Research in Gerontological Nursing

Original Research: Correlational 

Relationships Among Stress, Infectious Illness, and Religiousness/Spirituality in Community-Dwelling Older Adults

Bonnie L. Callen, PhD, RN, APN, BC; Linda Mefford, PhD, RN, APN, BC; Maureen Groër, PhD, RN, FAAN; Sandra P. Thomas, PhD, RN, FAAN

Abstract

The purpose of this study was to examine the relationships among stress, infectious illness, and religiousness/spirituality in community-dwelling older adults in the southeastern United States. Four assessment tools were completed by 82 older adults (mean age = 74, age range = 65 to 91): the Perceived Stress Scale, the Carr Infection Symptom Checklist (SCL), the Brief Multidimensional Measurement of Religiousness/Spirituality, and a demographic form. A significant correlation was found between stress and SCL scores; however, four dimensions of religiousness/spirituality moderated the relationship between stress and infection. Older adults who were unable to forgive themselves or forgive others, or feel forgiven by God, were more likely to have had an infection in the previous month. Increased infections also occurred when older participants did not feel they had religious support from their congregations. Using these findings, gerontological nurses are well positioned to deliver tailored stress management and forgiveness interventions when older adults report increased stress.

Abstract

The purpose of this study was to examine the relationships among stress, infectious illness, and religiousness/spirituality in community-dwelling older adults in the southeastern United States. Four assessment tools were completed by 82 older adults (mean age = 74, age range = 65 to 91): the Perceived Stress Scale, the Carr Infection Symptom Checklist (SCL), the Brief Multidimensional Measurement of Religiousness/Spirituality, and a demographic form. A significant correlation was found between stress and SCL scores; however, four dimensions of religiousness/spirituality moderated the relationship between stress and infection. Older adults who were unable to forgive themselves or forgive others, or feel forgiven by God, were more likely to have had an infection in the previous month. Increased infections also occurred when older participants did not feel they had religious support from their congregations. Using these findings, gerontological nurses are well positioned to deliver tailored stress management and forgiveness interventions when older adults report increased stress.

In the short term, stress can be beneficial, triggering a neuroendocrine immunity response (Ensel & Lin, 2000). During acute stress, different kinds of neurotransmitters and hormones from the brain and endocrine system improve immune function and mental functioning. However, this continual adjustment of the body to daily stressors, termed allostasis, can slide into damaging allostatic load when stress is prolonged (McEwen & Lasley, 2003; McEwen & Stellar, 1993), ultimately shortening the life span of cells (Epel et al., 2004); furthermore, it leads to changes and atrophy in the brain, such as a shrinking of the hippocampus, prefrontal cortex, or amygdala (Arnetz & Ekman, 2006).

An abundance of psychoneuroimmunological (PNI) research documents the impact of stressful life events on health. When perceived stress is higher, an increase in infectious illness such as colds has been demonstrated (Cohen, Tyrrell, & Smith, 1993). Research by Ensel and Lin (2000) showed that the more stressors people experienced within the past year, the more they reported physical distress symptoms (e.g., backaches, fatigue, stomach discomfort). Phillips et al. (2006) examined 582 Scottish participants (mean age = 63.6) who identified stressful life events in the previous 2 years and specified how disruptive the events were. A negative association was found between stress and secretory immunoglobulin A (sIgA) production, suggesting that high stress compromises production or transport of sIgA. Subsequently, this lowers immune resistance at mucosal surfaces, making individuals more susceptible to upper respiratory tract infections (Phillips et al., 2006). Despite the inclusion of older adults in the above-cited studies by Ensel and Lin (2000) and Phillips et al. (2006), the preponderance of the stress literature has focused on younger adults, much of it on college students (Loft et al., 2007) rather than older adults. The connection between stress and infectious illness in healthy older adults has received little attention. This is an important gap in the literature because older adults are more susceptible to multiple diseases due to the normal biology of aging and changes in immune system regulation.

