The Role of Religious Coping and Race in Alzheimer’s Disease Caregiving

Abstract

Alzheimer’s disease (AD) and other dementias are one of the most critical public health problems in elderly population. Using baseline data from the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) II study, this study examined the relationship between religious coping, burden appraisal, depression, and race among 211 African American, 220 White, and 211 Hispanic caregivers, using structural equation modeling (SEM). Caregiver burden appraisal mediated the effect of religious coping on depression with higher religious coping resulting in lowering caregiver burden appraisal and thereby reducing depression. The results also showed that religious coping mediation model was best supported by African Americans. Greater understanding of religious coping and its role in the caregiving process helps researchers discover better ways to assist racially diverse caregivers in dealing with burdens of AD caregiving.

Keywords

Alzheimer’s disease burden caregiving race religious coping

This study examines the role of religion as a source of support and a means of coping among those individuals providing care to victims of Alzheimer’s disease (AD). AD is the most common form of dementia disorder among older persons. Dementia is the loss of intellectual functioning in an otherwise awake and alert person (Hodgson & Cutler, 1994). Dementia involves multiple cognitive deficits that have a significant impact in social or occupational functioning (American Psychiatric Association, 1994). The average duration of AD from mild cognitive deficits until death is estimated to be 20 years (Sclan, 1995). In the United States, more than 5 million people are estimated to have AD (Alzheimer’s Association, 2009). By the mid-21st century, that number is expected to increase to 14.3 million (Diagnostic Center for Alzheimer’s Disease, 2006). With an estimated cost exceeding US$100 billion per year, AD is the third most costly disease in the United States, after heart disease and cancer (Alzheimer’s Drug Discovery Foundation, 2005).

Religion may help alleviate the impact of caregiving burden/stress (Chadiha & Fisher, 2003; Picot, Debanne, Namazi, & Wykle, 1997). In recent years, research has highlighted the importance of religion and spirituality as resources for coping with stressful life events. Religiosity has been associated with active and effective coping with problems and crises, such as terminal illness (Pargament, 1997; Tix and Frazier, 1998). Religiosity also has been associated with improved mental health in people under stress (Smith & McCullough, 2003). Koenig, McCullough, and Larson’s (2001) review of cross-sectional studies linking organized religious involvement with depression found that in more than 85% of the studies, participation in an organized religion was associated with lower depression. Similarly, higher levels of religious participation and commitments were also correlated with lower levels of anxiety and depression among the older adults (Johnson, 1995; Koenig & Pargament et al., 1998) and the bereaved (Gray, 1987).

Racial Difference in Religion and Caregiving

Literature suggests that African Americans are more likely to use religious coping to help reduce the negative impacts of providing care (Chadiha & Fisher, 2003; Fei, Kosberg, Leeper, Kaufman, & Burgio, 2010; Picot et al., 1997). Studies found that African American caregivers perceive less subjective burden and greater caregiving satisfaction than Whites (Lawton, Rajagopal, Brody, & Kleban, 1992). Dilworth-Anderson, Williams, and Gibson (2002) assert that African Americans tend to cope with the difficulties of caregiving using prayer, faith in God, and religion and emotional support from church (Dilworth-Anderson, Boswell, & Cohen, 2007; e.g., advice and encouragement). Moreover, Picot et al. (1997) implied that race was significantly related to perceived rewards, with African Americans reporting higher levels of reward than their White counterparts.

Religion plays a very important role among Hispanics. Morano & King (2005) found that Hispanic caregivers reported significantly higher religiosity than White caregivers and that both African American and Hispanic caregivers reported lower levels of depression than White caregivers. Studies indicated that Hispanic cultures are centered on the family and that family members are expected to provide care to the older adults (Clark & Huttlinger, 1998; Cox & Monk, 1993). Several studies reported that compared with White caregivers, Hispanic caregivers support filial responsibility beliefs and a stronger traditional caregiving roles (Luna, de Ardon, Lim, Philips, & Russell, 1996). The current study will explore the racial differences (African American, White, and Hispanic) in religious coping and depression.

