Relationship between religious involvement and psychological well-being: a social justice perspective.
To address this gap, the purpose of this article is to examine the relationship among religious involvement, private prayer, and depression in a low-income, clinical sample of 230 older U.S.-born and immigrant Latinos residing in a large metropolitan city in the United States. Focusing attention on this group is critical for several reasons. First, the Latino population over the age of 65, which numbered 2 million in 2002, is expected to grow to 13.4 million by 2050 and will comprise the largest racial and ethnic minority population in this age group by 2028 (U.S. Department of Health and Human Services [HHS], 2001b). Second, mental health in the later years is partly influenced by one's ability to balance stressful life events, to be able to count on others for support when needed, and to maintain a positive outlook on life. Personal and social resources such as religion and religious involvement are important to how people live their lives and cope with stress. The association between mental health and religious involvement has been documented with different clinical disorders, genders, ages, denominations, and racial and ethnic groups in the United States. The study presented here furthers the literature in its substantive and methodological approach: Except for a few empirical studies, little is known about how these theoretical relationships apply to older Latin living in the United States (Hill, Angel, Ellison, 8: Angel, 2005; Levin & Markides, 1985; Markides Levin, & Ray, 1987); methodologically, the study examines the effects of religious involvement and depressive illness by using clinically determined criteria for unipolar depression; and using a within-group comparative approach, we examine the experience of U.S.-born and immigrant Latinos.
Immigrants are more likely to participate in religious congregational life than are U.S.-born Latinos (Warner & Wittner, 1998). This can be partially explained by a postimmigration phenomenon explained by Hondagneu-Sotelo, Gaudinez, Lara, and Ortiz (2004) that underscores the nonassimilationist religious practices of Latinos: "Religious identities often intensify after immigration, and distinctive immigrant and ethnic congregations, rather than assimilationist religious forms, now prevail" (p. 135). Moreover, some religious congregations, primarily aligned (although not exclusively) with Roman Catholicism and Protestantism, also promote the principles of liberation theology in support of poor and oppressed people (Hondagneu-Sotelo et al.; Gutierrez, 1988; Levitt, 2001; Matovina & Riebe-Estrella, 2002; Warner &Wittner, 1998). Contemporary congregations can thus enable immigrants to partake in religious activities that reinforce their ethnic identities as well as provide a safe haven for sociopolitical activities that promote empowerment and social justice. Although liberation theology has its roots in Latin America, U.S.-born Latinos have embraced (although not without considerable debate) the theological underpinnings and social movements of liberation theorists with considerable attention to ethnic and racial identity in the United States (mestizaje or mixed European/Indian identities) and the accompanying struggle to balance disparities in power affecting access to religious, social, political, and occupational opportunities (Elizondo, 1983; Matovina & Riebe-Estrella, 2002). This has been well documented in the theological and cultural discourse on the Mexican American experience in the United States, but to a much lesser degree for other Latino subgroups such as Dominicans (Levitt, 2001) and Puerto Ricans (Alvarez, 1998).
DEPRESSION: IMPLICATIONS FOR SOCIAL JUSTICE
Affecting 20 million Americans (HHS, 2001b), or about 15 percent to 20 percent of older people (Koenig & Blazer, 1996; Lebowitz et al., 1997), depression is characterized by a combination of mood, cognitive, and physical symptoms sufficient to interfere with a person's daily functioning (NIH Consensus Development Panel on Depression in Late Life, 1992). Whether depression is the cause or consequence of assaults on well-being is still open to ideological and practical debate and is beyond the scope of this work. Undeniably, symptoms of unipolar depression--sad mood, loss of interest in usual and pleasurable activities, problems with memory and concentration, low energy, feelings of uselessness, problems with sleeping and appetite, thoughts of death, and so forth--interfere with the older person's typical activities and day-to-day functioning. These impairments can lead to persistent problems that are frequently the focus of social work practice, such as actualization of healthy human development, maintenance of social relationships in late-life, and activation of positive mutual exchanges and resources in the service of psychological well-being and quality of life.
Social work practice in health care settings has a long-standing tradition in addressing a client's ability to maximize her or his potential while at the same time addressing disparities in health care equity and access (Galambos, 2005). Drawing on the definition of distributive social justice, "... which emphasizes society's accountability to the individual ... how goods and resources are distributed in a society" (Van Soest & Garcia, 2003, p. 44), we can surmise that depressive symptomatology is a form of psychological "[d]eprivation--[the] lack of essential resources and supports for the achievement of physical, social, and cognitive development [that] impedes the actualization of human potentiality in individuals, families, and communities" (Prigoff, 2003, p. 115). Depression, which is often characterized as a state of hopelessness and powerlessness, can seriously interfere with the older adult's ability to participate actively in social spheres that promote advocacy, empowerment, citizen participation, and so forth (Parsons, Gutierrez, & Cox, 1998).
