Religious coping and psychosocial adjustment in patients with cystic fibrosis

Abstract

The role of religious coping (RC) in psychosocial outcomes and health-related quality of life (HRQoL) in adults with cystic fibrosis has not been addressed. Multivariate regressions evaluated the effects of baseline RC on depressive and anxiety symptoms and HRQoL at 3-month follow-up in 123 adult cystic fibrosis patients. Higher positive RC attenuated the effects of perceived stress on greater depressive and anxiety symptoms. Negative RC predicted less vitality and social HRQoL, as well as more digestion symptoms. Positive RC may buffer the impact of stress on patients’ psychological distress, whereas negative RC may contribute to lower health-related quality of life.

Keywords

anxiety chronic illness coping depression religion spirituality stress

Introduction

Cystic fibrosis (CF) is a life-threatening, autosomal recessive genetic disorder that predominantly affects individuals of European decent. Among US births, 1 per 2500–3500 live births is affected by CF (Walters and Mehta, 2007). CF primarily affects pulmonary and gastrointestinal systems due to thickened mucus secretions in the lungs and pancreas, leading to bacterial lung infections and reduced nutrient absorption (Bilton, 2008; O’Sullivan and Freedman, 2009; Xu et al., 2007). As patients age, they experience progressive decline of respiratory function, which can lead to pulmonary failure and need for lung transplant (O’Sullivan and Freedman, 2009). Life expectancy is shorter for CF patients than for healthy individuals but has increased substantially with advances in treatment. For instance, predicted median survival has increased from 32.8 years for those born between 1999 and 2003 to 44.4 years for those born between 2014 and 2018 (Cystic Fibrosis Foundation, 2018).

With increased life expectancy, better understanding of psychosocial adjustment of CF patients has become more prominent. Depression and anxiety are important determinants of health-related behaviors, such as treatment adherence and substance use (Conner et al., 2009; Epstein et al., 2009), and rates of depressive and anxiety symptoms can be 2–3 times higher in CF patients than in community samples (Quittner et al., 2014). Health-related quality of life (HRQoL), involving physical, social, psychological, and functional aspects of patients’ lives, has also become a greater focus in CF research. Much of the research on HRQoL in CF patients has centered on the role of disease severity, which can have a drastic effect on CF patients’ HRQoL (Abbott et al., 2008; Gee et al., 2005; Sawicki et al., 2011). However, different aspects of HRQoL also predict health outcomes, including survival, in CF patients (Abbott et al., 2009). Given the important role of psychosocial adjustment and HRQoL in CF patients’ health and health behaviors, as well as their intrinsic value as key well-being and functional outcomes, it is important to identify their determinants.

Individuals often draw upon their religiosity and spirituality when struggling with health and well-being (Koenig, 2009). One mechanism that can explain the impact of religiosity on health and well-being is the provision of religious coping (RC) resources and their effect on stress and health (Pargament et al., 1998, 2004). Research identifies two major types of RC: positive and negative. Positive RC includes perceptions of a secure relationship with a divine or transcendent force and connectedness with others, whereas negative RC is characterized by spiritual tension and struggles with the divine (Pargament et al., 2011). Both types of RC have shown a consistent relationship with psychosocial outcomes (Ano and Vasconcelles, 2005; Thuné-Boyle et al., 2006). For instance, positive RC is associated with positive psychological adjustment (e.g. acceptance, optimism, self-esteem) and less maladjustment (e.g. anxiety, depression, distress), whereas negative RC is related to more negative psychological outcomes and lower levels of positive psychological outcomes (Ano and Vasconcelles, 2005). RC is also related to health and HRQoL in patients with chronic illness (Boscaglia et al., 2005; Saffari et al., 2013; Tarakeshwar et al., 2006; Trevino et al., 2010). Among adolescent CF patients, positive RC predicts fewer depressive symptoms over time (Reynolds et al., 2014b), as well as slower pulmonary decline (%FEV₁), stable nutritional status (BMI), and fewer days hospitalized over a 5-year period (Reynolds et al., 2014a).