Conceptual Model

This study used a modified version of stress and coping model by Lazarus and Folkman (1984) to examine the pathways from religious coping to depression. According to this model, it is not the negative event per se that determines how well one will adapt, but rather the appraisal of both the event and one’s ability to meet the associated demands (Lazarus & Folkman, 1984). Studies illustrate that the way in which caregivers interpret their situation may be more consequential than objective characterizations of that situation. On the basis of this theoretical model, the extent to which caregivers demonstrate resiliency in caregiving is affected by their ability to appraise stressful situations and draw on available resources to cope with their individual situations. Religion may provide caregivers with a set of beliefs and values that facilitate positive appraisals (Salts, Denham, & Smith, 1991; Segall & Wykle, 1989).

In this study, religious coping is treated as a special resource, a personal, psychological trait, and set of implied behaviors and/or cognitions that acts to reduce the adverse effects of stress. The effects of religious coping are separated from other elements of religiosity (church attendance and prayer/meditation) to study its beneficial impact on depression, both directly and indirectly through its potential to reduce burden among caregivers. Burden is an appraisal measure; it is a measure of the construct of strain. Coping reasonably reduces strain from caregiving. Stress is implicit and represented at the psychological level in the burden measure. Picot et al. (1997) suggested that religiosity serves as a coping resource variable, which in turn operates as a stress deterrent. As a resource variable, the function of religious coping may be to raise the caregiver’s threshold for stress. For example, the caregivers in this study prayed more frequently, a behavior which has preceded their caregiving career, and therefore they have perceived less stress than nonreligious caregivers when confronted by the same caregiving situation. It is acknowledged that health could affect burden appraisal and depression (Frerichs, Aneshensel, Yokopenic, & Clark, 1982; Geerlings, Beekman, Deeg, & Tilburg, 2000), and it might relate to coping.

Purposes and Hypotheses

Stress coping models focus on identifying the factors that likely mediate or intervene between the stress of caregiving and subsequent outcomes (Haley, Levine, Brown, & Bartolucci, 1987). Although studies help us understand the general impact of religious coping, they do not provide greater awareness of how and which aspects of religion supports caregivers. It is critical to evaluate the influence of religious coping on caregivers and mediating variables in the caregiving process. In this study, a stress–strain–outcome model was used with coping as a resource.

The purpose of the current study is to provide a better understanding of the role of religious coping and underlying structures in the relationships between religious coping, burden appraisal, and depression in AD caregiving by analyzing baseline data from Resources for Enhancing Alzheimer’s Caregiver Health (REACH) II study. It will test a theoretical path model in which burden appraisal is a mediator of the effect of religious coping on depression. It will also explore the moderation effect of race.

Understanding the role of religious coping may inform us about intervention and mental health service delivery. The current study’s hypotheses will be evaluated controlling for caregiver’s physical health. The current study has the following three specific aims and hypotheses:

Aim 1 and Hypothesis 1: Examine the relationship between religious coping and depression. It is hypothesized that caregivers who have higher levels of religious coping will have lower levels of depression (Figure 1).

Aim 2 and Hypothesis 2: Test the mediation of burden in the relationship between religious coping and depression. It is hypothesized that religious coping will lower burden appraisal and burden appraisal will lower depression. It is expected to be a partial mediation (Figure 1).

Aim 3 and Hypothesis 3: Explore the moderating effect of race in the relationship between religious coping and depression (Figure 1). It is expected that the effects of religious coping on depression will be different for African American, White, and Hispanic caregivers.

Figure 1.

The conceptual path model of hypothesized relationships.

Method

Participants

The total sample (N = 642) for this study came from the REACH II study. Study participants are caregiver–care recipient dyads who meet the inclusion and exclusion criteria. In this study, only baseline assessment data (Time 1) was used for analysis, because there is larger N than follow-up data (Time 2) and follow-up data would be affected by intervention. The respondents consist of 211 African American, 220 White and 211 Hispanic caregivers.

REACH II was a multisite randomized clinical trial, funded by the National Institutes on Aging (NIA) and the National Institutes of Nursing Research (NINR) that tested the efficacy of a multicomponent social/behavioral intervention for caregivers of persons with AD. The randomized cohort of Hispanic/Latino, White, Black/African American caregivers was recruited from five sites in the United States: Birmingham, AL; Miami, FL; Memphis, TN; Palo Alto, CA; Philadelphia, PA. The study also included a coordinating center at the University of Pittsburgh. Participants were screened for eligibility, given a baseline assessment, and subsequently randomized to treatment or control condition within each of the three ethnic groups. Caregivers were assessed a second time, 6 months later after the intervention was completed. The primary outcome was a multivariate quality of life indicator that assessed caregiver burden, depressive symptoms, self-care, social support, and patient problem behaviors. In addition, caregiver clinical depression and patient institutional placement were assessed. The data were collected through telephone interview with caregivers.

