 2010.

The lung cancer patients were informed about the study by the medical staff and interested patients

were contacted by telephone by the researcher for more information about the project before giving

9

their informed consent to participate. Approximately 100 patients were informed by the staff about

the project, and 13 patients accepted to be contacted by the researcher and agreed to participate. The

questionnaire was send by mail to the 13 participants to be completed a couple of days before the

interview, and 3 participants chose to withdraw when they received the questionnaire. One of these

patients explained that he thought the questions were too intimidating. 10 interviews were

conducted and informed consent was obtained before the interviews took place. Participants were 5

women and 5 men between 43 and 81 years (mean 64.7). The interviews were all but one conducted

in the home of the patient, and one interview took place at a hospital. The interviews lasted between

20 and 75 minutes (mean: 43 minutes). Participants were asked to explain what they understood by

the terms “God” and “spiritual power”, what relevance the questionnaires had to them, and how (if

relevant) their religious or spiritual views impacted their ways of adjusting to their illness. To

reduce the potential burden of participating in an interview, 5 patients were asked specifically about

their understandings of half of the items in the questionnaires, and the other 5 patients were asked

about the other items. All interviews are conducted by the first author

Analysis

Interviews were transcribed verbatim, and analyzed using an interactive model in which

data collection, reduction, display, and conclusion-drawing constitutes a iterate process (Miles &

Huberman 1994). First each interview was analyzed to get an in-depth understanding of how the

participant(s) related to the questionnaire as a whole and to the single items. In this process, two

researchers analyzed and discussed the content of each interview using a deductive thematic

analysis (Boyatzis, 1998; Braun & Clarke, 2006; Hayes, 1997) in which the core functions of

religious coping (seeking meaning, control, spiritual support, relational support and transformation)

served as the theoretical frame. Participants’ statements about the single items were condensed and

displayed into a table with five themes covering the five functions of religious coping. The

10

participants were divided into three groups based on their perceptions and beliefs (or non-beliefs) in

God or a higher being, and statements about the single items were further reduced and ordered in

accordance with the three groups. These units of analyses were presented elsewhere (Pedersen,

Pedersen, Sinclair, & Zachariae, 2010). However, the deductive strategy was insufficient to cover

important new themes on the validity of the religious and spiritual coping measures as well as new

coping strategies that emerged from the data material. Therefore, an explorative, inductive thematic

analysis (Frith & Gleeson, 2004) was conducted by the first author and verified by an independent

researcher to investigate new themes emerging from the data material. This is the central unit of

analysis presented in this present article. Three core themes on the validity of measures on

religiosity and spirituality emerged and shed light on the response patterns found among patients,

healthy controls, and the three different belief groups respectively, which will be presented in the

remainder of the paper.

Results

Participants were divided into three groups depending on their beliefs and view of life. Participants

who held a belief in a personal God, characterized as either a father-figure or personalized entity

who intervenes in peoples’ lives were categorized as theists. Participants, who did not believe in a

personalized God but still held a belief in a spiritual being described as positive energy or

“something more“ were characterized as non-theists. Finally, people who did neither believe in God

or a spiritual being were characterized as non-believers. The term “atheist” is not used, as some of

the non-believers although not claiming to believe in anything transcendent, still valued the

Christian culture and characterized themselves as Christians. Furthermore, some of the non-

believers were reluctant to reject the idea of something transcendent permanently.

11

A private matter, or lack of common language?