While most studies examined the main effect of RC on outcomes, a stress-buffering model might be more appropriate, particularly for psychological outcomes (Smith et al., 2003). That is, RC may not impact psychological adjustment directly, but indirectly through reducing the negative effect of perceived stress. In other words, RC may moderate the effect of stress on psychological adjustment so that perceived stress is related to greater depression, anxiety, and distress only when patients use low levels of positive RC. Similarly, negative RC may amplify the effect of perceived stress on psychological adjustment. Relatively few studies have evaluated the stress-buffering effect of religiosity or RC on psychological outcomes. These studies provided evidence for a stress-buffering effect of religiosity and RC for depression and other psychosocial outcomes in healthy adults (Bjorck and Thurman, 2007; Lee, 2007; Reutter and Bigatti, 2014; Whitehead and Bergeman, 2019), but the stress-buffering effect of RC has not been studied in individuals with chronic health conditions, such as CF.

Aims/Hypotheses

The present study extends previous research on religious coping to adult CF patients by: 1) evaluating the direct effects of positive and negative RC on depressive and anxiety symptoms and HRQoL domains (e.g. physical, social, weight, and respiratory health); and 2) examining the moderating effects of positive and negative RC on the relationship between perceived stress and symptoms of depression and anxiety. To provide stronger support for the hypothesized direction of the effects, we use a short-term longitudinal design and control for baseline levels of the outcome variables. We hypothesize that higher positive RC and lower negative RC will predict fewer depressive and anxiety symptoms and better HRQoL over time. In addition, we hypothesize that positive RC will attenuate the negative relationship between perceived stress and symptoms of depression and anxiety.

Methods

Participants

Between 2016 and 2017, 123 CF patients were recruited from outpatient pulmonary clinics and inpatient units at the University of Alabama at Birmingham Hospital and Children’s Hospital of Alabama, which collectively serve about 230 adult CF patients. The study took place in Alabama, USA. The participation rate was 70%. The participants included 46% males, 93% Whites, and 7% African Americans. Most participants were affiliated with a Christian denomination (84%). Other religious affiliations included Jewish (1%), Buddhist (1%), other (2%), and unaffiliated (10%). Of the 123 participants who completed the baseline survey, 111 (90%) participated in the 3-month follow-up. Participants who completed the follow-up survey had higher HRQoL in the body image (M = 65.27 vs 45.37, p = 0.039) and weight symptoms domains (M = 68.77 vs 44.44, p = 040) than those who were lost to follow-up, but these groups did not differ on any other baseline variables.

Procedure

Eligibility criteria included a diagnosis of CF and age of 18 years or older. Participants were asked to complete online or paper questionnaires twice, three months apart. Participants provided written informed consent during recruitment and were compensated with a $30 Visa gift card for each survey. Health data were obtained from the CF Foundation registry database. The Institutional Review Board at the University of Alabama at Birmingham approved all study protocols.

Measures

Religious coping

The 14-item Brief RCOPE (Pargament et al., 1998) measured positive religious coping (e.g. I look for a stronger connection with God) and negative religious coping (e.g. I question the power of God) at baseline. Participants rated each item on a 4-point scale from 1 to 4 (Never to Always). Items on each 7-item subscale were averaged (α = 0.95 for positive and α = 0.84 for negative RC).

Depressive and anxiety symptoms

The 18-item Brief Symptoms Inventory (BSI-18; Derogatis and Melisaratos, 1983) measured symptoms of depression (e.g. How much were you distressed by feeling no interest in things?) and anxiety (e.g. How much were you distressed by spells of terror or panic?) at both baseline and 3-month follow-up. Participants rated each item on a 5-point scale from 1 to 5 (Not at all to Extremely). Items on each 6-item subscale were averaged (α = 0.88 and 0.91 for depressive symptoms, α = 0.86 and 0.87 for anxiety symptoms).

Perceived stress

The 10-item Perceived Stress Scale (PSS; Cohen et al., 1983) assessed recent perceived stress at baseline (e.g. How often have you felt nervous or “stressed” in the past month?). Participants rated each item on a 5-point scale from 1 to 5 (Never to Very often). The items were averaged (α = 0.89).