This study was not required to submit to the Institutional Review Board (IRB) for review/approval, because it used secondary data, thus it has no human subject involvement.

Measures

Religious coping

Religiosity (used as a term encompassing religious coping and attendance/prayer/meditation) was assessed by two measures. The first measure from the Brief RCOPE (Pargament, Smith, Koenig, & Perez, 1998), a 3-item questionnaire, assessed the use of religious coping. Religious coping consisted of 3 items that measured seeking spiritual support, seeking a spiritual connection, collaboration with God in problem solving. Caregivers indicated how often they engaged in each form of religious coping on a 4-point scale (0 = not at all to 3 = a lot). The Brief RCOPE has demonstrated good construct validity and internal consistency among those facing major life crises (e.g., Koenig et al., 1998) and caregivers (Tarakeshwar & Pargament, 2001). Cronbach’s alpha for the present study was .83.

Religious behavior

The second measure of religiosity was religious behavior. Religious behavior was assessed by 2-item question on religious behavioral practices. A question assessed how often the participant attends religious services, meetings, and/or activities (0 = never to 5 = nearly every day). The other question asked how often the participant pray or meditate (0 = never to 5 = nearly every day). These two religious behavior questions will be used separately from the religious coping measure in the analysis. The two behavioral items are used as separate measures in the path analysis. The religious behavior variables precede religious coping in the model to isolate the influence of religious coping from other aspects of religiosity.

Caregiver burden appraisal

Caregiver burden appraisal was measured by the brief (12-item) version of the Zarit Caregiver Burden Interview (Bedard et al., 2001; Zarit, Orr, & Zarit, 1985). Caregiver burden appraisal score is based on the sum of 11 items (e.g., “Feel stressed between caring for [the care recipient] and meeting other responsibilities?”). Caregivers rated each item on a 5-point scale from 0 (never) to 4 (nearly always), yielding a possible range of 0 to 44. Higher values indicated greater levels of caregiver burden appraisal. Cronbach’s alpha was .87.

Depression

Caregiver depressive symptoms were assessed by using the Center for Epidemiological Studies–Depression (CES-D) scale (Radloff, 1977). A short version of 10-item CES-D was used in this study. For each items, caregivers rated the frequency of this symptom on a 0 (rarely or none of the time) to 3 (most of the time) scale. The CES-D has demonstrated content, criterion-related, and construct validity in addition to good sensitivity and specificity (Geisser, Roth, & Robinson, 1997). Participant scores were generated by reverse coding negative items and average item scores within each subscale. Higher scores indicate greater depression. Cronbach’s alpha was .83.

Caregivers’ demographic variables

Race was measured by respondents’ self-identification. On the basis of the caregiving literature, caregivers’ self-rated physical health (Morrissey, Becker, & Rubert, 1990) will be included in the analysis as a potential predictor of religious coping, burden, and depression. Self-rated physical health of caregivers was assessed by one question “In general, would you say your health is?” Caregivers rated each item on a 5-point scale from 0 (excellent) to 4 (poor).

Data Analysis

The hypothesized path model composed of study variables was evaluated using structural equation modeling (SEM). EQS 6.1 for Windows software (Bentler, 2004) was used to analyze the hypothesized relationships. Four steps of analysis were performed. First, preliminary analysis of important demographic variables was performed to determine which variables should be included in the model. Second, bivariate relations between predictors and criterion are presented, including a background variable. Third, the specific tests for the significance of each path in the model were conducted. Finally, exploratory moderation test for the difference among race groups was examined using MSEM (multigroup structural equation model). Given that the data departed from normality (Mardia’s coefficient = 6.07), robust statistics (maximum likelihood estimation) were reported for the relationships among the hypothesized relationships to correct for nonnormal data (Satorra & Bentler, 1994). Control variables were selected based on highlighted importance in caregiving literature and on bivariate correlation results with depression. The preliminary analysis including other demographic characteristics (i.e., gender, age) and care recipient characteristics (i.e., severity of symptoms) was conducted, yet none of them was related to depression. It showed that only self-rated physical health was significantly associated with depression. Consequently, it was included as a predictor in all model tests.

Results

This study examined the role of religious coping in a sample of caregivers with persons of AD. It is expected that religious coping will have positive effects on psychological well-being of caregivers. The analyses were completed for associations between and among race, religious attendance, prayer/meditation, religious coping, burden appraisal, and depression.