Religion is said to be a private matter to Danes, and some claim that it may even be a greater taboo

than sex. This was already presented by Gordon Allport in 1950. There may be some truth in this

statement, but the first theme emerging from the data suggested that it might also be associated with

lack of common concepts and language about religious and spiritual issues, which increases the

demands to constructing appropriate instructions and response formats in measures. Across the

three groups of theist, non-theist and non-believers there were great differences in the level of

reflections on religious and spiritual matters and ability to verbalize thoughts on these matters. A

male participant belonging to the non-believer group said:

”Well, I don’t know, it’s like… it’s… I don’t think… it is something, but still nothing and…it is airy,

right? And… there is too much air… I can’t really explain, I lack the words to explain. But it is air

– it is nothing… Try to fill it out as best as one can…”

Concepts like “God” and “spiritual power” were difficult to explain and especially distinguish to

some of the participants, to whom belief in something transcendent was mostly described as a

childhood belief in “something more” or “something above us”. When asked about their

understandings of the items in Brief RCOPE and Brief SCOPE and why they responded as they did,

they were unable to elaborate further. An 81-year old male patient from the theist group said:

“You need to be theologian to answer this questionnaire…when you never have reflected on this

your whole life it is very difficult to answer”.

Others had very reflected and articulated beliefs or non-beliefs, but especially non-theists did not

accept the formulations offered to them in the questionnaires. A woman from the non-theist group

said:

12

“…that thing about [believing in] a personal God. Already at that point I get offended, a personal

God, what is that? Maybe I am totally behind, but I actually went to the library and made them

search for “a personal god”. It is not an expression that we used in my home”

She and others from the non-theist group felt offended by the items in Brief RCOPE

mentioning sin, devil and God’s punishment, because they perceived the items to reflect old-

fashioned and conservative Christian ideas, and responding to the items would be the same as

confessing this type of Christian belief. It was even suggested by some of non-theists that the

research team had a hidden agenda of missionizing by handing out questionnaires that were very

explicit about religious matters. A female patient belonging to the non-theist group said:

“It is like you have already decided that people should be (Christian) believers…because

God is mentioned in almost every item”

The problem of the response format; that participants felt like agreeing on the content

when they did not want to, was also found among non-believers, who emphasized, that if they

marked items like “Questioned the power of God” and “Questioned God’s love for me” with “Not

at all”, it could be interpreted as an implicit declaration of a belief in God. The response format

“Not relevant” was called for, and in its absence some chose to mark the highest score “Very

much”; not as a sign of religious or spiritual struggle, which was the original intent of these items,

but as a way of declaring their non-belief. The opposite was found among theists; that even though

the particular coping strategies were not prevalent in the particular situation, they felt like

dismissing their beliefs if they responded items like “Sought Gods love and care” with “Not at all”.

A healthy male from the theist group stated that:

13

“…my experience of God is what no eye has seen, and no ear has heard… But still it is a reality

that goes beyond everything. And then you make a questionnaire in our three-dimensional

world…you can’t do that”.

To this participant, the questionnaires were too limited and not fully capable of grasping the

experience of religious belief. Even though this particular participant had a more refined and

articulated belief system than some of the other participants and may have been better capable of

answering the questions adequately, he ultimately objected to the idea of measuring religious

experience by paper and pencil, and called for in-depth methods to maintain the complexity of the

religious experience. Furthermore, it was found that having an alternative to RCOPE was very

important to some of the non-theists, because they could better associate with the term “spiritual

power” than “God”. However, several of the items did not apply to their conceptions of a spiritual

power, especially the negative subscale, as a spiritual power was associated with something purely

positive, not possessing the capacity to intervene in peoples’ lives directly by punishments.

Increased relevance of religion and spirituality during critical life situations?

The second theme emerging was the importance of the life situation in which one is situated when

asked to respond to a questionnaire on religious and spiritual coping. According to the theory of

religious coping, life threatening situations like severe illness or bereavement may more likely

trigger religious or spiritual responses in coping, and this was found to be an underlying assumption

across the healthy participants as well as the patients. Theists, to whom religious belief was an

integrated part of their life, were able to elaborate in great detail what they understood by the

questions, but especially healthy participants holding beliefs in a personal God reported difficulties

responding to the questionnaires. Even though they were asked to think of a negative life event

within the last 12 months, this appeared difficult and it was outlined that the questionnaire was

14

more relevant in critical situations like severe illness, accident or loss. A healthy female participant

characterized as theist stated:

“It seems a little rigid. It does not apply in every situation”

Especially the item of feeling anger at God or a spiritual power made some of the healthy

participants conclude that the questionnaires was aimed at people experiencing life threatening

events. Despite non-believers’ rejection of the existence of something transcendent, it was found

that particular situations which the participants referred to in the interview were linked to thoughts

on religious issues. A male participant, who did not perceive himself as a believer told about his

friend, who were very close to retiring and looked forward to enjoying a more quiet life with his

wife and family. A couple of months before his retirement, this man was run over by a truck and

killed on the same road that he had been bicycling to work every day for 30 years. The interviewee

said:

”When I saw that, I doubted (God’s powers)… He (God) could have spared him. He could have

given him a little more time”

Paradoxically, even though this interviewee did not believe in God, God as a concept was still

present in the interpretation of this particular situation. The importance of the particular context in

which one is situated was confirmed by the finding that patients who did not view themselves as

very religiously minded, were more open to discuss and reflect on the importance of religion and

spirituality in relation to their illness, than healthy non-believing participants. To cancer patients,

the situation of being severely ill was a present reality and thereby patients may have been more

open to discuss the relevance of religious or spiritual coping. A male patient belonging to the non-

believer group reported that the interview had been thought provoking in a positive sense, because

he usually did not think much about religious or spiritual issues. He said:

15

“Well, it has been fine (the questionnaire) because it gives food for thought, you know, and makes

me think about things differently than I used to.”

Furthermore, it was also found that some patients having more or less articulated beliefs in God

thought that the items applied to them – both positive and negative questions depending on their

interpretations of having cancer. A woman who did not characterize herself as awfully religious, but

still holding on to her childhood beliefs had several thoughts about why God was punishing her. To

her lung cancer was interpreted as an unfair punishment stealing a lot of her time and resources. She

perceived herself to be a good person involved in aid work knitting for the Red Cross, and therefore

it was incomprehensible to her why God was punishing her. She said:

“I don’t think He has the right to punish me like that and give me a serious illness to fight with,

when I am so involved in helping others”

To her even positive religious coping items like “Looked for a stronger connection with God” were

interpreted negatively, because she thought God should have supported her more. A male patient

who was a former alcoholic and now a strong believer stated that his belief was an integrated part of

his life and that it had rescued him from dying of his alcohol abuse. Now he experienced that God

or a higher being helped him to get through his illness and through other people guided him to take

decisions regarding his illness. He said:

“…I also got help making the decision to receive chemo, because when I received the diagnosis I

thought I was already dead. Then someone told me that chemo treatment had already been booked

for me and I just needed to say “yes” or “no”. But I just got even more confused and shattered and

I could not make that decision. Then I said “God help me, I can’t get any further here”…over 2

days everything changed because I sought help from people who knew something about it (chemo),

16

and then I accepted my situation and decided to receive chemo… my thoughts about death turned

into thoughts about life”.

A universal or context-specific phenomenon?

The third theme incorporated the other two themes of language and context and concerns the

question of how well universal instruments like questionnaires are at capturing the particular

experience of the individual. The questionnaires did tap into some features of religious and spiritual

coping with varying precision depending on the context, vocabulary at hand, and history of the

individual. However, new religious and spiritual coping strategies that were not covered in the

questionnaires emerged during the interviews. A cancer patient, who had been spiritually seeking

throughout her life, but now characterized herself as too rational to believe in God, said that there

were no items covering her way of believing. She was convinced that there is “something more”

than meets the eye, but expressed a strong belief in herself and her capability to cope and said:

“I am my own God Almighty”

She and others called for items covering the phenomenon of personal or spiritual growth when

faced with life threatening situations. Others referred to the idea of fate or a pre-destined course of

life that gave a sense of meaning, and some called for items covering the importance of social

support in difficult situations, which to some extend was understood as a spiritual connection

between humans – also to deceased family members. A female patient characterized as non-theist

explained that she often talked to her deceased brother about her worries when looking at a picture

of him. She said:

“I really feel that he sits next to me and that it, well, helps…that it gives you a little extra energy”

17

Despite declared non-belief, some of the non-believing participants held beliefs about the

afterlife and hopes of being reunited with deceased relatives. A female patient characterizing herself

as a non-believer said:

“…at one point I have this naïve faith that when I die, then my grandmother, whom I cared

much about, and my father are waiting for me. I don’t know where this belief derived from, and it is

not something that has developed further, but they just stand somewhere telling me to go that way

and it’s a kind of comfort”

Others underscored the importance of the Evangelical Lutheran Church (Den Danske Folkekirke) as

a cultural institution offering a frame of rituals in connection to life transitions. A non-believing

male patient said:

“I am not a believer, but still I think it is important that we have the church, right, because I think it

can help in the situations when one gets married, or dies and needs to be buried…I don’t know if

that can be characterized as faith, but it is there back in one’s mind, that you’ve got the church to

rely on and the fellowship there.”

Thus, fragments of what could be characterized as religious or spiritual beliefs and hopes were

present among people who did not see themselves as traditional religious, but this was not covered

fully in the questionnaires at hand. A female patient from the non-theist group said:

“You have all the different religions, right, Buddhism, Islam, Judaism, Christianity and the Greek

Orthodox … they are all available to you depending on what task you perform any given

day…today you may chose this belief, tomorrow another…it may not necessarily be a belief written

in a book”.

18

To her a few items in the questionnaires applied, however as described above, every context and

situation called for different religious or spiritual interpretations and therefore the religious ideas

and concepts presented in the Brief RCOPE and Brief SCOPE were too narrow to describe her

rather context-specific and eclectic beliefs.

Discussion

In recent years discussions on methodology and validity have increased in the psychology of

religion recognizing the limitations of the dominating positivistic approach to studying complex

phenomena like religious and spiritual experience (Belzen, 2010; Emmons & Paloutzian, 2003;

Nelson, 2012; Williamson & Ahmad, 2007). The original intent of this present study was to

evaluate the face validity of a widely used instrument covering religious coping, Brief RCOPE, and

a newly developed scale measuring spiritual coping, Brief SCOPE, among Danes. However, an

explorative thematic analysis revealed three themes related to validity that is important to consider

when investigating religious and spiritual phenomena. It is suggested that cross-cultural validity is

not only a matter of taking cross-national differences into account, but just as well as being aware of

context specific differences within a given culture between people holding different views of life

regarding religious and spiritual issues, and the importance of the situation in which the individual

is stated. At first glance, the impression of the participants’ response patterns suggested that theists

having articulated beliefs in God responded adequately to the Brief RCOPE and had higher scores

on this measure than did non-theists and non-believers. As such, the findings seemed to be

supporting the hypothesis suggested by Pargament (1997; 2007), that the more integrated a

religious belief system is, the more likely it is involved in coping strategies. However, the

explorative thematic analysis revealed that the finding could just as well exemplify the importance

of holding the appropriate “religious capital” (Bourdieu, 1986) or language to be able to understand

and respond to a given question adequately, but not necessarily reflect validity of the questionnaire

19

or religious coping in the particular situation. The average Cultural Christian Dane may not possess

the conceptual codes that are needed to answer instruments like Brief RCOPE in an adequate and

valid way because it is characterized by theistic belief which to a high degree is decreasing due to

secularization Danes (Lüchau 2005). However, since 72% of Danes consider themselves to be

believers (The Danish Value Survey, 2008) religious or spiritual beliefs may not be disappearing.

