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Brazilian Journal of Psychiatry

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Original Articles • Rev. Bras. Psiquiatr. 37 (3) • Sept 2015 • https://doi.org/10.1590/1516-4446-2014-1507 copy

Religious coping and its influence on psychological distress, medication adherence, and quality of life in inflammatory bowel disease

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

Inflammatory bowel disease (IBD) is associated with elevated levels of anxiety and depression and a reduction in health-related quality of life (HRQoL). Nonadherence to treatment is also frequent in IBD and compromises outcomes. Religious coping plays a role in the adaptation to several chronic diseases. However, the influence of religious coping on IBD-related psychological distress, HRQoL, and treatment adherence remains unknown.

Method:

This cross-sectional study recruited 147 consecutive patients with either Crohn’s disease or ulcerative colitis. Sociodemographic data, disease-related variables, psychological distress (Hospital Anxiety and Depression Scale), religious coping (Brief RCOPE Scale), HRQoL (WHOQOL-Bref), and adherence (8-item Morisky Medication Adherence Scale) were assessed. Hierarchical multiple regression models were used to evaluate the effects of religious coping on IBD-related psychological distress, treatment adherence, and HRQoL.

Results:

Positive RCOPE was negatively associated with anxiety (b = 0.256; p = 0.007) as well as with overall, physical, and mental health HRQoL. Religious struggle was significantly associated with depression (b = 0.307; p < 0.001) and self-reported adherence (b = 0.258; p = 0.009). Finally, anxiety symptoms fully mediated the effect of positive religious coping on overall HRQoL.

Conclusion:

Religious coping is significantly associated with psychological distress, HRQoL, and adherence in IBD.

Inflammatory bowel disease; psychological distress; adherence; religious coping; quality of life

	Overall sample (n=147)	CD (n=64)	UC (n=83)	p-value
Age	45.1±14.08	43.86±14.29	46.06±13.93	0.350
Sex (female)	84 (57.1)	37 (57.8)	47 (56.6)	0.885
Race (white plus Brazilian mulatto)	96 (65.3)	44 (68.8)	52 (62.7)	0.441
Religion (Catholic)	108 (73.5)	46 (71.9)	62 (74.7)	0.701^* * Chi-square test; † two-tailed t-test. Statistically significant results are in bold.
Marital status (spouse/partner)	98 (66.7)	46 (71.9)	52 (62.7)	0.239^* * Chi-square test; † two-tailed t-test. Statistically significant results are in bold.
Education (years)	8.37±4.89	8.14±4.59	8.54±5.13	0.627^†
Gross monthly income (US$)	482.93±560.03	487.58±665.19	479.34±467.37	0.930^†
Time since diagnosis (months)	80.47±71.83	79.73±73.97	81.04±70.57	0.914^†
Relapse rate				0.023 ^* * Chi-square test; † two-tailed t-test. Statistically significant results are in bold.
1 = low (one or two in last 2 years)	53 (36.3)	23 (36.5)	30 (36.1)
2 = moderate (three to five in last 2 years)	61 (41.8)	20 (31.7)	41 (49.4)
3 = high (six or more in last 2 years)	32 (21.9)	20 (31.7)	12 (14.5)
Hospitalized for IBD	79 (53.7)	39 (60.9)	40 (48.2)	0.124^* * Chi-square test; † two-tailed t-test. Statistically significant results are in bold.
Surgery for IBD	26 (17.7)	20 (31.3)	6 (7.2)	< 0.001 ^* * Chi-square test; † two-tailed t-test. Statistically significant results are in bold.
Disease in remission^‡ ‡ Remission defined as CDAI score < 150 or TWT score ≤ 6, as appropriate.				< 0.001 ^* * Chi-square test; † two-tailed t-test. Statistically significant results are in bold.
No (medium/high activity/severity)	57 (38.8)	2 (3.1)	55 (66.3)
Yes (low activity/severity)	90 (61.2)	62 (96.9)	28 (33.7)
Religious coping
Positive religious coping score	25.63±3.95	24.97±4.64	26.13±3.26	0.091^†
Negative religious coping score	11.71±4.51	11.53±4.18	11.86±4.76	0.667^†
HRQoL
Overall HRQoL	3.88±0.81	3.94±0.75	3.84±0.85	0.485^†
Satisfaction with health	3.59±0.96	3.34±1.10	3.78±0.80	0.008 ^†
Physical HRQoL	3.48±0.64	3.42±0.60	3.54±0.67	0.272^†
Psychological HRQoL	3.82±0.67	3.68±0.61	3.92±0.71	0.030 ^†
Social HRQoL	3.90±0.74	3.98±0.74	3.83±0.74	0.234^†
Environmental HRQoL	3.38±0.53	3.41±0.54	3.36±0.53	0.554^†
Psychological distress
Anxious (HADS-A ≥ 8)	37 (25.2)	21 (32.8)	16 (19.3)	0.061^* * Chi-square test; † two-tailed t-test. Statistically significant results are in bold.
Anxiety score (HADS-A)	5.58±4.30	6.00±4.06	5.26±4.47	0.302^†
Depressive (HADS-D ≥ 8)	36 (24.5)	15 (23.4)	21 (25.3)	0.794^* * Chi-square test; † two-tailed t-test. Statistically significant results are in bold.
Depression score (HADS-D)	5.27±3.78	5.00±3.83	5.48±3.74	0.445^†
Morisky scale adherence score	5.57±1.75	5.56±1.85	5.58±1.69	0.946^†