Description of the Sample

Demographic characteristics of the sample are shown in Table 1. Initially, 648 caregivers of persons with Alzheimer’s were included in this study; however 6 persons were excluded in the analyses because they did not belong to any of 3 main race groups (Black, White, and Hispanic). Caregivers’ age ranged from 24 to 92 with a mean age of 62.3. The majority (79%) of the 642 respondents was women. The average years of education were 12.6 with a range of 0 to 22. The average personal income was in the US$20,000 to US$29,999 range. More than half of the caregivers identified themselves as religious; 30% were Roman Catholic, 24% were Baptist and 11% were other Christian denomination (Methodist, Presbyterian, Episcopal). Sixty-two percentage of caregivers indicated that they were in good, very good, or excellent physical health condition.

Table 1.

Description of the Sample: N and % (in parentheses) or M and SD (in parentheses).

Variables	Total (n = 642) N (%) or M (SD)	Black (n = 211)	White (n = 220)	Hispanic (n = 211)	Test statistics
Age (years)	62.3 (13.1)	62.4 (12.7)	62.4 (12.7)	63.8 (12.9)	F(2, 639) = 3.1*
Female (%)	506 (78.8)	174 (82.5)	172 (78.2)	160 (75.8)	χ²(2, 642) = 2.9
Physical health % (greater than “good”)	396 (61.7)	137 (64.9)	164 (74.6)	95 (45.1)	χ²(8, 642) = 85***
Education (years)	12.6 (3.1)	13.1 (2.2)	13.8 (1.9)	10.9 (4.1)	F(2, 639) = 58.9***
Income% (greater than “US$30,000”)	281 (43.7)	89 (42.2)	140 (63.6)	52 (24.6)	χ²(24, 642) = 121.7***
Religious coping	6.8 (2.6)	7.7 (1.9)	5.9 (3.1)	6.9 (2.4)	F(2, 632) = 26.3***
Burden	18.8 (9.9)	16.8 (8.7)	20.8 (9.6)	18.7 (10.7)	F(2, 630) = 8.8***
Depression	9.9 (6.5)	9.2 (6.3)	10.3 (6.2)	10.4 (7.1)	F(2, 237) = 2.2

p < .05. **p < .01. ***p < .001.

Results of tests of mean differences on demographic variables, religious coping, burden appraisal, and depression by race are also presented in Table 1. Racial differences for almost all of the variables are significant at p < .5 except gender and depression. Hispanic differed from Black and White respondents in that they were slightly older and had less formal education. Forty-five percentage of Hispanics reported that their self-rated health was better than good, whereas 65% of Blacks and 75% of Whites reported that their self-rated physical health was better than good. Only 25% of Hispanics reported that their household income was greater than US$30,000, whereas 42% of blacks and 64% of Whites reported the same level of income. However, Whites reported the lowest level of religious coping and highest level of caregiver burden appraisal, whereas Black respondents indicated the highest level of religious coping and lowest level of caregiver burden appraisal of the group.

Bivariate Relationships

The relationships between religious attendance, prayer/meditation, religious coping, burden appraisal, and depression are shown in Table 2. Religious attendance was associated with more practice of prayer/meditation (r = .38, p < .01) and higher level of religious coping (r = .47, p < .01). Prayer/meditation was positively correlated with religious coping (r = .71, p < .01). Consistent with the hypotheses, religious coping was associated with lower burden appraisal (r = −.18, p < .01) and lower depression (r = −.23, p < .01). Religious attendance was also associated with lower burden appraisal (r = −.12, p < .01), and lower depression (r = −.26, p < .01). Religious variables show a higher negative correlation with depression than burden appraisal. Burden appraisal was highly correlated with depression (r = .59, p < .01). Better self-rated physical health was marginally related to more practice of prayer/meditation (r = .09, p < .05). Self-rated physical health was negatively correlated with burden appraisal (r = −.19, p < .01) and depression (r = −.35, p < .01).

Table 2.

Correlation Among Study Variables.

Variables	1	2	3	4	5	6
1. Physical health	—
2. Religious attendance	.06	—
3. Prayer/meditation	−.09*	.38**	—
4. Religious coping	−.06	.47**	.71**	—
5. Burden	−.19**	−.12**	−.14**	−.18**	—
6. Depression	−.35**	−.26**	−.17**	−.23**	.59**	—

p < .05. **p < .01. ***p < .001.

