Religiosity and Adherence in the Hemodialysis Population

1. Religiosity and Adherence in the Hemodialysis Population Elisheva Berman, MD, MBE

2. Agenda • Goal, hypotheses and rationales • Compliance – definition and observations • Data collection and demographics • Scales • Results • Discussion

3. History • In the beginning religion and medicine were very connected • 19th century split between the two • A century later revival of interest in the spiritual and how it affects health

4. Some patient quotes • Each morning when I get up I thank G-d for another day.Religion helps me to be totally at peace.” LT age 70 • “Life is chaos without religion.Religion helps me to have structure.It gives me a reason to keep up with the program.” MP age 58

5. Hypothesis and rationales • Hypothesis # 1: Increased religiosity would lead to increased compliance • Rationales: Previous studies in medical conditions such as arthritis, diabetes, kidney disease, ALS show: • Patients identifying themselves as “religious” coped better (850 consecutively admitted hospitalized patients) • Religious involvement associates with greater levels of quality of life in patients with cancer and heart disease • Religious involvement associated with improved attendance at scheduled medical appointments, greater cooperativeness

6. Hypothesis and rationales (con’d) • Hypothesis # 2: Increased religiosity would lead to decreased morbidity and mortality • Rationales: • More religious people  lower blood pressure • More religious or spiritual  fewer cardiac events • More religious and spiritual  longer longevity - Hummer & al - Religious and US adult mortality – Demography Vol 36 p 273-285, 1999 • Religious involvement associated with better adherence and improved medical outcomes - Harris & al – Role of religion in heart transplant recipients’ health and well being – Journal of Religion and Health Vol 34 p 17-32, 1995 - Pressman & al – Religious belief, depression and ambulation status in elderly women with broken hips – American journal of psychiatry Vol 137 p758 – 760, 1990

7. Anti-hypothesis • Anti-hypothesis:Increased religiosity may lead to decreased adherence • Rationales: • Patients feeling that fate is in G-d’s hands • Studies show: • Religion associated with lower use of physician services in type II diabetes • Patients with stronger religious beliefs 2-3 times more likely to deteriorate or remain the same 9 months after admission (sample of 250 patients with chronic illness)

8. Third Possibility… …No correlation between religion and adherence!

9. What is compliance? • Definition: extent to which individual’s behavior coincides with a clinical prescription • Measures: • Dietary adherence: • Monitoring serum potassium levels • Circulating blood urea nitrogen • Interdialysis weight gain • Medication adherence: • Drug or marker assays of biological fluids • Direct patient observation • Pill counts • Direct patient reports • Prescription record reviews  Observation: non-compliance rates up to 50% in hemodialysis population

10. Additional definitions • Morbidity / Mortality “Of the nature of or indicative of disease.” • Religious / Spiritual “Relating to or affecting the human spirit.” “Relating to religion or religious belief.” • Adherence / Compliance

11. Methods • Patients approached at Gambro dialysis units at Presbyterian hospital and at 42nd & Walnut St. • Patients interviewed while being dialyzed • Questions read to patients and answers recorded by graduate student • Interview average duration: 45 minutes

12. Patient perspective • “I try to bring the Word to people and try to help them.The patients respond very well to prayer groups.It helps them to cope better with their illness.” GW age 49

13. Why Dialysis population? • High mortality • Easy to measure standards of adherence: • # of times patients show up to dialysis • interdialysis weight gain • blood chemistries • Inability to switch facilities or doctors easily • Long term treatment

14. Demographics • Average age: 54 years • AA: 89% • Employment rate: 11 % • 31 men and 43 women • Mean time on dialysis: 3.5 years • Mean intrinsic religiosity score: 38.4 (10-50) • Mean organizational religious activity score: 4 (2-9) • Nonorganizational religious activity score: 10.3 (3-15) • Mean adherence: 95 (61-100)

15. Scales • Hoge Intrinsic Religiosity Scale • Validated in different studies using priests and Rabbis as criterion standard • Captures intrinsic aspects of religiosity • Origins in intrinsic/extrinsic perspective of religious commitment developed at Harvard by Allport & Ross • 10-item scale graded 1-5

16. Examples of questions • My faith involves all of my life • My faith sometimes restricts my actions • I try hard to carry religion over into all my other dealings in life • In my life I experience the presence of the divine

17. IRS Distribution 22 Frequency 0 10 IRS 50

18. Histograms by religion Non-Baptist subgroup Baptist subgroup Frequency Non-affiliated subgroup IRS

19. Intrinsic Religiosity Scale • Varied predictably with: • Social support • Satisfaction with life • Employment • Beck Depression Inventory