HRQoL

The 50-item CF Questionnaire-revised (CFQ-R; Henry et al., 2003) was used at both time points to measure 12 domains of participants’ CF-related HRQoL (physical, role, vitality, emotion, social, body image, eating disturbances, treatment constraints, health, weight symptoms, respiratory symptoms, and digestive symptoms). Participants responded to each item using different 4-point scales. For each domain, scores were summed and standardized to a 100-point scale, with higher scores indicating better HRQoL. Reliability was acceptable (ranging from α = 0.68 to 0.95) for all domains except treatment burden (α = 0.42 and 0.45).

Covariates

Demographic covariates included participant age and gender obtained at consent, as well as baseline %FEV₁ and BMI obtained from the clinic visit closest to baseline.

Analytic plan

To test the direct effects of positive and negative RC, as well as their indirect stress-moderating effects on anxiety and depressive symptoms, a multivariate regression analysis was conducted in Mplus version 8.4. Baseline positive and negative RC, perceived stress, and interactions of perceived stress with positive and negative RC, respectively, were entered as predictors of anxiety and depressive symptoms at 3-month follow-up. Baseline anxiety or depressive symptoms, age, gender, %FEV₁, and BMI served as covariates. This analytic approach controls for the continuity in depressive and anxiety symptoms over time and tests the effects of the predictors on the change in the outcomes. Significant interactions were followed with tests of simple slopes for perceived stress at high and low levels of RC (1 SD above and below the mean; Aiken et al., 1991).

To test the direct effects of positive and negative RC on CF-related HRQoL, a second multivariate regression analysis was conducted. Baseline positive and negative RC were entered as predictors of the 12 HRQoL subscales measured at the 3-month follow-up. Covariates included age, gender, %FEV₁, BMI, and the 12 HRQoL subscales measured at baseline.

Results

Descriptive statistics

Overall, participants reported higher levels of positive RC (M = 2.78, SD = 0.90) than negative RC (M = 1.28, SD = 0.46). Levels of perceived stress at baseline were low to moderate (M = 2.58, SD = 0.72). The rates of depressive and anxiety symptoms were relatively low at both time points (M = 1.53 and 1.52 for depressive symptoms, M = 1.49 and 1.51 for anxiety symptoms).

Bivariate correlations

Among covariates, females reported more positive RC (r = 0.25, p = 0.006) and higher weight HRQoL (r = 0.22, p = 0.023). Older age was associated with lower %FEV₁ (r = −0.27, p = 0.002) and lower HRQoL in six of the 12 domains (physical, role, vitality, emotional, social, and health; r = −0.19 to −0.37, p < 0.05). Lower %FEV₁ was associated with lower HRQoL in eight of the 12 domains (physical, role, social, body image, eating, health, weight, and respiratory; r = 0.22 to 0.50, p < 0.05), but also higher digestive HRQoL (r = −0.23, p = 0.017). Positive and negative RC were weakly positively correlated (r = 0.23, p = 0.010). Positive RC was associated with less perceived stress and fewer depressive symptoms at baseline (r = −0.22 to −0.23, p < 0.05) and fewer depressive and anxiety symptoms at follow-up (r = −0.20 to −0.33, p < 0.05). Positive RC was also associated with higher HRQoL in vitality, emotion, eating, health, and weight domains at baseline (r = 0.21 to 0.26, p < 0.05) and eating, health, and weight domains at follow-up (r = 0.21 to 0.23, p < 0.05). Negative RC was related to more perceived stress, depression, and anxiety at baseline (r = 0.31 to 0.38, p < 0.01), but only anxiety at follow-up (r = 0.26, p = 0.007). Negative RC was also related to lower HRQoL in all domains except vitality, eating, and health at baseline (r = −0.19 to −0.41, p < 0.05) and to physical, vitality, emotional, social, body image, and respiratory domains at follow-up (r = −0.22 to −0.35, p < 0.05). Perceived stress was associated with more depressive and anxiety symptoms at baseline (r = 0.55 to 0.69, p < 0.01) and at follow-up (r = 0.51 to 0.60, p < 0.01). Depressive and anxiety symptoms were moderately correlated (r = 0.72 and 0.76, p < 0.001) and stable over time (r = 0.73 and 0.65, p < 0.001). Most HRQoL domains were positively associated with one another at baseline (r = 0.19 to 0.75, p < 0.05) and at follow-up (r = 0.20 to 0.77, p < 0.05) and stable over the 3-month period (r = 0.62 to 0.86, p < 0.001).