Biology of Aging and Immune System Regulation

Aging has been associated with several alterations in the immune system, which are collectively called immunosenescence (Arai, Duarte, & Natale, 2006; Butcher & Lord, 2004). In this state there is a reduced T-cell-mediated immunity (Pawelec, Koch, Gouttefangeas, & Wikby, 2006). The result is a blunted T-cell proliferation, altered cytokine production, and changes in lymphocyte distribution. Cytokines are peripherally and centrally produced proteins that regulate immunological response. Overproduction of interleukin-6, a proinflammatory cytokine, is associated with a spectrum of age-related conditions, including diabetes, osteoporosis, certain cancers, cardiovascular disease, arthritis, periodontal disease, frailty, and functional decline (Graham, Christian, & Kiecolt-Glaser, 2006; Kiecolt-Glaser et al., 2003; Larsson, Hallerstam, Rosfors, & Wallen, 2005; Pradhan, Cook, Buring, Manson, & Ridker, 2003; Ridker, Buring, Cook, & Rifai, 2003). Another clinical consequence is the negative impact on defense against new pathogens and infections, as well as a reduced antibody response to a number of vaccinations (Burns, Carroll, Ring, & Drayson, 2003; Cohen, Miller, & Rabin, 2001; Costanzo et al., 2004; Fulop et al., 2005; Miller et al., 2004; Yang & Glaser, 2002). This normal age-related immune dysregulation may be speeded by chronic stress (Graham et al., 2006). In later life, many stressful events occur, such as the chronic illness or death of a spouse, and the need to move away from a long-time residence.

However, there is never a simple stimulus-response relationship between stress and health outcomes. More important than the mere occurrence of such specific events are (a) older adults’ own perceptions of their stress and (b) their perceived ability to cope with it.

Spirituality as a Potential Resource for Older Adults Coping With Life Stress

Alongside the considerable body of research about the deleterious effects of stress is a complementary body of research on a variety of personal resources (e.g., self-esteem) and social resources (e.g., network support) that may buffer or mitigate its effects. For example, social resources mediated the effects of stress on physical symptoms for people of all ages in the study by Ensel and Lin (2000). However, the specific resource of spirituality, although highly salient to many older people, has not received sufficient attention from researchers. Nursing research on the topic has been hindered because spirituality is an elusive concept to clearly define and operationalize for research; it has been demonstrated to be multifactorial in nature (see Sessanna, Finnell, and Jezewski, 2007, for a concept analysis involving review of 90 references). Moberg (2005) summarized the state of the search for a single definition of spirituality by stating that “there is no universally accepted definition, but we clearly are moving toward a universal consensus that there is a ‘something’ about people that we call ‘the human spirit’ and therefore a reality that we label as spirituality” (p. 13).

Religiousness, or religiosity, is related to spirituality yet distinctly different, reflecting a commitment to a more formalized religious faith (e.g., Judaism, Christianity, Islam, Buddhism, Hinduism) and the behaviors and rituals within that faith tradition (Moberg, 2005). Therefore, spirituality deals more with the internal aspects of the human spirit and individuals’ specific beliefs about their own spiritual nature, whereas religiousness deals more with the external patterns through which individuals express their spiritual nature (Moberg, 2005). Due to the relatively recent introduction of the concept of spirituality into the mainstream language, older adults may be more familiar with the term religion than spirituality and therefore may label the spiritual aspects of their being as their “religion” (Nelson-Becker, 2005).

A review of survey results since 1939 reported by Moberg (2005) revealed that adults 65 and older have consistently scored higher than their younger counterparts on measures of religiousness and spirituality, with the exception of the oldest old, who indicate lower levels of attendance at religious services secondary to mobility issues prevalent within that age cohort. A study of 1,188 women ages 18 to 65+ within the Lutheran Church-Missouri Synod indicated that older cohorts scored significantly higher than younger ones on almost every indicator of religiousness and spirituality (Moberg, 1999).

Older adults have also been found to attribute much of the reason for their longevity to their faith and/or faith practices, such as prayer and meditation (Moberg, 2005). Religion has also been identified as a major coping mechanism older adults use to deal with stress. In a qualitative study, Nelson-Becker (2005) described the use of religion and spirituality as a problem-solving mechanism for responding to life stressors by 79 community-dwelling older adults in an urban setting. Forty-seven percent of the study participants were European American (mostly of the Jewish faith) and 53% were African American, with a median age of 78 (age range = 58 to 92). The primary problem-solving methods identified in this study were thematized as prayer, the use of religion as a moral compass, the use of scripture or sacred text, altruism (helping others), meditation, and help-seeking (especially seeking help from a formal religious figure such as a pastor, elder, or rabbi).