For Latinos, particular perceptions of the nature of depression and their implications for social justice are worth noting. Empirical and conceptual work exists to highlight the tendency for Latinos to somaticize psychological distress (see HHS, 2001b), which is regarded by some as a reflection of the intersection of mind--body--spirit in mental health, and conversely, of mental illness or depression. In more recent work that was based on a qualitative study of older, medically ill Latinos with a history of depression, the notion that depression was precipitated by persistent stress or "a wear-and-tear"-type lifestyle emerged as an illness attribution (Aranda & Ell, 2004). Also, the Spanish-language term for sad mood--desanimoda(o)--is literally translated as being in a "soulless" state. The study participants were likely to refer to depression as a result of life experiences (for example, life events, poor health, losses, trauma, and persistent strain) that eventually sap the person's vitality. Thus, these persistent experiences of loss and injury may present an assault to the "soul" of the person that transcends physical and psychological consequences and that poses serious challenges to the older person's ability to raise "questions about the relationship between various private problems and related public issues" (Parsons et al., 1998, p. 18). Thus, depression for older Latinos should be viewed as a deeply personal, culturally contextualized, and social justice phenomenon.
EFFECT OF RELIGIOUS INVOLVEMENT ON PSYCHOLOGICAL WELL-BEING
Religious involvement is defined here as encompassing formal, public, and collective involvement at worship-related services as well as more informal, private forms of involvement such as private prayer. Although the two forms of religious involvement are complementary and not mutually exclusive (people can engage in private prayer during worship services), examining the separate effects of each dimension on depression extends earlier work on the effects of religious attendance and private prayer on psychological well-being. The rationale for the distinction lies in the notion that each dimension may have differential effects on outcomes. For example, participation in worship services may play a more protective role due to its "public" or communal nature that parallels the sociocentric nature of Latinos and help-seeking or help-giving behavior during times of distress (Aranda & Knight, 1997). For the purpose of the work presented here, religious involvement is operationalized by examining two categories of involvement: participation in worship-related services and private prayer, respectively.
Religious involvement, as variously assessed in the lives of older adults, is an important psychological resource given its role "in establishing continuity across life-course stages, emphasizing the intrinsic and enduring meaning of life, fostering a sense of feeling blessed by God, and providing both personal and community resources that enhance coping with age-associated losses" (Levin, Markides, & Ray, 1996, p. 456). Religious involvement is directly associated with better mental health outcomes (see George, Larson, Koenig, & McCullough, 2000) such as life satisfaction (Anson, Antonovsky, & Sagy, 1990; Levin, Chatters, & Taylor, 1995), lower levels of psychological distress (Ellison, Boardman, Williams, & Jackson, 2001; Levin & Chatters, 1998), fewer depressive symptoms (Ai, Dunkle, Peterson, & Boiling, 1998; Garrison, Marks, Lawrence, & Braun, 2004; Idler, 1994; Koenig, Moberg, & Kvale, 1988; Smith, McCullough, & Poll, 2003; Strawbridge, Shema, Cohen, Roberts, & Kaplan, 1998), and decreased anxiety (Koenig et al., 1988). Religious involvement also decreases the likelihood of anxiety, alcohol and drug abuse and dependence, and clinical depression (see Hill et al., 2005).
The evidence supporting the association between religious involvement and depression has been equivocal (Strawbridge et al., 1998). Some studies support the association between religious involvement and decreased depression for some groups (Ellison, 1995; Nelson, 1990; Pressman, Lyons, Larson, & Strain, 1990), whereas other studies have found no relationship (Idler, 1994; Williams, Larson, Buckler, Heckmann, & Pyle, 1991). Still, in one large cross-sectional study, different forms of religious involvement (organizational, nonorganizational) were associated with exacerbated depression depending on specific types of life stressors, for example, child problems, marital problems, abuse, and caregiving (Strawbridge et al.).
