Dong Pil Yoon, Ph.D., University of Missouri Factor Analysis of the BMMRS among People with TBI from the US and India Dong Pil Yoon, Ph.D., University of Missouri

Purpose and Rationale for the Study It is important to determine if previously identified BMMRS religious, spiritual, and congregational support constructs are universal across different cultural and religious groups. To determine this, the current study completed a factor analysis of the BMMRS based on individuals from the US and India, including Christians, Hindus, and Muslims. Given the BMMRS was designed to examine religion and spirituality in relation to health, our cross-cultural and cross- religion research focused on a population with a serious health condition, i.e., individuals with traumatic brain injury (TBI).

Defining Religion and Spirituality Religion has generally been defined in behavioral terms, including frequency of or participation in culturally based activities/practices (“extrinsic” religion). Spirituality has generally been defined in emotional/experiential terms, often referring to feelings or experiences of awe, wonder, harmony, peace or connectedness with the universe or a higher power (“intrinsic religion”).

Historically, religiousness and spirituality were originally examined as a unidimensional construct utilizing single-item measure, although more recent research has attempted to identify and differentiate specific religious and spiritual constructs.

BMMRS The Fetzer Institute and the National Institute of Aging Working Group (1999) attempted to distinguish between religious and spiritual variables by creating the Multidimensional Measure of Religiousness and Spirituality (BMMRS).

12 Domains of BMMRS 3 Religiousness: Private religious practice, organizational religiousness, & religious support 4 Spirituality: Daily spiritual experiences, meaning, values/beliefs, & forgiveness 2 Combined R&S: Religious/spiritual coping & overall self- ranking 3 Non-direct domains: Religious/spiritual history, commitment, & religious preference

Previous studies Idler et al. (2003): 1,445, 1998 General Social Survey Neff (2006): 1998 General Social Survey Stewart & Koeske (2006): 355 social work students Piedmont et al. (2007): 452 undergraduate students Yoon & Lee (2005). 215 Rural elderly Johnstone & Yoon (2009). 168 persons with disabilities

Purpose of the Study It is necessary to use heterogeneous medical populations to statistically determine if empirically distinct constructs exist, and if they do, how can they be appropriately labeled. Identification of empirically derived and distinct BMMRS factors can lead to further research which can identify appropriate religious/spiritual interventions to improve health outcomes.

Measures Daily spiritual experiences: a 6-point scale (6 items), ranging from 1 (many times a day) to 6 (never) Meaning: a 4-point scale (2 items), ranging from 1 (strongly agree) to 4 (strongly disagree) Values/Beliefs: a 4-point scale (2 items), ranging from 1 (strongly agree) to 4 (strongly disagree) Forgiveness: a 4-point scale (3 items), ranging from 1 (always) to 4 (never)

Private religious practice: a 5 point (1 item) or 8 point (4 items) scale, ranging from 1 (greater frequency) to 5 or 8 (never) Religious/spiritual coping: a 4-point scale (7 items), ranging from 1 (a great deal) to 4 (not at all) Religious support: a 4-point scale (4 items), ranging from 1 (very often) to 4 (never) Organizational religiousness: a 6-point scale (2 items), ranging from 1 (more than once a week) to 6 (never)

Data Analysis For the current study all subscale items were standardized so that their scaling was equivalent. For instance, 1 to 4 (1 was subtracted from the actual score; 0 to 3 1 to 6 (1 was subtracted from the actual score; multiplied by 3/5) 1 to 8 (1 was subtracted from the actual score; multiplied by 3/7) 1 to 5 (1 was subtracted from the actual score; multiplied by 3/4)

In order to identify participants considered to be multivariate outliers, Mahalanobis distance was evaluated as Chi-square statistic with degrees of freedom equal to the number of variables in the analysis (Tabachnick and Fidell 1996). The data of four participants were dropped from the analysis, resulting in 109 participants.

A principle components factor analysis with varimax rotation and Kaiser normalization was conducted to assess the factor structure of the BMMRS All factors with Eigen values greater than 1.0 were retained for interpretation.