Facets of spirituality have been proposed to serve in a mediating or moderating role in various aspects of older adults’ health. Davis (2005) explored the role of spirituality as a mediator between hope and well-being in a community-dwelling sample of 130 older adults (85% women) with a mean age of 76.5 (age range = 62 to 89). Although spiritual perspectives did not serve as a mediator of the relationship between hope and well-being in this sample, statistically significant correlations were found between spiritual perspectives and hope and between spirituality and well-being. In a study of older adults with rheumatoid arthritis, Potter and Zauszniewski (2000) found that spirituality (operationalized as spiritual well-being) was correlated with the social, emotional, and physical impact of arthritis as well as with learned resourcefulness and general health perception.

An intriguing relationship between faith and the immune system has been proposed by Koenig and Cohen (2002), who postulated that “faith can affect the concentration of hormones released by nerve terminals and produced by the hypothalamic axis” (p. vii). They further speculated that “if faith can ameliorate the activation of the brain areas involved with activation of the nerves and release of the hormones associated with altered immune function, a more efficient and effective immune system would result, with decreased development of immune-related disease” (p. vii). A variety of researchers have begun to explore these proposed interrelationships between faith and health within the PNI framework. One study by Doster et al. (2002) explored the relationship between specific immune cell counts and spirituality, with spirituality operationalized in terms of both an intrinsically and extrinsically derived measure. The study sample consisted of 111 participants ages 29 to 63 (mean age = 42.29), with the majority men (68%) and Caucasian (87%). Although aspects of healthy immune functioning were associated with the measures of both intrinsic and extrinsic spirituality, the pattern of healthy immune functioning was more predominant with the markers of intrinsic spirituality. The researchers concluded that their study findings supported “the existence of a relationship between spirituality and health, underscoring the possible stress buffering role of spirituality in enhancing physical and emotional well-being” (Doster et al., 2002, pp. 49–50).

It has been well documented that spirituality and religiousness tend to become of higher importance as people age, perhaps reflecting a deeper contemplation of the meanings of life and death as the end of life approaches (Moberg, 2005). It is also well known, as discussed above, that the aging process is associated with an increased number and variety of immune-related health challenges, as well as a decline in the functioning of the immune system, and that stress is associated with infectious illness and immune dysfunction. However, research is needed to fill a gap in the literature regarding the proposed role of spirituality/religiosity as a moderator of the relationship of stress and infection among older adults. Therefore, the present study was conceived.

Study Purpose

The purpose of this study was to examine the relationships among stress, infectious illness, and religiousness/spirituality in community-dwelling older adults. The specific research questions for this study were:

  • What is the relationship between perceived stress and infectious illness?
  • What is the relationship between perceived stress and dimensions of religiousness/spirituality?
  • What is the relationship between infectious illness and dimensions of religiousness/spirituality?
  • Is the relationship between perceived stress and infectious illness moderated by dimensions of religiousness/spirituality?

Method

Sample and Setting

After securing approval from the university Institutional Review Board, participants were recruited by the researchers and graduate nursing students from church groups, community senior centers, and a clinic in a southeastern U.S. city. Inclusion criteria were being age 65 and older, living in the community, and the ability to read and write English. Flyers, word of mouth, and personal invitations were the methods of recruitment. Surveys were distributed with self-addressed postage-paid envelopes that participants mailed to the College of Nursing under conditions of anonymity. Surveys returned by individuals who did not disclose their age or did not meet the age eligibility criterion were not included in the study. Eleven surveys were eliminated for these reasons, leaving 82 that were usable.

Instruments

Perceived Stress Scale. The Perceived Stress Scale (PSS) is a 14-item instrument that measures the degree to which situations in an individual’s life are appraised as unpredictable, uncontrollable, and overloading (Cohen, Kamarck, & Mermelstein, 1983). The PSS was designed for use in community samples having at least a junior high school education. Scores are obtained by reversing the scores on seven positive items, then summing across the 14 items. Scores can range from 0 to 56. Cronbach’s alpha reliability coefficients are generally 0.84 or higher, and there is good evidence of concurrent and predictive validity (Cohen et al., 1983). This scale has been used in multiple samples of older adults (Park-Lee, Fredman, Hochberg, & Faulkner, 2009; Seematter-Bagnoud, Karmaniola, & Santos-Eggimann, 2010; Wrobel, Farrag, & Hymes, 2009).