Path Model Testing and Test of Mediation

The structural equation analysis (EQS) was run on all hypothesized paths. SEM is a useful tool that enables us to explain the relationships among variables and discover underlying structure by testing all variables simultaneously. Multiple fit indices were used to evaluate the fit of the data to the model. An overall chi-square index was used to assess the degree of fit between the estimated and observed covariance matrices. Lower values indicate better fitting models. The fit of the specified model, χ²(4, N = 642) = 97.085, CFI = .88, RMSEA = .19, p < .001, suggested poor fit of the data to the model. Self-rated physical health as control variable was included in the model because of its relationship to depression. Modification indices (Lagrange multiplier [LM] test) indicated a direct path from religious attendance to depression; this path was added to the model. Nonsignificant paths from self-rated physical health to religious attendance and physical health to prayer/meditation were removed. Reestimation of the model results in an improved fitting model, χ²(5, N = 642) = 11.68, CFI = .99, RMSEA = .05, p = .04. The model explained 55% of the variance in religious coping and 45% of the variance in depression. Table 3 reports the significance tests for each relationship in the hypothesized model. Figure 2 is a graphical depiction of this modified model with standardized coefficients reported. The nonsignificant relationship is notated with a dashed line and the mediation of burden is notated with a darker line.

Table 3.

Maximum Likelihood Parameter Estimates for Model.

DV	IV	B	SE	β	Z	P	R ²
Depression							.45
	Burden	0.34	.02	.51	16.42	<.001
	Religious coping	−0.23	.08	−.19	−4.89	<.001
	Religious attendance	−0.53	.13	−.14	−4.01	<.001
	Physical health	−1.49	.18	−.25	−8.11	<.001
Burden							.09
	Religious coping	−0.73	.14	−.19	−5.06	<.001
	Physical health	−2.02	.36	−.22	−5.53	<.001
Religious coping							.55
	Religious attendance	0.36	.05	.23	7.92	<.001
	Prayer/Meditation	1.36	.06	.62	21.17	<.001
	Physical health	−0.03	.06	−.01	−0.45	.65

Note: DV = dependent variable; IV = independent variable.

Figure 2.

The final path model of relationships with standardized coefficients (total sample).

Religious attendance was found to be a positive predictor of religious coping (β = .23, z = 7.92, p < .001). Prayer/meditation was also found to be a positive predictor of religious coping (β = .62, z = 21.17, p < .001). Religious coping was a negative predictor of depression (β = −.19, z = −4.89, p < .001). This is a significant path, suggesting that as caregivers’ level of religious coping increases, their level of depression decreases. Religious coping was a negative predictor of caregiver burden appraisal (β = −.19, z = −5.06, p < .001). This is a significant path, signifying that as caregivers’ level of religious coping increases, their level of caregiver burden appraisal decreases. The data show that there was a significant relationship between burden appraisal and depression (β = .51, z = 16.42, p < .001). This result indicated that as the caregivers’ level of burden appraisal increases, their level of depression also tend to increase. Religious attendance was a negative predictor of depression (β = −.14, z = −4.01, p < .001). This is only one not predicted and added path indicated by LM test. It was significant, suggesting that as caregivers’ level of religious attendance increases, their level of depression decreases.

Test of mediation

Caregiver burden appraisal was found to partially mediate the prediction of depression by religious coping (β = −.09, z = −2.63, p < .01). There was a significant negative prediction of caregiver burden appraisal by religious coping (β = −.19, z = −5.09, p < .001). There was a significant positive prediction of depression by caregiver burden appraisal (β = .51, z = 15.89, p < .001). There was a significant negative prediction of depression by religious coping after adjusting for caregiver burden appraisal (β = −.09, z = −2.63, p < .01). Given that the direct path between religious coping and depression remains significant after caregiver burden appraisal is accounted for, caregiver burden appraisal is acting as a partial mediator in the relationship between religious coping and depression. The result shows that higher levels of religious coping are related to lower levels of burden appraisal and the lower levels of burden appraisal are also related to lower levels of depression. The result supports the first hypothesis that religious coping will decrease caregivers’ depression (Hypothesis 1). It supports the hypothesis that caregiver burden appraisal will partially mediate the relationship between religious coping and depression (Hypothesis 2).

