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

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Hypothesis and rationales (cond)

• 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

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Anti-hypothesis

• Anti-hypothesis Increased religiosity may lead
  to decreased adherence
• Rationales
• Patients feeling that fate is in G-ds 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)

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Third Possibility

• No correlation between religion and adherence!

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What is compliance?

• Definition extent to which individuals 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
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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

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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

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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

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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

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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)

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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

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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

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IRS Distribution
Variable Obs. Mean Std. Dev. Min Max
irs 74 38.39139 7.887597 10 50
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Frequency
0
10
IRS
50
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Histograms by religion
Non-Baptist subgroup
Baptist subgroup
Frequency
Non-affiliated subgroup
IRS
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Intrinsic Religiosity Scale

• Varied predictably with
• Social support
• Satisfaction with life
• Employment
• Beck Depression Inventory

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More Patient Quotes

• G-d is everything.He took me up from the streets
  and saved me.It doesnt 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

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Scales (cond)

• 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

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ORA Distribution
Variable Obs. Mean Std. Dev. Min Max
ora 74 4.121622 2.1194 2 9
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Frequency
0
2
ORA
10
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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

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Scales (cond)

• 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
  patients subjective responses to questions (cf.
  following slide)

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Scales (cond)

• 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

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Scales (cond)

• 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

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Scales (cond)

• 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)

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Measures of satisfaction with life

• Life satisfaction refers to cognitive judgmental
  process
• Defined by Shin and Johnson as a global
  assessment of a persons 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.

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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.

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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

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Patient comment cont.

• I dont 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

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Why missed/shortened sessions?

• Most easy to measure
• Least likely to be confounded by other variables

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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

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Regression compliance age dialysis
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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

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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

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CONCLUSION

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

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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

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Other possible causes of nonadherence

• Complexity of treatment
• Cultural beliefs
• Relationship with doctor
• Psychological factors

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• 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

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Acknowledgements

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