Carr Infection Symptom Checklist. The Carr Infection Symptom Checklist (SCL) was developed by Groër and validated in several PNI studies of stress, infection symptoms, and immune markers (Groër & Davis, 2006; Groër et al., 2005; Groër, Davis, & Steele, 2004). The instrument contains a list of symptoms experienced in the previous month that are associated with infections. This 28-item instrument has five subscales divided by body systems: respiratory, skin/eye, genitourinary, gastrointestinal, and flu-like symptoms. Participants were instructed not to list symptoms they knew were the result of their allergies or other noninfectious conditions. Symptoms are ranked according to severity from 0 to 4, with 4 being a severe presentation of the symptom. The instrument has versions for both men and women. The female version has three questions about vaginal itching, yeast infections, and vaginal herpes.

Brief Multidimensional Measure of Religiousness/Spirituality. The Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS) is a 38-item instrument developed by a working group jointly sponsored by the Fetzer Institute and the National Institute on Aging (NIA) (1999). This working group included scholars with expertise in the interactions of religiousness/spirituality with both physical and mental health outcomes. These scholars recognized the deficiencies in previous instruments that had attempted to capture the effects of religiousness/spirituality within a single-summary scale measure; therefore, their goal was to develop a multidimensional instrument to measure religiousness/spirituality that would be uniquely suited for health research.

The developers of the BMMRS recognized that the distinction between “religiousness” and “spirituality” is difficult to clearly articulate, noting that while some experts view the two concepts as inextricably linked together, others view “religiousness” as having specific behavioral, doctrinal, and communal aspects, yet for others, “spirituality” is more concerned with the transcendent aspects of life and the ultimate meaning of life. Therefore, the concept of “religiousness/spirituality” in the BMMRS is intentionally treated as a single construct composed of multiple dimensions to reflect that “it is possible to adopt the outward forms of religious worship and doctrine without having a strong relationship to the transcendent” (Fetzer Institute & NIA, 1999, p. 2). The BMMRS developers acknowledged that many of the BMMRS items have a core Judeo-Christian focus (consistent with the majority population of the United States, where the instrument was developed); however, the developers intentionally attempted to include items within the instrument that have relevance for individuals of other backgrounds and with other spiritual practices (Fetzer Institute & NIA, 1999).

The BMMRS includes 11 domains: daily spiritual experiences, values/beliefs, forgiveness, private religious practices, religious and spiritual coping, religious support, religious/spiritual history, commitment (including time and financial), organizational religiousness, religious preference, and overall self-ranking. With regard to the latter domain, respondents are asked, “To what extent do you consider yourself a religious person?” and “To what extent do you consider yourself a spiritual person?” It should be noted that within the religious and spiritual coping domain, both positive religious coping (perceiving God as a loving, supportive presence) and negative religious coping (perceiving God as a punitive or abandoning presence) are assessed. Within the religious support domain, both congregational benefits (e.g., assistance during illness) and congregational problems (e.g., criticism or demands by congregation members) are assessed. Response options for all questions except religious preference are recorded on a Likert-type scale, with higher scores indicating higher levels of the dimension being assessed.

Initial work to evaluate validity and reliability of the BMMRS was done when items from the instrument were included in the 1998 General Social Survey (Idler et al., 2003). The instrument demonstrated moderate to good internal consistency and reliability scores on the various subscales, along with adequate content validity. Additional construct validation work on the tool has been done with older adults (Konopack & McAuley, 2007), social work students and individuals undergoing treatment for alcohol or drug use (Stewart & Koeske, 2006), a chronic pain sample (Rippentrop, Altmaier, Chen, Found, & Keffala, 2005), and adults with a variety of chronic and acute medical conditions (Johnstone, Yoon, Franklin, Schopp, & Hinkebein, 2009).

Finally, a researcher-developed demographic form was used to collect data on age, gender, income, marital status, and health indicators.