Results Six factors were identified which had extraction Eigen values greater than 1.0 (i.e., 9.29, 3.43, 3.34, 2.25, 2.14, & 1.89 respectively), and which explained a cumulative total of 72.1% of the variance in the scores.

Table 1: Demographics (Entire Sample)   N Percent Gender Male 78 71.6 Female 31 28.4 Ethnicity Caucasian 32 29.4 African American 26 23.9 Indian/Asian 50 45.9 Hispanic 1 0.9 Education Less than HS/Some HS 25 22.9 HS Diploma 17 15.6 Some College Bachelor’s Degree 13 11.9 Master’s Degree PhD/JD/MD 2 1.8 Unknown Religious Affiliation Christian 55 50.2 Hindu 30 27.5 Muslim 20 18.3 Missing 4 3.7

Table 4: BMMRS Descriptive Statistics (Entire Sample)   N Min. Max. Mean SD BMMRS Daily Spiritual Experiences 109 6 36 21.36 7.71 Meaning 108 2 8 4.29 1.43 Values/Beliefs 4.14 1.36 Forgiveness 3 12 6.92 2.01 Religious/Spiritual Coping 107 7 25 16.26 3.85 Private Religious Practices 37 23.67 8.58 Organizational Religiousness 8.35 2.73 Religious Support 96 8.14 2.00

5 Factors Positive Spirituality/Private Religious Practices (15 items, α = .96) Positive Congregational Support (5 items, α = .84) Negative Sprituality/Congregational Support (5 items, α = .82) Organizational Religiousness (2 items, α = .74) Forgivenss (2 items, α = .56)

Conclusions The current results suggests that rather than conceptualizing the BMMRS as assessing religious versus spiritual constructs with several subdomains, it may be best to conceptualize the BMMRS as measuring the positive and negative aspects of three general domains.

1) the emotional experiences individuals report related to religious traditions (i.e., spiritual experience) 2) the behavioral practices associated with one’s religious traditions (i.e., religious practices) 3) the perceived support they receive from their respective congregations (i.e., congregational support)

It is further suggested that the forgiveness factor identified in the current study be considered as a specific coping strategy that can be offered/experienced in either religious or non-religious contexts.

By de-emphasizing the focus on religious versus spiritual variables, and by focusing on these empirically identified BMMRS factors, it may be easier to determine the specific mechanisms whereby these religious/spiritual variables impact health (i.e., reduction of behavioral risks, expansion of social support, enhancement of coping skills, and physiological mechanisms).

Conceptualization of the BMMRS in this manner is consistent with psychoneuroimmunological models of health which focus on the impact of thoughts/behaviors (including religious/spiritual ones) and social support (including congregational support) on physiological and immunological functioning and ultimately health. Psychoneuroimmunolgocial models of health are based on the premise that thoughts, beliefs, and behaviors affect the manner in which body responds physically to stress, which in turn affect the ability of the body to fight disease/infection.

Identification of the specific spiritual experiences, religious practices, and congregational support factors which impact health can subsequently lead to the development of specific interventions (which can be conceptualized as religious or spiritual in nature) to improve health (i.e., meditation/prayer/forgiveness protocols to enhance coping and reduce physiological stress; culturally based activities to promote health behaviors and decrease health risk factors: reliance on congregational support networks to provide support and reduce stress/ etc)

With this in mind, it is proposed that the BMMRS scales be conceptualized according to three general domains, including 1) spiritual experiences (i.e., the positive and negative emotional experiences associated with feeling connected with a higher power); 2) religious practices (i.e., culturally based activities/practices associated with different faith traditions); and 3) congregational support (i.e., the positive and negative perceived social support associated with individual’s congregations).

It is suggested that the forgiveness factor identified in the current study be conceptualized as a specific coping strategy that can be considered in either religious or non-religious contexts.

Future Study It is suggested that future research on the BMMRS and health outcomes focus on three areas, including psychometric properties of the BMMRS, use of the BMMRS with different health conditions and faith traditions, and determining the causal mechanisms between these variables and health outcomes.