Additional mediation

Looking at the relationship between variables, multiple mediators are possible in this mediation model. Religious coping acted as a mediator between religious attendance and depression. Expanded mediation occurs in the paths from religious attendance to religious coping and from religious coping to burden appraisal and depression.

Test of Moderation

To test moderation of race, multisample SEM was conducted. Mutlisample SEM is to test for differences on the parameters of a model among samples. In SEM, one way to test for a moderation is to perform MSEM where the grouping variable is a moderator. MSEM provides a direct method for simultaneous testing and evaluating of hypotheses about group effects.

To test MSEM, the first step was to analyze each group (Black, White, and Hispanic) separately. Then a common model (baseline model) with all the parameters from the groups was tested. The baseline model hypothesizes (a) no significant group differences in parameter estimates and (b) equivalent model fit for all groups (Scott-Lennox & Lennox, 1995). Typically, the first step of a MSEM is to test an unconstraint baseline model, which assumes the structural model holds identically for three ethnic groups and no invariance exists in parameter estimates. The baseline model among groups was estimated simultaneously. Next, restrictions were placed on a model by constraining parameters to be equal across groups. The second, group sensitive model estimated acknowledges that race subgroups may have distinct relationships among religious coping and depression. To identify significant group-specific differences, LM tests of equality constraints across samples were examined.

The overall model fit for each sample is as follows: Black, χ²(5, N = 211) = 2.233, p = .82, CFI = 1.000, RMSEA = .000; White, χ²(5, N = 220) = 11.097, p = .05, CFI = .98, RMSEA = .08; Hispanic, χ²(5, N = 211) = 2.336, p = .801, CFI = 1.000, RMSEA = .000. Unstandardized parameter estimates are reported in MSEM (Table 4). In MSEM, unstandardized parameter estimates are being compared rather than standardized estimates, as a standard error of a standardized solution is unknown. Parameter constraints were added to the baseline model to test for a structural invariance among race groups. Chi-square difference test was conducted to observe if there is overall difference among groups. The overall test of constraints showed that there is no significant difference among race groups (Table 5). Yet LM tests indicated one of the parameters (from religious coping to burden) was noninvariant.

Table 4.

Maximum Likelihood Parameter Estimates for Multisample (Unstandardized Coefficient).

		Black		White		Hispanic
DV	IV	B	P	B	P	B	P
Depression	Burden	0.35	<.001	0.36	<.001	0.31	<.001
	Religious coping	−0.77	<.001	−0.31	<.001	−0.11	.49
	Religious attendance	−0.34	.07	−0.30	<.001	−0.23	<.001
	Physical health	−1.41	<.001	−1.32	<.001	−1.78	<.001
Burden	Religious coping	−1.17	<.001	−0.38	.07	−0.56	.06
	Physical health	−1.76	<.001	−0.23	<.001	−2.73	<.001
Religious coping	Religious attendance	0.47	<.001	0.50	<.001	0.18	<.001
	Prayer/meditation	1.21	<.001	1.33	<.001	1.32	<.001
	Physical health	0.25	<.001	−0.05	.69	−0.01	.95

Note: DV = dependent variable; IV = independent variable.

Table 5.

Model Fit and Comparison.

Model	χ²	df	P	CFI	RMSEA	Δχ²	Δdf	P
Baseline	16.443	15	.353	.998	.022
Structural invariance	34.418	27	.154	.991	.039	17.431	12	.134

Note: CFI = comparative fit index; RMSEA = root mean square error of approximation.

From separate analyses for each group, there are a few notable differences in the parameters among groups (Figure 3). The path from religious coping to depression was significant for Blacks (β = −.25, z = −3.79, p < .001) and Whites (β = −.22, z = −3.02, p < .01), but not for Hispanics (β = −.09, z = −1.69, p = .49). Religious coping was a significant predictor of burden appraisal only for Blacks (β = −.26, z = −4.23, p < .001). Baron and Kenny’s (1986) criteria for mediation test rest on the presence of (a) a relationship between the independent variable (religious coping) and the dependent variable (depression), (b) a relationship between the independent variable (religious coping) and the mediator (burden appraisal), and (c) a relationship between the mediator (burden appraisal) and the dependent variable (depression). For Hispanics, the model is not consistent with mediation because the paths from religious coping to depression (Criterion 1) and religious coping to burden appraisal (Criterion 2) were not significant. For Whites, a mediation model could not be established because religious coping was not significantly correlated with burden appraisal (Criterion 2). The separate analyses showed that the mediation path model was supported only for Blacks. Self-rated physical health was a significant predictor of religious coping only for Blacks (β = .12, z = 2.16, p < .01), and the direction of the relationship was the opposite of Whites and Hispanics. Figure 3 is a graphical depiction of the final model by race with standardized coefficients reported. Despite the absence of significant invariance, there are apparent differences of interest that may be suggestive and are therefore presented. It suggests that, despite the absence of a formal significant race interaction from the standpoint of overall invariance, the model works most persuasively for Blacks.