Results

Demographic Characteristics of the Sample

Eighty-two older adults completed the surveys. The mean age of the sample was 74 (age range = 65 to 91). Slightly more than two thirds (67%) were women. Half (51%) were married, 5% were single, 13% were divorced, and 31% were widowed. The majority (83%) were fully retired. Overall, this was a fairly affluent sample, with more than half having an annual income of $30,000 or more. Only 5 participants smoked. While the sample was generally healthy, more than half were taking cardiovascular medications. Other medications, reported at low frequency, were for diabetes, arthritis, and other chronic conditions typical of the older adult population. Sixty-eight of the 82 participants reported exercising between 30 minutes to more than 2 hours per week.

PSS Scores

The mean PSS score was 19.09, with a range of 4 to 43. Gender differences were found in gastrointestinal symptoms related to stress: Women had significantly more gastrointestinal symptoms than men (t = 2.5, p < 0.014). Women also had a greater frequency in how often they felt nervous or stressed (r = 0.249, p = 0.03) and felt they could not cope (r = 0.232, p = 0.144). Women had higher PSS scores (20.1) than men (16.8), but the difference was not significant (p < 0.08). Neither marital status nor retirement status was associated with perceived stress scores.

SCL Scores

The mean number of symptoms on the SCL was 5 (range = 0 to 29). Respiratory symptoms had the highest occurrence, with runny nose and cough occurring most often. Neither marital status nor retirement status was associated with occurrence of infection symptoms.

BMMRS Scores

The mean summary scores for each of the BMMRS dimensions were:

  • Daily spiritual experiences = 27.65 (range = 11 to 36 of a possible range of 6 to 36).
  • Values/beliefs = 6.8 (range = 4 to 8 of a possible range of 2 to 8).
  • Forgiveness = 10.25 (range = 4 to 12 of a possible range of 3 to 12).
  • Private religious practices = 21.42 (range = 10 to 37 of a possible range of 5 to 37).
  • Religious and spiritual coping: Positive religious coping = 9.15 (range = 3 to 12 of a possible range of 3 to 12).
  • Religious and spiritual coping: Negative religious coping = 4.53 (range = 3 to 12 of a possible range of 3 to 12).
  • Religious and spiritual coping: Religion as coping = 3.23 (range = 1 to 4 of a possible range of 1 to 4).
  • Religious support: Congregational benefits = 6.55 (range = 2 to 8 of a possible range of 2 to 8).
  • Religious support: Congregational problems = 3.05 (range = 2 to 6 of a possible range of 2 to 8).
  • Religious/spiritual history: Gain in faith = 2.60 (range = 2 to 4 of a possible range of 2 to 4).
  • Religious/spiritual history: Loss in faith = 1.23 (range = 1 to 2 of a possible range of 1 to 2).
  • Commitment: Intrinsic religiousness = 3.33 (range = 1 to 4 of a possible range of 1 to 4).
  • Commitment: Financial = $2,666.61 per year (range = $0 to $20,000 of a possible range of $0 to no upper limit).
  • Commitment: Time = 4.96 hours per week (range = 0 to 20 of a possible range of 0 to no upper limit).
  • Organizational religiousness = 8.51 (range = 2 to 12 of a possible range of 2 to 12).
  • Religious preference: Protestant (74%); no preference (15%); and Catholic, Unitarian, or nondenominational (11%).
  • Self-ranking of religiousness/spirituality = 6.18 (range = 2 to 8 of a possible range of 2 to 8).

Increasing age was positively correlated with feeling God’s presence more often, meditating more frequently, and attending church services more often; it was also positively correlated with increased participation in other activities in a place of worship, reading the Bible more, and increased participation in organized religious services. Those who were unable to forgive themselves, forgive others, or feel forgiven by God were more likely to have an infection in the previous month. Increased infections also occurred when older adults did not feel they had religious support from their congregations.

Answers to Research Questions

Research Question 1: What Is the Relationship Between Perceived Stress and Infectious Illness?Table 1 shows the correlations among the individual PSS items and the SCL subscales. Table 2 shows the correlations of the PSS total score with both the total score and subscale scores of the SCL. These data indicate a relationship between perceived stress and infectious illness in general (r = 0.41, p < 0.01), as well as with the subscales for skin-eye infections, genitourinary infections, and flu-like symptoms.