Religious coping and stress predicting depressive and anxiety symptoms

The multivariate regression model predicting depressive and anxiety symptoms had acceptable fit to the data, χ²(2) = 3.981, p = 0.137, CFI = 0.991, TLI = 0.893, RMSEA = 0.090, SRMR = 0.012. See Table 1 for standardized path coefficients. After adjusting for symptoms at baseline and other covariates, depressive symptoms at follow-up were predicted by less positive RC (β = −0.25, p < 0.001) and greater perceived stress (β = 0.17, p = 0.045) at baseline, as well as their interaction (β = −0.29, p < 0.001). Anxiety symptoms at follow-up were predicted by greater perceived stress at baseline (β = 0.20, p = 0.022) and the interaction of perceived stress with positive RC (β = −0.17, p = 0.024).

Table 1.

Standardized regression coefficients for religious coping predicting depressive and anxiety symptoms.

Predictors (baseline)	Depressive symptoms, 3-month follow-up	Anxiety symptoms, 3-month follow-up
Age	−0.06	0.08
Female	0.10	0.04
%FEV₁	−0.06	−0.03
BMI	0.06	−0.09
Depressive symptoms	0.40***	–
Anxiety symptoms	–	0.44***
Positive RC	−0.25***	−0.13
Negative RC	0.09	0.08
Perceived Stress	0.17*	0.20*
Stress × Positive coping	−0.29***	−0.17*
Stress × Negative coping	0.02	0.06

p < 0.05; ***p < 0.001.

Simple slope analyses indicated that perceived stress was only associated with an increase in depressive symptoms for participants who reported low positive RC (β = 0.42, p < 0.001), but not high positive RC (β = −0.09, p = 0.394; Figure 1). Similarly, perceived stress was only associated with an increase in anxiety symptoms for participants who reported low positive RC (β = 0.33, p < 0.001), but not high positive RC (β = 0.03, p = 0.802; Figure 1).

Figure 1.

Perceived stress predicts more depressive and anxiety symptoms only at low levels of positive religious coping.

Religious coping predicting HRQoL

The multivariate regression model predicting the 12 HRQoL domains had acceptable fit to the data, χ²(132) = 209.371, p < 0.001, CFI = 0.947, TLI = 0.886, RMSEA = 0.069, SRMR = 0.048. Standardized coefficients for positive and negative RC are listed in Table 2. After adjusting for baseline HRQoL in the same domain and other covariates, negative RC uniquely predicted lower HRQoL in the domains of vitality (β = −0.17, p = 0.013), social (β = −0.16, p = 0.012), and digestive symptoms (β = 0.17, p = 0.039). Positive RC was not a significant predictor of any HRQoL domain.

Table 2.

Standardized regression coefficients for religious coping predicting HRQoL domains at follow-up.

Predictors(baseline)	Physical	Role	Vitality	Emotion	Social	Body image	Eating disturbances	Treatment constraints	Health	Weight	Respiratory	Digestive
HRQoL Domain	0.71**	0.54**	0.66**	0.59**	0.65**	0.80**	0.62**	0.58**	0.68**	0.67**	0.55**	0.65**
Age	−0.05	−0.10	0.00	−0.18*	−0.14*	0.01	−0.05	0.00	−0.05	0.09	0.03	−0.10
Gender	−0.03	−0.12	−0.12	−0.03	−0.00	−0.02	−0.01	−0.09	0.08	0.06	0.01	−0.14
%FEV₁	0.15*	0.15*	0.00	0.03	0.12	0.05	0.04	0.02	0.09	0.12	0.16*	−0.15*
BMI	−0.04	−0.05	−0.08	0.04	−0.02	0.04	−0.04	0.16*	−0.14*	−0.07	−0.04	−0.10
Positive RC	0.06	0.14	0.05	−0.06	0.04	0.03	0.08	−0.02	0.11	0.06	−0.01	0.14
Negative RC	−0.03	−0.07	−0.17*	−0.11	−0.16*	−0.09	−0.05	0.02	−0.09	0.09	−0.12	0.17*

p < 0.05; **p < 0.01.