The life stress paradigm is a promising and coherent approach to understanding the positive relationship between religious involvement and mental health outcomes (Ellison et al., 2001). Briefly stated, religious involvement may lead to better mental health by encouraging participants to avoid negative behaviors (for example, high-risk behaviors, risky sexual practices, alcohol and drug use, other addictions), thereby avoiding or delaying stressful life events. Of particular importance is the role that health status plays in the relationship between religious attendance and depression. Hill and his associates (2005) posited that physically and functionally robust older adults are more likely to attend religious activities than are less healthy older adults because of their more favorable health status. Thus, the persistence of a religious effect on psychological well-being should be tested while adjusting for the effects of selective factors such as functional status (Hill et al.). In other words, the salutary effects of religious involvement on well-being can be accounted for not only by lower levels of stress exposure as a result of decreased risk behaviors, but also by better functional health. Moreover, the availability of social resources or support that may arise in religious activities may account for the relationship between religious involvement and psychological well-being (Ellison et al., 2001; George et al., 2000; Hill et al.; Strawbridge et al., 1998). Social resources such as availability of social ties and the perception that others are available during times of need are important links to positive mental health. In summary, the conceptual model (Figure 1) posits that the relationship between religious involvement and psychological well-being should also be tested while controlling for the effects of stressors, functional status, and perceived availability of confidant support.
[FIGURE 1 OMITTED]
RELIGIOUS ATTENDANCE AND PSYCHOLOGICAL WELL-BEING AMONG OLDER LATINOS
Earlier epidemiological studies on the health and well-being of older Latinos have focused exclusively on older Mexicans (65 years of age and older) living in the Southwestern United States. (Hill et al., 2005; Levin & Markides, 1985; Levin et al., 1996; Markides et al., 1987). This body of work to date has focused exclusively on religious attendance and not on private prayer. The research suggests that religious attendance is positively related to higher life satisfaction (Levin et al., 1996; Markides et al., 1987), negatively associated with depressive symptoms (Levin & Markides), and negatively associated with mortality (Hill et al.).
Older Latinos, whether born in the United States or abroad, have a very strong connection to their religious affiliation and practices. For example, more than 50 percent of Mexican Americans are 55 years old or older and attend religious services at least one time per week, and almost 70 percent report receiving "a great deal" or "quite a bit" of guidance in their daily lives from religion (Stevens-Arroyo & Diaz-Stevens, 1998). Although Latinos have historically self-identified as Roman Catholic, a significant movement in the last half of the 20th century has shown an increase in Latino Protestantism in the United States (Hunt, 1999). Latinos have demonstrated a rich history of rituals, devotions, and faith expressions that both reinforce tradition and expand on devotional and inspirational practices (Sanchez, 1993) as seen in El Via Crucis (The Way of the Cross, a spiritual meditation done during the season of Lent) (Davalos, 2002), El Dia de los Muertos (The Day of the Dead celebration) (Salvador, 2003), and the evangelical altar call (Avalos, 2001).
The effects of immigration status or nativity (U.S.-born or immigrant) were not explicitly examined in the aforementioned studies on religion and psychological well-being. Examining the relationship of immigrant status with religious involvement and psychological well-being is important given that about 56 percent of older Latinos were born outside of the United States (Villa & Aranda, 2000) and continue to maintain close ties with traditional social values (Espinosa, Elizondo, & Miranda, 2003). Earlier studies on the association between immigrant and foreign-born status and depression among U.S. Latinos have indicated that immigrant Latinos report more favorable mental health outcomes (see HHS, 2001a).The converse appears to be true for older Latinos; older immigrant Latinos (especially women) tend to be at higher risk of depressive symptomatology as shown in several population-based studies (Black, Markides, & Miller, 1998; Gonzalez, Haan, & Hinton, 2001; Kemp, Staples, & Lopez-Aqueres, 1984; Mendes de Leon & Markides, 1988).
The study presented here addresses the gap in the literature on the influence of religious involvement and older Latinos' mental health, specifically in a low-income, clinical population of older Latinos. The work focuses on the association of religious involvement (religious attendance and private prayer) and the outcome measure of depression by using clinical criteria based on the DSM-IV (American Psychiatric Association, 1994). Focus on diagnostic, criteria-based outcomes is important. First, prior work in this area has examined depression exclusively in terms of depressive symptomatology in general. This study is the first to focus on unipolar depression, in particular, through the use of diagnostic criteria for major and minor depression. Second, major and minor depressive disorders are widely distributed in the adult and older adult population and are typically associated with substantial symptom severity and role impairment (Kessler et al., 2003) that may interfere with an individual's normative activities and life span development.
Thus, this study examines the association among religious attendance, religious prayer, and depressive illness while adjusting for the effects of physical functioning, stress exposure, and social support. Specifically, the following three hypotheses are tested:
1. Higher levels of religious attendance will be associated with lower risk of depression after adjusting for physical functioning, stress exposure, and social support.
2. Higher levels of private prayer will be associated with lower risk of depression after adjusting for physical functioning, stress exposure, and social support.
3. Immigrant status (non-U.S.-born nativity) will be associated with higher risk of depression after adjusting for physical functioning, stress exposure, and social support.