	Religious coping method	Scores	Factor I loadings^* * Factor loadings obtained after varimax rotation.	Factor II loadings^* * Factor loadings obtained after varimax rotation.
Positive religious coping subscale^† † Positive coping subscale score is the sum of the scores of the seven items that loaded in factor I, i.e., positive coping strategies.		25.63±3.95
1. Looked for a stronger connection with God	Spiritual connection	3.74±0.65	0.85	0.01
2. Sought God’s love and care	Seeking spiritual support	3.79±0.61	0.83	0.02
3. Sought help from God in letting go of my anger	Religious forgiving	3.67±0.81	0.76	0.16
4. Tried to put my plans into action together with God	Collaborative religious coping	3.76±0.61	0.89	0.04
5. Tried to see how God might be trying to strengthen me in this situation	Benevolent religious reappraisal	3.71±0.74	0.70	0.06
6. Asked forgiveness of my sins	Religious purification	3.70±0.73	0.71	0.01
7. Focused on religion to stop worrying about my problems	Religious focus	3.26±1.03	0.60	0.26
Negative religious coping subscale^‡ ‡ Negative coping subscale score is the sum of the scores of the seven items that were loaded in factor II, i.e., negative coping strategies.		11.71±4.51
8. Wondered whether God had abandoned me	Spiritual discontent	2.03±1.12	0.14	0.63
9. Felt punished by God for my lack of devotion	Punishing God reappraisal	1.93±1.15	0.11	0.76
10. Wondered what I did for God to punish me	Punishing God reappraisal	2.03±1.18	0.15	0.74
11. Questioned God’s love for me	Spiritual discontent	1.75±1.16	0.02	0.75
12. Wondered whether my church had abandoned me	Interpersonal religious discontent	1.33±0.81	0.06	0.60
13. Decided the devil made this happen	Demonic reappraisal	1.51±1.04	0.07	0.46
14. Questioned the power of God	Reappraisal of God’s powers	1.14±0.59	0.25	0.31
Eigenvalues			4.46	2.68
Variance explained			31.8%	19.1%
Cronbach’s alpha			0.87	0.74

	Anxiety symptoms(HADS-A)		Depressive symptoms(HADS-D)		Adherence(MMAS-8)		Adherence (MMAS-8) (modified model)
	Beta	p-value		Beta	p-value	Beta	p-value	Beta	p-value
Age	0.213	0.040		0.203	0.044	0.002	0.983	N/I
Sex (female)	0.074	0.404		0.139	0.112	0.084	0.380	0.091	0.290
Race (white)	0.040	0.646		0.112	0.183	0.138	0.137	0.132	0.132
Religion (Catholic)	0.077	0.356		0.034	0.673	0.083	0.350	0.079	0.357
Education (years)	0.174	0.085		0.006	0.952	0.068	0.525	0.069	0.443
Income (US$)	0.079	0.388		0.081	0.364	0.133	0.172	0.130	0.159
Disease (UC)	0.069	0.529		0.078	0.468	0.039	0.738	0.046	0.673
Time since diagnosis (months)	0.223	0.013		0.190	0.030	0.060	0.535	0.062	0.494
Surgery	0.021	0.809		0.098	0.243	0.015	0.874	N/I
Relapse rate	0.223	0.007		0.107	0.176	0.088	0.318	0.082	0.322
In remission	0.017	0.876		0.068	0.514	0.049	0.666	0.053	0.627
Positive RCOPE	0.256	0.007		0.222	0.016	0.020	0.843	N/I
Negative RCOPE	0.211	0.018		0.307	< 0.001	0.258	0.009	0.262	0.005
Anxiety symptoms	N/I			N/I		0.02	0.848	N/I
Depressive symptoms	N/I			N/I		0.14	0.214	0.131	0.150
Adjusted R²	0.130			0.170		0.040		0.060
Significance of F	0.003			< 0.001		0.180		0.045