Figure 3.

The final path model of relationships with standardized coefficients by race.

Discussion

This study examined the relationship between religious attendance, prayer/meditation, religious coping, burden appraisal, and depression in a sample of people who provide care for their family members with AD. A preliminary conceptual model adapted from the stress and coping model by Lazarus and Folkman (1984) was tested using path analysis. The hypothesized theoretical model was largely supported. Caregiver burden appraisal mediated the effect of religious coping on depression with higher religious coping resulting in lower caregiver burden appraisal and thereby reducing depression. The following pathways were predicted and supported: The path between religious attendance, prayer/meditation, and religious coping was significant. The direct pathways between religious coping and burden appraisal, burden appraisal and depression, religious coping and depression were significant. The path between religious attendance and depression was not predicted and had to be added to the model. The moderating effect of race was tested using MSEM. Although the overall chi-square difference test was not significant, separate analyses showed some differences among groups. The results of this study revealed the importance of religious coping among caregivers. Religious coping was most commonly used by African American caregivers, and the theoretical model of religious coping worked better for African American caregivers than White and Hispanic caregivers.

Religion and Mental Health

The tested path model demonstrated that religious coping was associated with lower burden appraisal and depression. The caregivers with higher levels of religious coping reported significantly lower levels of burden appraisal and depression. This result supports our hypothesis and is consistent with the existing literature (Folkman, 1997). Caregivers in this study used religion to provide relief and support to their arduous situation and as a resource for dealing with overwhelming stress. The reliance on religious faith can provide the sense of support and strength many caregivers need to continue in the caregiving role. The only finding that was not predicted, thus had to be added to the model was the relationship between religious attendance and depression. The results indicated that religious attendance was associated with lower depression. Although prayer/meditation has a negative correlation with depression (r = −.17, p < .01), it did not significantly predict depression. The finding that religious attendance was more consistently associated with depression than prayer/meditation, is consistent with previous work (Baetz, Griffin, & Bowen, 2004; Hebert, Dang, & Schulz, 2007). Religious attendance allows caregivers to interact with people of similar religious values and perspectives (Hebert et al., 2007). Religious attendance affords people opportunities for social support that caregivers need through relationship with other believers. Social support within religious community may account for some of the inverse association of religious attendance and depression.

Burden Appraisal as a Mediator

Religious coping had a strong negative association with depression. After testing the indirect effect of religious coping on depression through burden appraisal, burden appraisal was found to mediate some part of the relationship between religious coping and depression. This indicates that burden appraisal did not explain all of the variance in the relationship between religious coping and depression and thus should be considered as one of potential explanatory factors, and alternative models are also theoretically plausible. Partial mediation allows for other routes (unstudied) through which such coping might also reduce depression.

Racial differences

Confirming some of the earlier research in this area (Fei et al., 2010; Foley, Tung, & Mutran, 2002; Haley et al., 2004), this study also found that African American caregivers reported the highest level of religious coping as well as the lowest levels of burden appraisal. African American caregivers were most likely to report greater attendance at religious services and more practice of prayer/meditation than White and Hispanic caregivers. The religious coping mediation model also worked best for African Americans (see Figure 3). These findings are consistent with suggestions by Dilworth-Anderson and her colleagues (2002) and are of particular interest in understanding racial differences in coping with caregiving. Hispanic caregivers were found to have higher religious coping and lower burden appraisal than White caregivers.

Despite the fact that African American and Hispanic caregivers had lower education and income, they still appraised their caregiving situation as less burdensome. The lowest level of caregiver burden appraisal found in African American caregivers may be due to powerful internal resources, such as religious coping and resilience to stress (Haley et al., 2004). This may also be explained by what is appraised as normal versus abnormal among the groups of caregivers. It is through the appraisal process that one determines what is stressful for the individual (Lazarus and Folkman, 1984). In traditional African American culture, illness is a natural part of life as one ages and therefore dementia may not be appraised as stressful or threatening (Yee & Weaver, 1994). Providing care for the older adults is part of the African American family norm, values, and expectations (Brody, 1985; Kelly, 1994). Such factors as prior experience with adversity and cultural support for caregiving have been stated as possible explanations for racial difference in coping related to caregiving.