Data Sources and Procedures
This is a cross-sectional design that used face-to-face interviews of 230 low-income, English- and Spanish-speaking, male and female Latino consumers (50 years of age and older) of primary medical care services at AltaMed Health Services in the greater Los Angeles area. AltaMed Health Services is a private, nonprofit health and human services organization with a 30-year history of providing medical, preventive, and long-term care to a predominantly Latino community. Potential respondents who met the inclusion criteria (Latino, 50+ years) were identified with the assistance of AltaMed staff. From the list of respondents, the first 230 who were willing to participate were interviewed either at the corresponding clinic sites or in their homes by a trained interviewer. The interviews averaged approximately one to two hours, were conducted by trained interviewers in English or Spanish, and followed a closed-ended, structured survey format.
Depressive Disorder. The dependent variable was depression as measured by the nine-item Depression subscale of the Patient Health Questionnaire (PHQ-9), a standardized diagnostic assessment procedure designed for clinical and research settings (Spitzer, Kroenke, &Williams, 1999). Respondents indicate for each of the nine depressive symptoms (anhedonia, dysphoric mood, sleep and appetite disturbances, decreased energy or fatigue, feelings of worthlessness or guilt, poor concentration psychomotor retardation or agitation, thoughts of death, or suicidal ideation), if during the previous two weeks, the symptom has bothered them "not at all," "several days," "more than half the days," or "nearly every day." Scores on the PHQ-9 are calculated by using a diagnostic algorithm delineated by Spitzer and his associates (1999) and categorized into threshold disorders (corresponding to specific DSM-IV diagnoses, such as major depressive disorder, major depression in partial remission, dysthymia, or other depressive disorder). For the purpose of the work reported here, only the presence of a unipolar depressive disorder ("yes" or "no") was considered.
Religious Involvement. Frequency of attendance at religious services was calculated by asking the respondent, "How often did you attend church, religious or worship services in the last 12 months?" (Hill et al., 2005). Use of private prayer was calculated by asking the respondent, "How much do you pray privately as an individual?" For both items, values were coded as never or almost never = 0, several times a year = 1, once or twice a month = 2, once a week = 3, more than once a week = 4, or daily = 5.
Physical Health. Functional ability was measured by the Physical Role Functioning subscale of the Medical Outcomes Study 36-Item Short-Form Survey (SF-36) (McHorney, Ware, & Raczek, 1993). The four-item (yes or no) subscale assesses the degree to which one's physical health interferes with or limits the person's ability to perform usual activities. The items were summated and a total functional limitation score was calculated. Scores ranged from zero to four, with higher scores indicating higher levels of role or functional limitations. Although the study did not control for specific physical problems, previous work has suggested that functional ability is better suited as a determinant of psychological well-being in older adults than is a list of medical conditions or problems (Berkman & Marimaldi, 2001).
Acute Life Stressors. Respondents were asked to identify (yes or no) all stressors that they had experienced in the previous 12 months from a checklist of 18 acute stress life events. Sample items include illness of spouse, death of family member, increased responsibilities (work, caregiving), relocation from the home, and so forth. These categories of items are frequently used in stress research in older adult populations because of the greater relevance and success in predicting health and mental health outcomes (Aldwin et al., 1996; Glass, Kasl, & Berkman, 1997). Affirmative answers were summated for a total acute life events score.
Social Support. Respondents were queried in the area of confidant support. One item was taken from the Arizona Social Support Interview Schedule (Barrera, 1981) that measures the number of available confidants the person identifies. The number of nonduplicated people was summated for a total confidant support score.
Sociodemographic Measures. Additional items include self-reports of respondent's age, gender, marital status, years of education, annual household income, nativity (U.S.-born or immigrant); and religious preference or identification.
Statistical Analyses. First, descriptive analyses were performed to report depression rates as well as to provide descriptive information of the major variables of interest. Second, the association between the dependent variable (depressive disorder) and the predictor variables was examined with logistic regression modeling (Hosmer & Lemeshow, 2000). The relationship between depressive disorder and predictor variable is represented as an odds ratio indicating the odds of a depressive diagnosis or no diagnosis, given the presence of the specific risk factor delineated in the model.
Overall, the sample of 230 respondents ranged in age from 50 to 94 (M = 69.6, SD = 10.1) (see Table 1). Sixty-seven percent of the sample were women, and two-thirds of the respondents were not married. Slightly more than 60 percent (61.7 percent) of the respondents were born in the United States, and 24.7 percent reported Mexico as their place of birth. Three out of four respondents (77.4 percent) self-identified as Roman Catholic, and 16.9 percent self-identified as Protestant. Only one of three respondents (34.3 percent) reported having at least a high school diploma. About one-half of the sample reported annual household incomes of less than $7,500. Immigrant respondents reported significantly lower household incomes and lower levels of education than did their U.S.-born counterparts (see Table 1).