	Overall HRQoL				Satisfaction with health
	Model 1	Model 2	Model 3	Model 4	Model 1	Model 2	Model 3	Model 4
Age	0.114	0.105	0.188	0.104	0.158	0.154	0.108	0.215 ^* * p < 0.05; † p < 0.01; ‡ p < 0.001. Statistically significant results are in bold.
Sex (female)	0.115	0.112	0.136	0.106	0.099	0.078	0.145	0.100
Race (white)	0.120	0.119	0.154	0.138	0.073	0.090	0.126	0.098
Religion (Catholic)	0.054	0.058	0.064	0.034	0.027	0.045	0.067	0.032
Education	0.097	0.117	0.065	0.132	0.099	0.081	0.093	0.163
Income	0.020	0.010	0.012	0.043	0.118	0.110	0.118	0.159
Disease (UC)		0.067	0.091	0.117		0.335 ^†	0.325 ^†	0.307 ^†
Time since diagnosis		0.068	0.023	0.064		0.106	0.057	0.052
Surgery		0.116	0.085	0.076		0.128	0.108	0.089
Relapse rate		0.081	0.118	0.031		0.045	0.073	0.027
In remission		0.066	0.073	0.079		0.117	0.159	0.160
Positive RCOPE			0.092			0.213 ^†	0.086
Negative RCOPE			0.092			0.030	0.148
Anxiety symptoms				0.387 ^‡				0.399 ^‡
Depressive symptoms				0.009				0.111
Adjusted R²	0.030	0.020	0.050	0.170	0.020	0.030	0.060	0.230
Significance of F	0.135	0.263	0.098	0.001	0.699	0.164	0.076	0.001
R² change	0.030	0.010	0.030	0.120	0.020	0.050	0.020	0.170
Significance of F change	0.135	0.575	0.044	< 0.001	0.699	0.044	0.070	< 0.001

	Physical HRQoL				Mental HRQoL
	Model 1	Model 2	Model 3	Model 4	Model 1	Model 2	Model 3	Model 4
Age	0.164	0.166	0.231 ^* * p < 0.05; † p < 0.01, ‡ p < 0.001. Statistically significant results are in bold.	0.108	0.033	0.007	0.107	0.009
Sex (female)	0.189 ^* * p < 0.05; † p < 0.01, ‡ p < 0.001. Statistically significant results are in bold.	0.151	0.157	0.103	0.150	0.105	0.167	0.107
Race (white)	0.021	0.020	0.044	0.008	0.046	0.028	0.081	0.039
Religion (Catholic)	0.007	0.007	0.007	0.029	0.005	0.015	0.034	0.002
Education	0.004	0.004	0.047	0.025	0.041	0.038	0.076	0.025
Income	0.089	0.102	0.084	0.037	0.080	0.116	0.091	0.046
Disease (UC)	−	0.156	0.136	0.121	−	0.197	0.170	0.172
Time since diagnosis	−	0.141	0.111	0.013	−	0.226 ^†	0.158	0.042
Surgery	−	0.068	0.044	0.019	−	0.060	0.021	0.011
Relapse rate	−	0.236 ^†	0.264 ^†	0.153 ^* * p < 0.05; † p < 0.01, ‡ p < 0.001. Statistically significant results are in bold.	−	0.087	0.136	0.043
In remission	−	0.103	0.087	0.092	−	0.028	0.046	0.061
Positive RCOPE	−	−	0.128	0.060	−	−	0.297 ^‡	0.163
Negative RCOPE	−	−	0.171	0.030	−	−	0.136	0.008
Anxiety symptoms	−	−	−	0.412 ^‡	−	−	−	0.281 ^‡
Depressive symptoms	−	−	−	0.174	−	−	−	0.279 ^‡
Adjusted R²	0.050	0.100	0.120	0.170	0.010	0.040	0.100	0.290
Significance of F	0.045	0.007	0.004	< 0.001	0.517	0.107	0.010	< 0.001
R² change	0.050	0.060	0.020	0.120	0.010	0.050	0.060	0.190
Significance of F change	0.045	0.023	0.096	< 0.001	0.517	0.040	0.006	< 0.001

		Indirect effect; z (p)
Outcome variable	Direct effect (p)	Through anxiety symptoms	Through depressive symptoms
Overall HRQoL	0.021 (0.326)	0.020; 2.205 (0.028)	0; 0.085 (0.932)
Satisfaction with health	0.019 (0.340)	0.025; 2.256 (0.024)	0.006; 0.975 (0.330)
Psychological HRQoL	0.029 (0.063)	0.012; 1.995 (0.046)	0.011; 1.834 (0.067)
Social HRQoL	0.037 (0.022)	0.018; 2.234 (0.026)	0.008; 1.567 (0.117)

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