Discussion

This study was one of the first longitudinal examinations of the relationship between religious coping and psychosocial outcomes in CF patients. The study further investigated the indirect, stress-buffering effect of religious coping on depressive and anxiety symptoms. We hypothesized that higher levels of positive RC and lower levels of negative RC would predict better psychosocial adjustment over time and that positive RC would attenuate the negative relationship between perceived stress and depressive and anxiety symptoms. Our findings confirmed that positive RC buffered the effect of stress on both depressive and anxiety symptoms over time. In addition, negative RC predicted decreased health-related quality of life in the vitality, social, and digestive domains.

Consistent with previous research conducted in adolescents with chronic illness (including CF; Reynolds et al., 2014b), our findings provide evidence for a longitudinal association between positive RC and improved mental health in adults with CF. Further, our results suggest that positive RC buffers the effects of perceived stress on depressive and anxiety symptoms in adults with CF. Patients with CF are confronted with multiple illness-related challenges, including periodic exacerbations, time-consuming daily therapies, and healthcare costs, and our results suggest that positive RC helps reduce the effect of stress on depressive and anxiety symptoms. Previous research evaluating this stress buffering hypothesis for depression in healthy adults found only marginal support for a buffering effect of RC (Lee, 2007), which may be due to combining positive and negative RC into a single variable or use of a healthy sample with less stress. Consistent with previous findings in chronic illness patients (including CF patients), our results suggest that negative RC is related to poorer psychosocial adjustment concurrently (Boscaglia et al., 2005; Reynolds et al., 2014b). Negative RC did not uniquely predict depressive or anxiety symptoms over time in this study, consistent with previous research suggesting that depressive symptoms are an antecedent rather than a consequence of negative RC (Reynolds et al., 2014b).

Positive and negative RC were related to multiple HRQoL domains concurrently. However, only negative RC predicted poorer HRQoL over time – specifically in the vitality, social, and digestive domains. These longitudinal findings provide stronger support for the causal role of RC in HRQoL than previous cross-sectional studies of associations between RC and HRQoL in other chronic illness populations (Saffari et al., 2013; Tarakeshwar et al., 2006). This study further extends prior research by distinguishing between positive and negative RC and evaluating their unique contributions to psychosocial adjustment and HRQoL. Interestingly, only negative RC was a significant predictor of HRQoL outcomes. This is consistent with a meta-analytic review of 15 studies evaluating psychosocial adjustment in adolescents with CF which found a significant association between negative RC and poorer HRQoL, but no significant relationship between positive RC and HRQoL (Reynolds et al., 2016). It has been suggested that negative RC may lead to poorer HRQoL by its negative impact on optimism, self-esteem, coping, and social support (Pargament et al., 2011).

The results of the current study illustrate the effects that patients’ religious beliefs can have on their health. Clinicians may use these results to assess patients’ use of positive and negative RC and recommend resources to enhance healthy coping (e.g. referring patients to pastoral care). These findings can also inform interventions aimed at improving patients’ coping strategies and psychosocial adjustment. Specifically, interventions that strengthen positive RC and reduce negative RC may help CF patients better manage stress, experience fewer depressive and anxiety symptoms, and achieve better HRQoL, with positive implications for long-term mental and physical health outcomes.

These results should be interpreted in the context of the study limitations. For example, individuals residing in the Southeastern United States place greater emphasis on religiosity than many other US regions as well as many areas outside the US. Therefore, the results may not generalize to other cultural and religious contexts (e.g. Islam, Buddhism, and Hinduism) or geographic areas with lower levels of religiosity and spirituality. Specifically, the RCOPE was an appropriate assessment of RC for our sample, but the phrasing of the items may not apply to other contexts. Future research is needed to develop new instruments and study religious and spiritual coping in other cultural and geographic contexts. Further, although our moderately sized sample is considered a strength in the context of research conducted with CF patients, it may have contributed to a lack of power for our analyses to detect smaller effects. Future research in this area should strive to conduct studies over multiple sites in order to recruit a larger, more diverse sample that includes chronically ill individuals from varied demographic and religious backgrounds as well as different geographic areas. The current study considered the buffering effect of RC only for general perceived stress, without distinguishing between normative and illness-specific stressors (e.g. treatment burden and death-anxiety) that may influence mental health in different ways. Future research should examine whether RC attenuates the negative effect of illness-specific stressors as well as more general stressors.

