1. The Role of Spiritual Self-efficacy Beliefs in Mediating and Moderating Frail Elders’ Affective Response to Functional Difficulty Presented by: Marie P. Dennis, Ph.D., Laura N. Gitlin, Ph.D., Laraine Winter, Ph.D., and Yeon K. Chee, Ph.D. Center for Applied Research on Aging and Health Thomas Jefferson University (Funded by NIA #AG 13687; PI – L. N. Gitlin)

2. Theoretical Foundations _________________________________________________________________________________________________  Lawton et al. (2001) – defined VOL as a cognitive-affective schema consisting of complex judgments, emotions and projections influenced by demographic and QOL factors (internal and external to person)  A broad construct intended to capture active embrace of life, attachment to life, one’s total reason for living through core constructs of hope, futurity, meaning/purpose in life, persistence and self-efficacy Reflect subjectively experienced worth of a person’s life Dynamic assimilation-accommodation process of adjustment to illness and decline  Independent of psychopathology, domain-specific QOL, and health-related factors  Preliminary validation study of Lawton et al.’s 13-item VOL yielded two dimensions: Spiritual Self-efficacy Beliefs and Personal Agency (Dennis et al., 2005)

3. Here are statements about the meaning of life and personal goals. For each statement, indicate whether you (5) agree very strongly, (4) agree, (3) neither agree or disagree, (2) disagree, (1) disagree strongly Life has meaning for me I have a strong will to live right now My personal beliefs allow me to maintain a hopeful attitude Each new day I have much to look forward to I intend to make the most of my life My life these days is a useful life My life is guided by strong religious or ethical beliefs I feel hopeful right now Spiritual Self-efficacy Beliefs Scale (α=.87)

4. Relevant Research ____________________________________________________________________________________________________________ Physical Function and Negative Affect  Health-related stressors positively associated with depressive symptoms (Schulz et al., 1994)  Depressive symptoms are affected by the extent to which daily routines become difficult or restricted  Functional difficulties associated with depressed affect and anxiety  Consistent finding across impairment groups  Relationship is reciprocal and predictive of each other over time (Lenze et al., 2001) Religion/Spirituality and Health Research  Large body of research in social, behavioral and health sciences (Koenig et al., 2001)  Religion/Spirituality has a protective effect on a variety of health outcomes  Higher levels of religious/spiritual involvement associated with greater well-being, less anxiety, stress and depression

5. Relevant Research (Continued) ______________________________________________________________________________________________________ Moderation Studies  Benjamins (2004)  Found religious attendance associated with decrease in functional limitations but age did not moderated this relationship  Religious salience associated with increased functional limitations; age moderated this relationship Moderate amount of religious salience had stronger moderating effect for older persons  Kirby (2004)  Spirituality significant predictor of psychological well-being  Spirituality moderated effects of frailty on psychological well-being

6. Need _________________________________________________________________________________________________________  Few studies have addressed the mediating or moderating role of spiritually-related constructs in accounting for the relationship of functional difficulty to negative affective outcomes  Understanding the pathways through which functional difficulty influences depression and anxiety may lead to fruitful interventions to reduce the stress associated with functional decline in older adults transitioning to frailty

7. Purpose of the Study _______________________________________________________________________________________________________________________  Examine the bivariate associations among Spiritual Self- efficacy Beliefs, anxiety, depressive symptoms and functional difficulty in functionally-vulnerable, community-dwelling elders  Examine the mediating and moderating effect of Spiritual Self-Efficacy Beliefs on the relationship between older adults’ functional difficulty and depressive symptoms  Examine the mediating and moderating influence of Spiritual Self-efficacy Beliefs on the relationship between older adults’ functional difficulty and anxiety

8. Study Design (N = 319) __________________________________________________________________________________________________________  Participants recruited from PCA, Paratransit client lists, media announcements, senior centers, senior housing from 1999 – 2003 for Project ABLE Respondents screened by telephone for eligibility (N=423) 78.3% willing to participate Unwilling did not differ from willing respondents  In-home structured two hour interview Participants rated level of difficulty in performing activities of daily living, psychological health and use of control strategies

9. Inclusion Criteria ___________________________________________________________________________________  Ambulatory community-living adults  70 years of age or older  English-speaking  Functionally vulnerable:  Difficulty performing > 2 IADLs  Difficulty with 1+ ADL task  Use of mobility device  Pain  Difficulty with bathing, transferring  1+ falls  MMSE > 24

10. Overall Sample (N = 319) _____________________________________________________________________________________________________________  Mean Age: M =79 (SD = 5.9)  Race: 57.2% White, 47.3% Non-white  Gender: 18.2% Male, 81.8% Female  Education: HS (36.7%)  Religion: Jewish (22.7%), Christian (71.4%), Other (3.1%), None (2.8%)  Functional Difficulty: M = 2.2 (SD=.5) “a little difficulty to some difficulty”  MMSE: M = 26.9 (SD=1.8)  Health Conditions: M = 6.9 (SD=2.7)

11. +2.65 1.44 Anxiety Increase = 4.08 Depression Increase = 7.84 +3.68 +4.17

12. Measures _____________________________________________________________________________________________________________ Predictor  Daily Functional Difficulty – 22-items assessing Basic, ADL, IADL, and mobility functional difficulty from Ettinger et al.’s (1997 ) FAST inventory; higher mean scores = greater difficulty (α=.85) Criterion  Anxiety –Spielberger et al.’s (1983) 10-item S-Anxiety Subscale; higher total scores = greater anxiety (α=.87)  Depressive Symptoms - Radloff’s (1977) 20-item CES-D measure of the frequency of depressive symptoms in past week; higher total scores = more depressive symptoms (α=.72)