20. More Patient Quotes • “G-d is everything.He took me up from the streets and saved me.It doesn’t matter what religion you are from. Just pray and have trust.” -MM age 63 • “Belief helps me to cope with my illness. You have to have hope that things will get better.” - MM age 63 • “I am not exactly religious, but I believe.The fact that I am still here is an indication that G-d exists.”-LR age 51

21. Scales (con’d) • Organizational Religious Activities Scale • Used to measure degree to which patients participate in group religious activities • Consists of 2 questions • Non organizational Religious Scale • Asked about private religious activities • Consists of 3 questions  Both scales used to capture both people belonging to organized religion, and those who describe themselves as spiritual

22. ORA Distribution 24 Frequency 0 2 ORA 10

23. Another Patient remark • “I just believe in G-d. Everything is just G-d. I like the doctors.The important thing is to believe in G-d.” –MB age 69 • “Religion is everything.Now(that I am religious)I am so grateful for everything I have .Just walking outside and felling the sun on my face is enough to make me happy.”-LT age 45

24. Scales (con’d) Beck depression scale • Designed by Aaron Beck at University of Pennsylvania • Used previously in dialysis patients • Asks about both cognitive and somatic aspects of depression • Measures both presence of depression and its level • Higher scores on Beck indicate more depression • Different from Hamilton scale in that based on patient’s subjective responses to questions (cf. following slide)

25. Scales (con’d) Hamilton Scale: • 21-item scale • Most widely used scale in selection and follow up studies • Measures severity of depression but not presence • Must be use with rater guide

26. Scales (con’d) KARNOFSKY Performance Scale • Determines the functional ability of patients • Score below 70 – requires assistance • Score below 50 – requires institutionalization • Used extensively in patients with ESRD

27. Scales (con’d) • “Satisfaction with life” scale • Asks about satisfaction with past and present life • Good internal reliability and 2 month test-retest reliability • Has also been used in the dialysis population • Consists of 5 items which are scored from 1 to 7 • Possible range of scores between 5 and 35 (35 indicating the most satisfaction with life)

28. Measures of “satisfaction with life” • Life satisfaction refers to cognitive judgmental process • Defined by Shin and Johnson as “a global assessment of a person’s quality of life according to his chosen criteria” • Assessment based on a standard which every individual sets for himself • Different people may place different values on particular criterion such as health, money, family, etc.  We therefore need to ask people about their overall evaluation of their life.

29. Validation of selected scale • Satisfaction with life scale chosen was tested in both the college and geriatric population. • Correlated positively with many other scales which measure subjective well being.

30. Multidimensional scale of perceived social support • Perceives social support from three areas: • Family • Friends • Significant other  Respondents use 7 point Likert scale to indicate responses to the questions

31. Patient comment cont. • “ I don’t consider myself very religious. I believe that you have to have family support to get you through.” • “Family is very important.They are the ones who give me strength.You should get married and have children of your own.”-CC age 61

32. Why missed/shortened sessions? • Most easy to measure • Least likely to be confounded by other variables

33. Results-When using Missed sessions as measure • High scores on Intrinsic Religiosity Scale strongly associated with high scores on Satisfaction with Life Scale • Age and high Organizational Religious Activities scores strongly associated with high scores on satisfaction with medical care scale • Positive relationship between adherence and years on dialysis therapy

34. Regression compliance age dialysis

35. When using shortened sessions as measure • Increased age correlated with greater adherence. (Only significant predictor) • Age associated with greater satisfaction with life • Number of years on dialysis therapy correlates inversely with adherence

36. Other correlations • Satisfaction with life related to a number of factors including: • Age • Beck Depression Inventory • Higher intrinsic religiosity scores • Tuesday/Thursday/Saturday schedule of dialysis

37. CONCLUSION • In both cases no significant association between religious beliefs and adherence. • Both measures of adherence are affected by factors other than religion

38. Discussion Why did we find no association? • We had a small number of irreligious patients in our sample • Most patients we interviewed were Baptist • Difficulty quantifying religion on scales

39. Other possible causes of nonadherence • Complexity of treatment • Cultural beliefs • Relationship with doctor • Psychological factors

40. “Science without religion is lame,religion without science is blind.” Albert Einstein 1879-1955 Science, Philosophy and Religion,1941 • “Formerly when religion was strong and science weak, men mistook magic for medicine ;now when science is strong and religion weak, men mistake medicine for magic.”Thomas Szasz 1921- The second sin ,1973

41. Acknowledgements Jon Merz Michael Rudnick Rich Snyder Katherine Rogers James Lee David Johnson Ari Mosenkis Ajay Israni Paul Wolpe Josh Lipschutz