Impact of Physical Health

Self-rated physical health was strongly and negatively related to burden appraisal and depression. Caregivers with worse self-rated physical health had higher burden appraisal and depression. In racial group comparisons African American and Hispanic caregivers perceived their health to be significantly worse than White caregivers. This is consistent with previous studies (Haley et al., 1995; Mui, 1992). Racial minority groups are considered to face greater health problems and disparities. Racial minority caregivers’ poorer physical health may be influenced by limited access to quality health care (Williams & Wilson, 2001), lower levels of insurance coverage (Sotomayor & Randolph, 1988), and a life time of racial discrimination (Finch, Hummer, Kolody, & Vega, 2001).

Limitations

This study reports on data collected at baseline from a randomized trial, so our information is cross sectional. Therefore, the results cannot address the causality or the direction of the associations between religious coping, burden appraisal, and depression. The recruited sample of caregivers limits the ability to generalize any of the findings from this study to other AD caregiving populations. As the data are from a trial of an intervention, a selection bias may have occurred in that those who participated did so because of the possibility of receiving an intervention that they felt they needed. Correlational data does not provide information about the process of religious coping over time or its long-term effects. Longitudinal studies are needed to better address the threat arising from the time ordering issue and examine the process of coping and its effects over longer period of time.

Still, this study adds to the literature in several important ways. It examines the relationships between religious variables and mental health outcomes by demonstrating the differential effect of each religious variable separately (religious attendance, prayer/meditation, religious coping). It also investigates the role of religious coping among three different racial groups using multisample SEM. This study is one of the few studies that include three racial groups of caregivers and the only study that used MSEM for moderation effect in caregivers of persons with dementia.

Implications for Practice, Policy, and Research

The current study has several significant implications for social work practice, service delivery, and policy. First, it is important for social workers to ask caregivers if and how they use religion to help them to cope. Simply acknowledging and respecting their religious belief can be very helpful. Second, it is important for agencies or hospitals to provide services and training for caregivers that include the components of religiosity and its impact on the caregivers’ perception of burden and depression. Spiritual/religious issues could be sensitively addressed in existing programs. Such training will help caregivers to be aware of their own religious beliefs and cope with difficult situations in caregiving. Future research into the most useful methods for accomplishing caregiver service programs will need to incorporate the important issues of religious coping that influence caregiving outcomes for families dealing with AD. Social workers should raise awareness and knowledge of issues of religious coping in AD caregiving. Finally, policy makers could advocate for improving caregiver support by providing faith-based programs/interventions. Future research might also continue to examine the different pathways of religious coping to caregiving outcomes. Researchers should explore other factors impacting caregiver burden and depression. It would also be interesting to see which dimension/nature of religion or demographic variables affects differently the various elements of the caregiving process.

The findings also suggest that it may be and appropriate to encourage particularly African American caregivers to use religious coping resources. The results indicate that incorporating some form of religious support could serve as a protective factor, especially with ethnically diverse caregivers. Moreover, given existing health disparities and physical health problems among minorities, programs for caregivers not only have to focus on psychological well-being and depression as outcomes but also have to create interventions to improve the physical health of caregivers (Pinquart & Sorensen, 2005).

Future research might compare motivation for caregiving, coping processes and spiritual/religious perspective of different racial groups. Qualitative research could provide a deeper understanding of how racially diverse group of caregivers use religion to cope with caregiving burden differently. Expansion of the substantive knowledge base concerning racial differences and the religious/spiritual dimension of caregiving are critical for enhancing prevention and intervention initiatives for mental and physical health of caregivers from racially different background.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Grace Jeongim Heo, PhD (social work, University of Pittsburgh) is an assistant professor at Youngstown State University, Department of Social Work. Her recent research has focused on religion/spirituality, depression, caregiving, Alzheimer’s disease, racial/ethnic relations and end of life care.

Gary Koeske, PhD (social psychology, Northwestern University) is a professor at University of Pittsburgh, School of Social Work. His published work reflects a connection between his interest in social psychological and personality constructs and characteristics of workers that affect social work practice. His research areas include work stress, social support, religion/spirituality and research methodology/statistics.

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