Major Variables of Interest
Rates of depression indicate that overall almost one out of three (32.2 percent) respondents reported symptoms sufficient to meet the criteria for a PHQ depression diagnosis (see Table 1). The U.S.-born and immigrant groups did not differ significantly in terms of their respective rates of depression. Table 1 also shows the descriptive results for the remaining variables of interest. Overall, respondents were more likely to state that they attended religious services between once a week and once or twice a month (M = 2.29, SD = 1.34). Immigrants were significantly more likely to attend services (M = 2.61, SD = 1.39) than were U.S.-born respondents (M = 2.09, SD = 1.28). For example, immigrants were more than two times more likely to attend services once a week or more than their U.S-born counterparts (10.6 percent compared with 23.9 percent, respectively). No significant differences were found in terms of the frequency of private prayer. Both groups reported high levels of private prayer, with 76.8 percent of U.S-born and 84.1 percent of immigrants reporting they prayed daily or more than once a week.
In terms of physical role functioning, the total sample can be characterized as having a moderate level of functional impairment that interfered with their daily activities: Respondents averaged a physical role functioning score of 1.82 (SD = 1.76) from a possible range of zero to four. There were no significant differences between U.S.-born and immigrant respondents in terms of physical role functioning. It is important to note that both groups reported on average more than three chronic medical conditions (data not shown). Overall, the total sample reported a mean score of 2.25 stress events (SD = 1.63). U.S.-born respondents reported significantly higher levels of stress events (M = 2.51, SD = 1.61) than did the immigrant respondents (M = 1.83, SD = 1.59). Respondents were able to identify an average of three people they could rely on to talk about things that were personal or private (M = 3.27, SD = 3.14). No differences were found in terms of perceived availability of confidant support.
Multivariate Analyses. Three predictor variables were significantly associated with the presence of a depressive disorder: annual household income, religious attendance, and physical role functioning. Religious attendance was negatively associated with depression (odds ratio [OR] = 0.762, 95% confidence interval [CI] 0.594-0.979, p = .034) (Table 2) such that respondents with higher levels of attendance were 24 percent less likely to have a depressive disorder. Second, an increased risk of depression was found among respondents with poor physical role functioning (higher limitations in performing or accomplishing typical physical activities). Respondents with lower levels of functional limitations were 37 percent less likely to have a depressive disorder (OR = 0.762, 95% CI 0.511-0.765, p = .000). A negative association was also found between annual household income and the presence of depression. Respondents with higher levels of income were 15 percent less likely to report depression (OR = 0.854, 95% CI 0.739-0.987, p = .033). After adjusting for potentially confounding variables, no other variables were significantly associated with the risk for depression in the model. In summary, respondents more likely to be at risk of depression were those with low religious attendance, poor physical role functioning, and lower incomes.
The purpose of this article was to examine the relationship among religious involvement, private prayer, and depression in a low-income, clinical sample of older U.S.-born and immigrant Latinos. The cross-sectional data presented here lend support to earlier work that suggests attendance at church-related services or activities is a protective factor against depressive symptoms for older Latinos (Levin & Markides, 1985). Going to church services offers a protection for low-income older Latinos with chronic medical conditions, even when functional limitations, stress exposure, and confidant support could have explained possible health-related engagement in--or disengagement from--activities.
The data point to the positive effects of attendance after controlling for usual confounders of the link between attendance and psychological well-being, namely functional limitations, social support, and stress. Nevertheless, the mechanisms by which these salubrious effects occur cannot be disentangled with the data presented here. Those mechanisms that account for the association between attendance and better psychological well-being cannot be explained given that no information was tapped regarding specific activities related to the religious involvement (nature of the worship services, social contacts involved, perceived benefits of participation, and so forth). Early writers on religion, such as Durkheim (1915/1965), posited that religion is a social phenomenon (not a divinely inspired one) such that religion provides a way to counteract the breakdown of social norms and the increasing impersonality of social life as a result of the ills of modernization. Durkheim regarded anomie as a social and individual state void of order or rules. He also saw that all forms of deviant behavior emanated from the state of anomie, including the act of suicide; so religion offers a vehicle by which people can gather to reaffirm social order, cohesion, and meaning. Thus, as cited by Musick and his associates (2004), "While the ritualistic attachment to the sacred may be celebrated in private, he (Durkheim) argues that these expressions are most powerful when set within a group of like believers" (p. 201).