Pearson Correlations Between Stress and Infectious Illness Variables

Table 1: Pearson Correlations Between Stress and Infectious Illness Variables

Correlations Between Perceived Stress and Infectious Illness

Table 2: Correlations Between Perceived Stress and Infectious Illness

Research Question 2: What Is the Relationship Between Perceived Stress and Dimensions of Religiousness/Spirituality? Table 3 shows the correlations between the PSS total score and the dimensions of religiousness/spirituality, as measured by the BMMRS. Statistically significant positive correlations were demonstrated between stress and the subscales for negative religious coping (i.e., higher stress linked to negative coping, such as believing God is punishing for sins) and congregational problems (i.e., higher stress linked to excessive demands or criticism from members of the congregation).

Correlations Between Perceived Stress and Dimensions of Religiousness/Spirituality

Table 3: Correlations Between Perceived Stress and Dimensions of Religiousness/Spirituality

Research Question 3: What Is the Relationship Between Infectious Illness and Dimensions of Religiousness/Spirituality? Infectious illness was related to multiple dimensions of religiousness/spirituality in these older adults. Table 4 shows the correlations between the SCL total score and each of the measured dimensions of religiousness/spirituality. Statistically significant inverse correlations were demonstrated between infectious illness and each of the following dimensions: daily spiritual experiences, values/beliefs, forgiveness, positive religious coping, religion as coping, congregational benefits, and intrinsic religiousness. Statistically significant positive correlations were noted between infectious illness and negative religious coping, congregational problems, and loss in faith.

Correlations Between Infectious Illness and Dimensions of Religiousness/Spirituality

Table 4: Correlations Between Infectious Illness and Dimensions of Religiousness/Spirituality

Research Question 4: Is the Relationship Between Perceived Stress and Infectious Illness Moderated by Dimensions of Religiousness/Spirituality? Moderation of the effect of perceived stress on infectious illness was assessed by performing hierarchical regressions using the interaction terms between the PSS scores and scores on the various BMMRS dimensions, with the total SCL score used as the dependent variable. Each score was centered around its respective mean to minimize the effects of any multicollinearity. The individual scores (e.g., stress, forgiveness) were entered first, then the interaction terms. Four dimensions were demonstrated to have statistically significant moderating effects: forgiveness (p = 0.033, standardized beta weight = −1.136), positive religious coping (p = 0.033, standardized beta weight = −1.247), financial commitment (p = 0.012, standardized beta weight = −1.053), and overall self-ranking of spirituality/religiousness (p = 0.026, standardized beta weight = −1.371). Tables 5 through 8 present the regression coefficients for each of these models.

Forgiveness as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Table 5: Forgiveness as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Overall Self-Ranking of Religiousness/Spirituality as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Table 8: Overall Self-Ranking of Religiousness/Spirituality as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Discussion and Implications

This study demonstrates the relationship between stress in the daily lives of well older adults and symptoms of infection. It also shows that four dimensions of spirituality moderated the stress-infection relationship. These findings contribute to the extant literature, as researchers have seldom examined the relationships among these variables in community samples of older adults. A strength of the study is the use of a comprehensive multidimensional measure of spirituality/religiousness, the BMMRS, permitting identification of specific aspects meriting further study (e.g., forgiveness). Given that positive religious coping was a moderator of the stress-infection relationship in this study, gerontological nurse researchers should investigate ways to foster both clients’ perceptions of God as a loving, supportive presence, rather than a punitive or abandoning presence, and clients’ ability to forgive themselves and others. Collaboration with clergy is advisable, especially when distressful discord within the church congregation is identified by older adults.

Forgiveness is a modifiable dimension of spirituality that deserves increased attention from both researchers and clinicians. Holding onto resentful grudges perpetuates heightened cardiovascular and sympathetic nervous system reactivity (e.g., increased heart rate and blood pressure), increasing allostatic load (vanOyen Witvliet, Ludwig, & Vander Laan, 2001). Sustaining a resentful grudge maintains the activation of physiological systems, even when the stressor, such as interpersonal conflict, has been terminated. Research with middle-aged adults has shown that forgiveness leads to better health by reducing the magnitude of stress (Lawler et al., 2005) and that forgiveness reduces psychological symptoms (Wade & Meyer, 2009); these studies should be replicated with older samples.