13. Study Hypotheses __________________________________________________________________________________________________________________________________  Functional difficulty will be significantly and positively associated with both depression and anxiety  Spiritual Self-efficacy Beliefs will be significantly but inversely related to functional difficulty, anxiety and depressive symptoms  Spiritual Self-efficacy Beliefs will mediate and moderate the relationship between functional difficulty and depressive symptoms  Spiritual Self-efficacy Beliefs will mediate and moderate the relation between overall functional difficulty and anxiety

14. Conditions for Mediation and Moderation a ____________________________________________________________________________________________________________________________________________________________ Mediation  Functional difficulty should be associated with Spiritual Self-efficacy Beliefs, anxiety and depressive symptoms  When Spiritual Self-efficacy Beliefs are included in the regression model, the influence of functional difficulty on affect should be attenuated (ratio of betas < 1.0) after controlling for demographic, religious and health-related factors Moderation  The effect of the interaction of functional difficulty and Spiritual Self- efficacy Beliefs should be statistically significant after controlling for demographic, religious and health-related factors ____________________________________________________________________ a Baron and Kenny (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173 – 1182.

15. Predicting Depressive Symptoms from Functional Difficulty (N = 319) Note: Blocks were adjusted for age, race, living arrangement, a living arrangement by age interaction, economic well-being, social support, health conditions and religious preference. a DV = Functional Difficulty b p (Sobel Test) =.012 BSE (B)pRatio Model I Spiritual Self-efficacy Beliefs a -1.44.51.005 Model II Functional Difficulty5.201.05.000 Model III Functional Difficulty4.21.95.001.81 b Spiritual Self-efficacy Beliefs-.88.10.000

16. Predicting Anxiety from Functional Difficulty (N = 319) Note: Blocks were adjusted for age, race, living arrangement, a living arrangement by age interaction, economic well-being, social support, health conditions and religious preference. a DV = Functional Difficulty b p (Sobel Test) =.019 BSE (B)pRatio Model I Spiritual Self-efficacy Beliefs a -1.44.51.005 Model II Functional Difficulty2.54.68.000 Model III Functional Difficulty2.09.65.001.82 b Spiritual Self-efficacy Beliefs-.40.07.000

17. 15.2 pts. 40.0 pts.

18. p (interaction) =.099 5.8 pts. 19.5 pts.

19. Mediation Effects _________________________________________________________________________________________________________  Functional difficulty was positively associated with depressive symptoms and anxiety and inversely related to Spiritual Self-efficacy Beliefs  When Spiritual Self-efficacy Beliefs was entered into the regression model, the influence of functional difficulty on depressive symptoms and anxiety was substantially reduced but not eliminated Depressive symptoms - ratio of the betas =.81, p =.012 Anxiety - ratio of betas =.82, p =.019  Other mediators may also be contributing to older adults’ negative affective response to functional decline

20. Moderation Effects _________________________________________________________________________________________________________  Relationship between functional difficulty and depressive symptoms was moderated or strengthened by use of Spiritual Self-efficacy Beliefs Elders who use Spiritual Self-efficacy Beliefs in coping with functional difficulty experience less depressive symptoms than those at the same level of difficulty who do not use Spiritual Self-efficacy Beliefs Spiritual Self-efficacy Beliefs protect against the negative affective consequences of functional difficulty  The relationship between functional difficulty and anxiety was not moderated (statistically) by Spiritual Self-efficacy Beliefs although anxiety level was reduced

21. Implications ________________________________________________________________________________________________________  Functional difficulty influences older adults’ affect indirectly through Spiritual Self-efficacy beliefs  Present research extends applicability of one dimension of positive VOL to the domain of physical functioning  Interventions designed to reduce the negative affective consequences of functional impairment need to address older adults’ Spiritual Self-efficacy Beliefs as a domain of need and potential avenue of treatment

22. Future Directions _______________________________________________________________________________________________________________  Evaluate pattern of relationships for diverse populations  Longitudinal research to evaluate length of protection afforded by Spiritual Self- efficacy Beliefs  Examine the mediating and moderating influence of Spiritual Self-efficacy Beliefs on functional decline in specific domains: basic, ADL, IADL and mobility

23. References _______________________________________________________________________________________________________ Baron and Kenny (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173 – 1182. Benjamins, M. R. (2004). Religion and functional health among the elderly: Is there a relationship and is it constant? Journal of Aging and Health, 16, 3, 355 – 374. Dennis, M.P., Winter, L., Black, H., Gitlin, L.N. (2005). What is valuation of life for frail community-dwelling older adults: Factor structure and criterion validity of the VOL. Paper presented at annual meeting of the Gerontological Society of America. November. Kirby, S. E., Coleman, P. G., and Daley, D. (2004). Spirituality and well-being in frail and nonfrail older adults. Journal of Gerontology, Psychological Sciences, 59B, 3, 123 – 129. Koenig, H. G., McCullough, M. E., & Larson, D. B. (2001). Handbook of religion and health. Oxford, UK: Oxford University Press. Lenze, E.J. et al. (2001). The Association of Late-life Depression and Anxiety with Physical Disability. Am J Geriatr Psychiatry, 9, 113 - 135. Powell, M.P., Moss, M., Hoffman, C., Kleban, M.H., Ruckdeschel, K., Winter, L. (2001). Valuation of life: A concept and a scale. Journal of Aging and Health, 13, 1, 3-31. Schulz, R., Heckhausen, J., O’Brien, A. (1994). Control and the Disablement Process in the Elderly. Social Behavior and Personality, 9, 139 – 152. Williamson, G., and Schulz, R. (1992). Pain, activity restriction and symptoms of depression among community-residing elderly. J. of Gerontology, 47, 367-372.