Overall, the level of religious attendance for the total sample was on average about one to two times per month. Although this may have been the case, almost one out of three respondents (32.2 percent) reported attending services "never or almost never." Thus, caution should be used when ascribing worship behaviors to this group of older Latinos. With that said, the immigrant group engaged in significantly higher levels of worship services (no less than once to twice a month) than their U.S.-born counterparts: 64.8 percent compared with 47.2 percent, respectively. This finding comes as no surprise as U.S. immigrants are more likely to participate in religious worship services than are their U.S.-born counterparts (Warner & Wittner, 1998). Theologians, historians, and social activists have accounted for the increased level of immigrants' participation in religious services as a normal transfer of the sacred from the homeland to the host country, and as important, church is a place that allows celebration of the sacred in one's own language and community (Levitt, 2002; Matovina & Riebe-Estrella, 2002; Warner & Wittner). As stated by Warner and Wittner, "Today, as in the past, people migrating to the United States bring their religions with them, and gathering religiously is one of the ways they make a life here. Their religious identities often (but not always) mean more to them away from home, in their diaspora, than they did before, and those identities undergo more or less modification as the years pass (p. 3)." Religion, therefore, is maintained as a strong indicator of a sociocultural resource in a society that is perniciously oppressive to older Latinos' beliefs, customs, ideologies, and collective realities (Magilvy, Congdon, Martinez, Davis, & Averill, 2000).
The small, yet growing literature on mental health interventions for older racial and ethnic minority groups tends to regard organizational religion not only as an important part of a person's individual and collective identity, but also as a reflection of the person's integration in a web of supportive networks and a potential point of recruitment and psychological intervention efforts. Yet, as older adults become increasingly unable to perform their usual and typical activities, the level of participation in more public forms of worship and interaction with others may be compromised. The data lend support to the negative influence of lower income and lower physical role functioning on psychological well-being. The link between lower socioeconomic status and mental illness (including depression) follows a long empirical tradition (Hudson, 2005). Likewise, the link between poor functional status and depression is well documented and evident in multiple populations (Yang & George, 2005).These circumstances may lead to fewer opportunities for the older adult to engage in such public and mutual exchanges of positive affirmation, tangible or instrumental assistance and guidance, and reinforcement of shared beliefs and meanings in life.
Mutual exchanges can be regarded as a type of social capital in that they are based on access to institutional resources vis-a-vis membership in social networks (Bourdieu, 1985; Ebstyne King & Furrow, 2004), and facilitation of interaction on the basis of norms and meanings, that is, obligations and expectations, informational channels, and social norms (Coleman, 1988). In his study of church-based social support and mortality among 1,500 older adults, Krause (2006) found that providing social support (not receiving support) to fellow church members buffered the effects of financial strain on mortality. Thus, formal church affiliation and church-based support may provide the opportunity for mutual exchanges needed for "the actualization of human potentiality in individuals, families, and communities" (Prigoff, 2003, p. 115) as well as the opportunity for individuals to move from the private spheres of worship to more public spheres of advocacy and empowerment at the small group and institutional levels (Parsons et al., 1998).
With regard to private prayer, overall the data suggest that prayer is a highly practiced activity in this sample. Close to 80 percent of the total sample prayed privately either daily or more than once a week. These results corroborate earlier work by Levin and Taylor (1997) that "prayer is a frequently used form of religious expression among adults in general and older adults in particular" (p. 85). Nevertheless, the second hypothesis that private prayer would be associated with lower risk of depression after adjusting for physical functioning, stress exposure, and social support was not supported by the data. Although regarded as an important indicator of individual coping in the face of medical problems in older adults (Kotarba, 1983; Levin &Taylor, 1997; Pargament & Hahn, 1986), private prayer was not a statistically meaningful correlate of depressive illness in this sample. Unlike attendance at church services, which is an inherently public and social activity, private prayer is just that--private. Perhaps private prayer does not afford this group of respondents the ability to demonstrate publicly their beliefs and commitment to religious doctrine regarding congregational interaction and celebration of important rituals and observances. That notwithstanding, the fact that private prayer was not related to depression could simply be because there was little variance in the responses. Moreover, not all prayer is the same, such that people may pray for many reasons and in many different formats (prayer, meditation, reading sacred literature, and so forth), which was not accounted for in this study. It is important to note that private prayer did not exert the same influence as religious attendance on depression, and there were no significant differences noted between U.S.-born and immigrant study participants. The high levels of private prayer suggest that the variable may not be sensitive enough because of limited variance and thus is of limited value in this analysis. Future work should focus on better ways to operationalize this variable in similar populations.