Forgiveness interventions can be delivered to both individuals and groups. Gerontological nurses are well positioned to conduct psychoeducational group forgiveness interventions, such as that described by Harris et al. (2006), which produced a reduction in perceived stress in the treatment group (p < 0.001) at 6 weeks posttest. Even if implementation of a formal forgiveness intervention is not practical, clinicians can use other well-established interventions such as reminiscence and life review, which could help older adults consider forgiving themselves and others (Wilt & Smucker, 2001). Taking a careful spiritual history (Hart, 2008) is mandatory before initiating any spiritual interventions (see Wilt and Smucker, 2001, for additional recommendations about spiritual care).

Limitations

Limitations of this study include the cross-sectional design, which precludes inferences of causality and suggests caution regarding our recommendations for nursing interventions. Another limitation is the lack of biological data to corroborate self-reports of infectious illnesses. Furthermore, instrument packets were not distributed in a manner that permitted calculating response rate, and thus older adults who returned the packets may differ in unknown ways from others who attended the senior centers and other data collection sites.

The relative affluence of the sample limits generalizability of the findings to less privileged older adults. Moreover, the stress instrument used assesses only participants’ perceptions of the current stress; it does not permit identification of past stressors experienced by study participants. Past stressors were shown to have continued impact for years in the study conducted by Ensel and Lin (2000). A final limitation is the small subsample for some of the correlations, which has implications for replicability of the results. Because different correlations are based on different subsets of respondents—which may not be random subsets of the total sample—bias could be present in the data.

Conclusion

This study demonstrates that even healthy older adults have increased risk for infection when stressed. The strength of the relationship between stress and infection in the everyday life of a relatively affluent, largely retired sample of older adults indicates a need for nurses and other health care professionals to deliver stress management in community settings. Behavioral interventions can improve allostasis and decrease allostatic load (McEwen & Lasley, 2003). Tailoring stress management programming to the specific concerns of older adults is recommended; a generic stress management approach is not likely to be effective. Promoting spiritual health through evidence-based interventions such as forgiveness groups (Harris et al., 2006) may be influential in decreasing older adults’ risk of infection.

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Pearson Correlations Between Stress and Infectious Illness Variables

Carr Infection Symptom Checklist Subscales
Perceived Stress Scale Items Respiratory Skin/Eye Genitourinary Gastrointestinal Flu-Like Symptoms
Have been upset 0.178 0.280* 0.351** 0.292* 0.306*
Felt unable to control things in your life 0.305** 0.361** 0.446** 0.184 0.368**
Felt nervous or stressed 0.205 0.137 0.278* 0.134 0.121
Were unsuccessful handling life hassles 0.162 0.000 0.025 0.232 –0.068
Did not cope effectively 0.040 –0.045 –0.090 –0.066 –0.121
Felt confident handling problems 0.007 –0.236* –0.120 –0.070 –0.276*
Felt things were going your way –0.205 –0.207 –0.104 –0.271* 0.006
Felt you could not cope 0.172 0.357** 0.364** 0.236 0.465**
Felt able to control irritations –0.254* –0.303* –0.182 0.026 0.264*
Felt on top of things –0.239* –0.326** –0.199 –0.221 –0.208
Have been angered 0.127 0.305* 0.135 0.160 0.237*
Have been thinking about things to accomplish 0.172 0.132 0.118 0.190 0.216
Have been able to control the way you spend your time –0.107 –0.159 –0.113 –0.112 –0.115
Felt overcome by difficulties 0.252* 0.358** 0.371** 0.168 0.333**

Correlations Between Perceived Stress and Infectious Illness

Perceived Stress Scale Total Score
Carr Infection Symptom Checklist Subscales Pearson Correlation n
Total score 0.413** 68
Respiratory 0.239 67
Skin/eye 0.400** 65
Genitourinary 0.360** 65
Gastrointestinal 0.197 64
Flu-like symptoms 0.389** 65

Correlations Between Perceived Stress and Dimensions of Religiousness/Spirituality