Instead, the concept of “religion” is changing and may be characterized as “unpacked” – meaning

that religion can no longer be described as system of ideas, institutions and practices that shares the

same core, a so called “packed religion”, but instead as several distinct aspects not sharing a

common core (Rosen, 2009). One of these aspects is personal beliefs which are defined as:

“…beliefs emerge as highly personal emotions and reflections that reside in the inner life of each

individual and are developed cognitively through life experiences. Such beliefs are difficult to

express not only due to lack of language, but also for the reason that they are usually tacit, seldom

systematized and usually actualized ad-hoc in respect to context (Rosen, 2009:8)

Some have argued that the Western world is becoming religious “illiterate” (Smith & Denton,

2005), because of a general neglect of religious and spiritual issues that follows secularization

(Pargament, Mahoney, Exline, Jones & Shafranske, 2013). Whether or not one calls it religious

illiteracy or tacit knowledge as in the above mentioned definition, results from this present study

suggests that it may be problematic to individuals living in secularized societies to decode a

questionnaire like Brief RCOPE because their beliefs are not made very explicit and cannot be

assumed to represent a coherent worldview. Especially patients, who held on to a childhood belief

or the sense of “something more”, had great difficulties expressing what this meant to them.

The theme on the importance of the context one is situated in is crucial to consider when

asking participants to respond to questions about religious and spiritual coping. In accordance with

the theory of religion as unpacked in Denmark (Rosen, 2009) it was found that personal beliefs

20

were actualized ad hoc in very specific contexts of for example negative life events that called for

explanations, comfort or hope – also among participants who did not view themselves as believers.

Furthermore, part of the critiques of the questionnaire may stem from methodological difficulties of

relating to a traumatic event on command and to report religious coping strategies retrospectively as

the healthy participants were asked to do (Fowler 1995).

The third theme encompassing the other two underscored the challenge of developing a

methodology that is sensitive to the individual’s religious, spiritual or secular existential view of life

and the context one is situated in, and at the same time being able to identify general patterns of

religious and spiritual ways of coping with crisis. This may be an even harder task as individualism

and secularism erodes the common cultural heritage that used to be adopted more or less

automatically through traditions and narratives rooted in philosophy and religion which shaped

identity and social life (Gergen, 1991). In a postmodern world, everything is individually

constructed and the individual may be more critical towards attempts of defining and measuring

human experience because he demands full autonomy to define his own unique experience (Iversen,

2006). This was reflected in the participants’ reluctance towards being categorized within a certain

religious category without further discussion and several participants argued that their views of the

Sacred or “something more” was not presented in the questionnaires at hand. From a social

constructionist perspective it is argued that the attempt of measuring a given phenomenon is a lost

cause, because we will never be able to determine whether we are talking about the same constructs.

However, trying to avoid the two extremes of positivism and constructionism, researchers still aim

at developing methodologies to observe and register human experience which are designed to make

participants able to express their experiences in such a way, that it may be generalized, because it is

assumed that there are phenomena in the real world that have common features and which can be

compared across individuals, contexts and cultures. In the psychology of religion it is even more

21

important to be sensitive to the phenomenon at hand because the structure and functions of beliefs

are closely tied to the contents of beliefs, which is highly influenced by the given culture and the

experiences of the individual, and measures should be developed with sensitivity to time, context,

and language of the individual. Thus, we do not argue for or against one methodology or another,

but recognize quantitative and qualitative methods as complementary. The most important point is

to acknowledge that what can be said about a specific phenomenon may be limited, and that a

specific operationalization of a given phenomena is just one aspect of the complexity of the real

world, that may be inflicted by the researchers pre-assumptions and biases.

Limitations and future directions

Some limitations should be highlighted in this present study. Given the methodology of qualitative

interviews and relatively few participants, cautions should be made in generalizing the results to

other contexts. In general, the focus group participants were more critical toward the questionnaires

than the patients, and besides the points about the importance of context (being severely ill or

healthy), this finding may be related to methodological differences too. Focus groups may be

subject to polarizing effects, with individuals taking more extreme positions than they would in

private, and this might especially have been the case in the focus group of the mixed group of non-

believers and Cultural Christians. The opposite might have been the case in the religious and

spiritual groups which may have been subject to the creation of consensus opinion (Morgan, 1997).