Conclusion

This was the first study with CF patients to evaluate a stress-buffering model of RC on psychosocial outcomes and one of the first to do so in any chronic illness population. In addition, the present study was the first to longitudinally examine the relationship between RC and HRQoL in patients with CF. The main and interactive effects observed in this study demonstrate the important role of RC in psychosocial outcomes of CF patients. Our results suggest that positive RC helps buffer the negative impact of stress on depressive and anxiety symptoms in adults with CF, and that negative RC contributes to poorer HRQoL over time. These results have important implications for healthcare providers, supporting the use of pastoral and psychosocial care in multidisciplinary teams in CF treatment settings (Koenig, 2000).

Supplemental Material

Figure_supplementary – Supplemental material for Religious coping and psychosocial adjustment in patients with cystic fibrosis

Supplemental material, Figure_supplementary for Religious coping and psychosocial adjustment in patients with cystic fibrosis by B Edwin Burgess, Bria Leigh Gresham, Sylvie Mrug, Leigh Ann Bray, Kevin Jay Leon and Robert Bradley Troxler in Journal of Health Psychology

Supplemental Material

Table_supplementary – Supplemental material for Religious coping and psychosocial adjustment in patients with cystic fibrosis

Supplemental material, Table_supplementary for Religious coping and psychosocial adjustment in patients with cystic fibrosis by B Edwin Burgess, Bria Leigh Gresham, Sylvie Mrug, Leigh Ann Bray, Kevin Jay Leon and Robert Bradley Troxler in Journal of Health Psychology

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the University of Alabama at Birmingham Center for Palliative and Supportive Care. This funding source had no involvement in: study design; collection, analysis and interpretation of data; writing of the report; or the decision to submit the article for publication.

ORCID iD

B Edwin Burgess

Supplemental material

Supplemental material for this article is available online.

References

Abbott

Hart

Morton

, et al. (2008) Health-related quality of life in adults with cystic fibrosis: The role of coping. Journal of Psychosomatic Research 64(2): 149–157.

Abbott

Hart

Morton

, et al. (2009) Can health-related quality of life predict survival in adults with cystic fibrosis? American Journal of Respiratory and Critical Care Medicine 179(1): 54–58.

Aiken

West

Reno

(1991) Multiple Regression: Testing and Interpreting Interactions. Thousand Oaks, CA: Sage.

Ano

Vasconcelles

(2005) Religious coping and psychological adjustment to stress: A meta-analysis. Journal of Clinical Psychology 61(4): 461–480.

Bilton

(2008) Cystic fibrosis. Medicine 36(5): 273–278.

Bjorck

Thurman

(2007) Negative life events, patterns of positive and negative religious coping, and psychological functioning. Journal for the Scientific Study of Religion 46(2): 159–167.

Boscaglia

Clarke

Jobling

, et al. (2005) The contribution of spirituality and spiritual coping to anxiety and depression in women with a recent diagnosis of gynecological cancer. International Journal of Gynecologic Cancer 15(5): 755–761.

Cohen

Kamarck

Mermelstein

(1983) A global measure of perceived stress. Journal of Health and Social Behavior 24(4): 385–396.

Conner

Pinquart

Gamble

(2009) Meta-analysis of depression and substance use among individuals with alcohol use disorders. Journal of Substance Abuse Treatment 37(2): 127–137.

10.

Cystic Fibrosis Foundation (2018) Cystic Fibrosis Foundation Patient Registry. 2018 Annual Data Report. Bethesda, MD, pp. 4–90.

11.

Derogatis

Melisaratos

(1983) The brief symptom inventory: An introductory report. Psychological Medicine 13(3): 595–605.

12.

Epstein

Induni

Wilson

(2009) Peer reviewed: Patterns of clinically significant symptoms of depression among heavy users of alcohol and cigarettes. Preventing Chronic Disease 6(1): A09.

13.

Gee

Abbott

Hart

, et al. (2005) Associations between clinical variables and quality of life in adults with cystic fibrosis. Journal of Cystic Fibrosis 4(1): 59–66.

14.