The third hypothesis that immigrant status (foreign-born Latinos) would be associated with depressive illness was not supported. Although in the bivariate analysis the two groups differed in terms of religious attendance (the immigrant group being more likely to report going to church services), the presence or absence of a depressive illness was not affected by immigration status. A potential explanation for this nonsignificant finding is that the immigrants in this particular sample have been living in the United States for a long time. The longer settlement period coupled with the fact that both groups had comparable rates of health care insurance could have mitigated some of the disparities documented in earlier work indicating higher rates of depression and lower worship service use among older Latino immigrants. There is also a dearth of both clinical and empirical information on the relative experiences of specific subgroups of Latino elders in this area of research as well as in practice. Thus, more comparative information is needed to help disentangle potential similarities and distinctions in this line of inquiry.
Several caveats are worth mentioning. First, the study did not incorporate other measures of religion and religious beliefs that give more information regarding the plethora of church attendance or types of private prayer that may have accounted for some of the relationships (or lack thereof) in the model (Levin et al., 1996). Second, there was very little variance in the responses in terms of religious preference or identification. The respondents were overwhelmingly Roman Catholic (close to 80 percent) followed by Protestant (17 percent). The data cannot answer the question of whether the nature of being Roman Catholic or Protestant makes a difference in terms of church attendance, private prayer, spiritual beliefs, and psychological well-being.
Last, although the theoretical model controlled for social support, the notion that organizational religion is in itself a faith community and thus a form of social capital cannot be ignored. Social support was narrowly defined in the study as the number of available confidants. Religious involvement in faith community-related activities on the other hand provides a critical social group, as posited by Garrison and her associates (2004) in their work with poor, rural mothers of young children. Similarly, although older Latinos may have confidants whom they can turn to during difficult times, being part of a larger web of social contacts connected by purpose and reciprocal exchanges of admiration, respect, and commitment may provide the needed assets and interpersonal resources to buffer the effects of adversity and affronts to empowerment (Hodge, 2001).
Social workers strive to ensure meaningful participation in decision making for all people regardless of age, gender, race or ethnicity, creed, physical ability, and so forth. For many communities and people from socioeconomically disadvantaged backgrounds, participation in a faith community is an empowering source in their lives. It is crucial that social workers approach the biopsychosocial assessment with an examination of the three factors that influenced depression in this study: income, physical ability, and religious involvement. Social workers are advised to assess the individual's spiritual and religious beliefs, activities, and expectations that may influence desired goals of fulfillment and personal realization. Several approaches are now available to serve as guides to social workers in the area of gerontology and social work, including qualitative and narrative queries (see Hodge, 2001, 2005; Ortiz & Langer, 2002). Qualitative assessment methods are well suited for future efforts to contextualize people's experiences by "accounting for the different ways of being religious and practicing religion" (Levin et al., 1996, p. 454). For example, Ortiz and Langer (2002) and Hodge (2001, 2005) provided spiritual assessment protocols that assist social work practitioners in exploring and evaluating their clients' spiritual history, strengths, and current challenges. These tools help practitioners understand client characteristics such as religious affiliation, religious practices, sources of comfort and strength, cross-cultural meanings, influence of immigration, ties with the faith community, and empowerment goals. Last, social workers are well positioned to interact with faith-based groups and institutions to understand those processes that enhance individual and group functioning and integrate these processes into health-promoting interventions.
Original manuscript received January 4, 2006
Final revision received March 22, 2007
Accepted June 19, 2007
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Maria P. Aranda, PhD, LCSW, is associate professor, School of Social Work, University of Southern California, Montgomery Ross Fisher, #214, Los Angeles, CA, 90089-0411; e-mail: firstname.lastname@example.org. An earlier version of this article was presented at the conference on Religion and Social Justice for Immigrants sponsored by the Center on Religion and Civic Culture, University of Southern California, February 1, 2005, Los Angeles, CA. This study was funded in part by the John A. Hartford Foundation/The Gerontological Society of America and the Center for Religion and Civic Culture/The Pew Charitable Trusts, University of Southern California.