Perceived Stress Scale Total Score
Brief Multidimensional Measure of Religiousness/Spirituality Subscales Pearson Correlation n
Daily spiritual experiences –0.128 67
Values/beliefs 0.003 69
Forgiveness –0.200 68
Private religious practices 0.116 66
Religious and spiritual coping
  Positive religious coping 0.073 69
  Negative religious coping 0.305* 69
  Religion as coping –0.060 69
Religious support
  Congregational benefits –0.185 66
  Congregational problems 0.377** 64
Religious/spiritual history
  Gain in faith –0.100 67
  Loss in faith 0.215 68
Commitment
  Intrinsic religiousness –0.118 68
  Financial commitment 0.045 53
  Time commitment –0.077 50
Organizational religiousness –0.004 66
Overall self-ranking of spirituality/religiousness –0.147 68

Correlations Between Infectious Illness and Dimensions of Religiousness/Spirituality

Carr Symptom Infection Checklist Total Score
Brief Multidimensional Measure of Religiousness/Spirituality Subscales Pearson Correlation n
Daily spiritual experiences –0.241* 74
Values/beliefs –0.354** 76
Forgiveness –0.426** 76
Private religious practices –0.063 74
Religious and spiritual coping
  Positive religious coping –0.228* 76
  Negative religious coping 0.326** 76
  Religion as coping –0.233* 78
Religious support
  Congregational benefits –0.293* 74
  Congregational problems 0.416** 71
Religious/spiritual history
  Gain in faith 0.101 74
  Loss in faith 0.362** 77
Commitment
  Intrinsic religiousness –0.221* 77
  Financial commitment –0.085 58
  Time commitment –0.098 54
Organizational religiousness –0.189 73
Overall self-ranking of spirituality/religiousness –0.182 76

Forgiveness as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Unstandardized Coefficients Standardized Coefficient
Measure B SE Beta tValue pValue
Constant 0.269 0.725 0.371 0.712
Perceived stress score 1.183 0.423 1.428 2.799 0.007
Forgiveness score 0.615 0.921 0.173 0.668 0.507
Stress × forgiveness interaction –0.093 0.043 –1.136 –2.176 0.033

Positive Religious Coping as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Unstandardized Coefficients Standardized Coefficient
Measure B SE Beta tValue pValue
Constant 0.370 0.735 0.503 0.617
Perceived stress score 1.213 0.399 1.423 3.040 0.003
Positive religious coping score 0.935 0.846 0.343 1.105 0.273
Stress × positive religious coping interaction –0.092 0.042 –1.247 –2.174 0.033
Positive Religious Coping as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Table 6: Positive Religious Coping as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Financial Commitment as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Unstandardized Coefficients Standardized Coefficient
Measure B SE Beta tValue pValue
Constant 1.478 0.934 1.582 0.120
Perceived stress score 0.698 0.167 0.749 4.183 0.000
Financial commitment score 0.003 0.001 0.910 2.420 0.019
Stress × financial commitment interaction 0.000 0.000 –1.053 –2.613 0.012
Financial Commitment as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Table 7: Financial Commitment as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Overall Self-Ranking of Religiousness/Spirituality as Moderator of Effect of Stress on Infectious Illness (Centered Values)

Unstandardized Coefficients Standardized Coefficient
Measure B SE Beta tValue pValue
Constant 0.736 0.777 0.947 0.347
Perceived stress score 1.417 0.484 1.661 2.925 0.005
Self-ranking score 2.581 1.548 0.523 1.668 0.100
Stress × self-ranking interaction –0.179 0.079 –1.371 –2.274 0.026
Authors

Dr. Callen is Associate Professor, Dr. Mefford is Clinical Assistant Professor, and Dr. Thomas is Professor, University of Tennessee, College of Nursing, Knoxville, Tennessee; and Dr. Groër is Professor, University of South Florida, College of Nursing, Tampa, Florida.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Address correspondence to Sandra P. Thomas, PhD, RN, FAAN, Professor, University of Tennessee, College of Nursing, 1200 Volunteer Boulevard, Knoxville, TN 37996; e-mail: sthomas@utk.edu.

Received: July 31, 2009
Accepted: May 13, 2010
Posted Online: October 29, 2010

10.3928/19404921-20101001-99

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