Henry

Aussage

Grosskopf

, et al. (2003) Development of the Cystic Fibrosis Questionnaire (CFQ) for assessing quality of life in pediatric and adult patients. Quality of Life Research 12(1): 63–76.

15.

Koenig

(2000) Religion, spirituality, and medicine: Application to clinical practice. JAMA 284(13): 1708.

16.

Koenig

(2009) Research on religion, spirituality, and mental health: A review. The Canadian Journal of Psychiatry 54(5): 283–291.

17.

Lee

B-J

(2007) Moderating effects of religious/spiritual coping in the relation between perceived stress and psychological well-being. Pastoral Psychology 55(6): 751–759.

18.

O’Sullivan

Freedman

(2009) Cystic fibrosis. The Lancet 373(9678): 1891–1904.

19.

Pargament

Feuille

Burdzy

(2011) The Brief RCOPE: Current psychometric status of a short measure of religious coping. Religions 2(1): 51–76.

20.

Pargament

Koenig

Tarakeshwar

, et al. (2004) Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: A two-year longitudinal study. Journal of Health Psychology 9(6): 713–730.

21.

Pargament

Smith

Koenig

, et al. (1998) Patterns of positive and negative religious coping with major life stressors. Journal for the Scientific Study of Religion 37(4): 710–724.

22.

Quittner

Goldbeck

Abbott

, et al. (2014) Prevalence of depression and anxiety in patients with cystic fibrosis and parent caregivers: Results of the international depression epidemiological study across nine countries. Thorax 69(12): 1090–1097.

23.

Reutter

Bigatti

(2014) Religiosity and spirituality as resiliency resources: Moderation, mediation, or moderated mediation? Journal for the Scientific Study of Religion 53(1): 56–72.

24.

Reynolds

Mrug

Britton

, et al. (2014a) Spiritual coping predicts 5-year health outcomes in adolescents with cystic fibrosis. Journal of Cystic Fibrosis 13(5): 593–600.

25.

Reynolds

Mrug

Hensler

, et al. (2014b) Spiritual coping and adjustment in adolescents with chronic illness: A 2-year prospective study. Journal of Pediatric Psychology 39(5): 542–551.

26.

Reynolds

Mrug

Wolfe

, et al. (2016) Spiritual coping, psychosocial adjustment, and physical health in youth with chronic illness: A meta-analytic review. Health Psychology Review 10(2): 226–243.

27.

Saffari

Pakpour

Naderi

, et al. (2013) Spiritual coping, religiosity and quality of life: A study on M uslim patients undergoing haemodialysis. Nephrology 18(4): 269–275.

28.

Sawicki

Rasouliyan

McMullen

, et al. (2011) Longitudinal assessment of health-related quality of life in an observational cohort of patients with cystic fibrosis. Pediatric Pulmonology 46(1): 36–44.

29.

Smith

McCullough

Poll

(2003) Religiousness and depression: Evidence for a main effect and the moderating influence of stressful life events. Psychological Bulletin 129(4): 614–636.

30.

Tarakeshwar

Vanderwerker

Paulk

, et al. (2006) Religious coping is associated with the quality of life of patients with advanced cancer. Journal of Palliative Medicine 9(3): 646–657.

31.

Thuné-Boyle

Stygall

Keshtgar

, et al. (2006) Do religious/spiritual coping strategies affect illness adjustment in patients with cancer? A systematic review of the literature. Social Science & Medicine 63(1): 151–164.

32.

Trevino

Pargament

Cotton

, et al. (2010) Religious coping and physiological, psychological, social, and spiritual outcomes in patients with HIV/AIDS: Cross-sectional and longitudinal findings. AIDS and Behavior 14(2): 379–389.

33.

Walters

Mehta

(2007) Epidemiology of cystic fibrosis. Cystic Fibrosis 3: 21–45.

34.

Whitehead

Bergeman

(2019) Daily religious coping buffers the stress–affect relationship and benefits overall metabolic health in older adults. Psychology of Religion and Spirituality. DOI: 10.1037/rel0000251.

35.

Shi

Chen

, et al. (2007) Cystic fibrosis transmembrane conductance regulator is vital to sperm fertilizing capacity and male fertility. Proceedings of the National Academy of Sciences 104(23): 9816–9821.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.06 MB

0.04 MB