Table 1: Sample Characteristics, by Nativity Status Total Sample (N = 230) Variable M SD n (%) Age (range: 50-94) 69.6 10.1 <60 41 (17.8) 60-69 71 (30.9) 70-79 82 (35.7) 80+ 36 (15.6) Female 154 (67.0) Country of birth United States Mexico Caribbean Central America Other Latin American country Religious preference Catholic 178 (77.4) Protestant 39 (16.9) Other 13 Marital status Married 79 Widowed 73 Separated/divorced 61 Never married 17 Education * No education 10 Elementary 58 Junior high school 32 Some high school 51 High school graduate 23 Some college 56 Annual household income * [less than or equal to] $7,500 107 $10,001-20,000 57 $20,001+ 43 Depression diagnosis (a) 74 Religious attendance (range: 0-5) 2.29 1.34 Daily/more than once a week 9 Once a week 27 Once or twice a month 88 Several times a year 32 Never 74 Private prayer (range: 0-6) 4.53 1.14 Daily/>once a week 183 Once a week 23 Once or twice a month 6 Several times a year 7 Never 10 Functional limitations (range: 0-4) 1.83 1.76 Stress events * (range: 0-7) 2.25 1.63 Confidant support (range: 0-23) 3.27 3.14 U.S.-Born (n = 142) Variable M SD n.(%) Age (range: 50-94) 68.1 9.98 <60 31 (21.8) 60-69 47 (33.1) 70-79 48 (33.8) 80+ 16 (11.2) Female 95 (66.9) Country of birth United States 142 (61.7) Mexico Caribbean Central America Other Latin American country Religious preference Catholic 105 (73.9) Protestant 29 (20.4) Other 8 (5.6) Marital status Married 49 (34.5) Widowed 41 (28.9) Separated/divorced 30 (28.1) Never married 12 (8.5) Education * No education 3 (2.1) Elementary 20 (14.1) Junior high school 23 (16.2) Some high school 42 (29.6) High school graduate 18 (12.7) Some college 36 (25.4) Annual household income * [less than or equal to] $7,500 55 (44.4) $10,001-20,000 38 (30.6) $20,001+ 31 (25.0) Depression diagnosis (a) 45 (31.7) Religious attendance (range: 0-5) 2.09 1.28 Daily/more than once a week 2 (1.4) Once a week 13 (9.2) Once or twice a month 52 (36.6) Several times a year 24 (16.9) Never 51 (35.9) Private prayer (range: 0-6) 4.47 1.90 Daily/>once a week 109 (76.8) Once a week 15 (10.6) Once or twice a month 6 (4.2) Several times a year 4 (2.8) Never 8 (5.6) Functional limitations (range: 0-4) 1.79 1.78 Stress events * (range: 0-7) 2.51 1.61 Confidant support (range: 0-23) 3.44 3.23 Immigrant (n = 88) Variable M SD n (%) Age (range: 50-94) 71.99 9.76 <60 10 (11.4) 60-69 24 (27.3) 70-79 34 (38.6) 80+ 20 (22.8) Female 59 (67.0) Country of birth United States -- Mexico 57 (24.7) Caribbean 14 (6.0) Central America 13 (5.5) Other Latin American country 5 (2.1) Religious preference Catholic 73 (83.0) Protestant 10 (11.3) Other 5 (5.7) Marital status Married 30 (34.1) Widowed 32 (36.4) Separated/divorced 21 (23.8) Never married 5 (5.7) Education * No education 7 (8.0) Elementary 0 (43.2) Junior high school 9 (10.2) Some high school 9 (10.2) High school graduate 5 (5.7) Some college 20 (22.7) Annual household income * [less than or equal to] $7,500 52 (62.7) $10,001-20,000 19 (22.9) $20,001+ 12 (14.4) Depression diagnosis (a) 29 (33.0) Religious attendance (range: 0-5) 2.61 1.39 * Daily/more than once a week 7 (8.0) Once a week 14 (15.9) Once or twice a month 36 (40.9) Several times a year 8 (9.1) Never 23 (26.1) Private prayer (range: 0-6) 4.64 1.06 Daily/>once a week 74 (84.1) Once a week 8 (9.1) Once or twice a month 0 (0) Several times a year 3 (3.4) Never 3 (3.4) Functional limitations (range: 0-4) 1.89 1.73 Stress events * (range: 0-7) 1.83 1.59 Confidant support (range: 0-23) 3.00 3.01 Notes: Some percentages do not add up to 100 because of missing data. Where appropriate, means, standard deviations, and ranges are included for continuous variables. (a) Depression diagnoses were derived from the Depression subscale of the Patient Health Questionnaire with Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (American Psychiatric Association, 1994) criteria. These rates include major depression and other unipolar depression diagnoses. * p [less than or equal to] 05. Table 2: Logistic Regression Analysis of the Association between the Presence of Depression and Sociodemographic, Religion-Related, Physical Health, Stress, and Social Support (N = 230) Odds Variable Ratio 95% CI p 0.99 0.952-1.020 .401 Gender 1.77 0.850-3.681 .127 Education 1.00 0.970-1.031 .987 Household income 0.85 0.739-0.987 .033 U.S.-born 1.41 0.702-2.818 .336 Religious attendance 0.76 0.594-0.979 .034 Private prayer 0.94 0.691-1.286 .710 Functional limitations 0.63 0.511-0.765 .000 Acute stress events 0.92 0.732-1.154 .468 Confidant support 1.07 0.964-2.818 .207 Note: CI-confidence interval.