However, this present study suggests that studying religious and spiritual phenomena

in general, and in cross-cultural studies in particular, requires thoughtful reflections on the

importance of contexts and language when constructing or translating measures keeping in mind the

limitations of different methodologies. By using standardized questionnaires the ability to compare

across cultures is maintained, but will be limited by the instrument’s conceptual frame, and opt to

22

ignoring important information about other forms or functions of religious and spiritual coping

strategies as was the case in this present study. Qualitative methods are called for to avoid naïve

realism and postmodern anti-realism, and help remain within the framework of critical realism

(McGrath 2004:195). Qualitative, inductive methods may be a starting point for developing

concepts of religious, spiritual, and existential coping that are sensitive to a particular culture.

Despite the limited cross-cultural generalizability of qualitative studies, they may give a richer

understanding of a particular culture’s concepts and metaphors that are present when humans try to

come to terms with some of life’s most critical and vulnerable situations. Regarding the measure

Brief RCOPE, future studies are recommended to apply new, culture-sensitive measures of

religious, spiritual, and secular existential meaning-making processes if the psychology of religion

is to grasp the complexity of how different worldviews may function or dysfunction during times of

distress among people living in highly secular societies (DeMarinis, 2008).

Acknowledgements

We wish to thank Robert Zachariae, Unit for Psychooncology and Health Psychology, Aarhus

University Hospital and Aarhus University for critical comments. Furthermore we wish to thank

Charlotte Jonassen, Department of Psychology, Aarhus University, for fruitful discussions on

methodology and the topic at hand

23

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Table 1: The Brief RCOPE and Brief SCOPE

Brief RCOPE Not

at

all

A

little

bit

Quite

a bit

A

great

deal

1 Looked for a stronger connection with God 0 1 2 3

2 Sought God’s love and care 0 1 2 3

3 Felt punished by God 0 1 2 3

4 Wondered whether God had abandoned me 0 1 2 3

5 Sought help from God in letting go of my anger 0 1 2 3

6 Tried to put my plans into action together with God 0 1 2 3

7 Asked for forgiveness for my sins 0 1 2 3

8 Wondered what I did for God to punish me 0 1 2 3

9 Tried to see how God might be trying to strengthen me

in this situation

0 1 2 3

10 Questioned God’s love for me 0 1 2 3

11 Wondered whether my religious community had

abandoned me

0 1 2 3

12 Focused on religion to stop worrying about my problems 0 1 2 3

13 Decided that an evil power (like the devil) made this

happen

0 1 2 3

14 Questioned the power of God 0 1 2 3

15 God granted me the strength to handle my

illness/situation

0 1 2 3

16 Thought God had a meaning with my illness/situation

after all

0 1 2 3

29

Brief SCOPE Not

at

all

A

little

bit

Quite

a bit

A

great

deal

1 Looked for a stronger connection though my faith/

spiritual conviction

0 1 2 3

2 Sought love and care through my faith/spiritual

conviction

0 1 2 3

3 Felt spiritually punished 0 1 2 3

4 Felt spiritually abandoned 0 1 2 3

5 Sought help through my faith/spiritual conviction to let

go of my anger

0 1 2 3

6 Tried to put my plans into action together with another

spiritual power

0 1 2 3

7 Sought spiritual purification 0 1 2 3

8 Wondered what I did for a spiritual power to punish me 0 1 2 3

9 Tried to see how another spiritual power might be trying

to strengthen me in this situation

0 1 2 3

10 Questioned spiritual love for me 0 1 2 3

11 Wondered whether my fellow believers had abandoned

me

0 1 2 3

12 Focused on my spiritual conviction to stop worrying

about my problems

0 1 2 3

13 Decided that a negative power made this happen 0 1 2 3

14 Questioned the spiritual 0 1 2 3

15 I felt an inner spiritual power and strength that helped

me cope with my illness/situation

0 1 2 3

16 Found spiritual meaning with my illness/situation 0 1 2 3