1. Top of page
  2. Abstract
  8. Acknowledgements


Strategies to improve coping with chronic disease are increasingly important, especially with the aging US population. For many, spirituality serves as a source of strength and comfort. However, little is known about the prevalence of daily spiritual experiences (DSE) and how they may relate to physical and mental health.


We surveyed older adults age >50 years with chronic health conditions seen in a primary care setting about their DSE, health perceptions, pain, energy, and depression.


Of 99 patients, 80% reported DSE most days and many times per day. Women had significantly lower DSE scores than men (reflecting more frequent DSE, mean ± SD 37.3 ± 15.0 versus 45.8 ± 17.5; P = 0.012). African American women reported the most frequent DSE and white men reported the least frequent DSE (mean ± SD 35.9 ± 13.6 versus 52.2 ± 19.1). Frequent DSE were significantly associated with a higher number of comorbid conditions (P = 0.003), although not with age, education, or employment status. Persons with arthritis reported significantly more DSE than those without arthritis (mean ± SD 35.2 ± 12.1 versus 47.1 ± 18.6; P < 0.001). After adjustment for age, race, sex, pain, and comorbid conditions, more frequent DSE were associated with increased energy (P < 0.009) and less depression (P < 0.007) in patients with arthritis.


DSE are common among older adults, especially those with arthritis. Increased DSE may be associated with more energy and less depression. DSE may represent one pathway through which spirituality influences mental health in older adults.


  1. Top of page
  2. Abstract
  8. Acknowledgements

The aging of the American population and the increasing prevalence of chronic health conditions presents a major challenge to the health care system. As of 2003, 100 million Americans were estimated to have chronic conditions and this number is expected to increase to 148 million by 2030 (1). The development of additional cost-effective ways to treat or improve coping with chronic disease is critically important.

The awareness and experience of spiritual feelings is common. Ninety percent of American adults believe in God and >82% of adults pray at least once a week (2). Many consider spirituality to be an important psychological aspect of overall well-being with the potential to influence mental and physical health. For example, Underwood and Teresi (3) note that positive emotional experiences and expectations have been linked with favorable effects on immune functioning, independent of the negative effects of stress.

Spiritually based strategies are commonly used to cope with health challenges. A 2004 survey of urban low-income patients presenting to a primary care clinic noted that prayer was the most frequently reported alternative medical practice (4). Community surveys have shown that women and African Americans report the highest rates of spirituality or religiosity (5). Indeed, 1 study of patients with depression found that African Americans were much more likely than whites to cite spirituality as an important element in the treatment of depression (6). Older African American women who reported more frequent daily spiritual experiences (DSE) used fewer long-term care services, even after controlling for the influence of social support (7). Older patients with rheumatoid arthritis (RA) who reported higher levels of spirituality also appeared to view their health more positively (8).

Spirituality also appears to be associated with better health outcomes (9, 10). A higher level of spirituality has been associated with less mortality from cardiac causes (11, 12), lower blood pressure (13), quicker recovery from depression (14, 15), and improved ability to cope with a serious illness such as cancer (16, 17). A community-based survey of people with musculoskeletal pain found that prayer was the most common unconventional treatment used by patients and was rated the second most helpful practice in controlling their pain (18). Despite this, little is known about the frequency of spiritual experiences in older adults with chronic health problems and the effect of these experiences on health outcomes.

We surveyed adults age >50 years with common chronic illnesses in a primary care setting. Our goals were to describe the prevalence and types of DSE and the relationships between DSE and sociodemographic factors, pain, self-rated health, and mood. We hypothesized that women, African Americans, and individuals with arthritis (the most common painful chronic condition in primary care practice) would report more frequent DSE and improved health perceptions, as well as less pain and depression.


  1. Top of page
  2. Abstract
  8. Acknowledgements

Johns Hopkins Community Physicians (JHCP) is a network model of 15 community-based, primary care offices in Baltimore City and Maryland. The JHCP serves ∼100,000 patients, 60% of whom have fee-for-service insurance and 40% who have capitated insurance. Approximately 22% of patients have insurance for retired military personnel and their dependents. This study was conducted at one of the largest primary care sites of the JHCP, which is located in Baltimore, Maryland, and was approved by the Institutional Review Boards of the Office of Human Subjects Research at the Johns Hopkins School of Medicine.

Eligibility included being ≥50 years of age, having ≥1 chronic medical condition, and answering affirmatively to the recruitment question, “Have you felt more nervous or stressed in the last month?” (We asked this question to select for a group of older patients who were currently experiencing some level of coping difficulties.) All participants were English speaking, judged by their clinician and/or the research assistant to have minimal or no hearing, visual, or mental impairment, and were not acutely ill.

Patients who appeared to meet eligibility criteria and had a scheduled appointment were sent a letter inviting them to participate. Notices about the study were also included in a health newsletter mailed to staff and retired military personnel and their dependents. The survey was completed either before or after the regular medical appointment. Participants received a $20 gift certificate after completing all study requirements.

Dependent measures.

A questionnaire that surveyed basic sociodemographic and health history was developed by the investigators. Other factors assessed are listed below.


The Daily Spiritual Experience Scale (DSES) (3) was used to assess spirituality. The DSES evaluates the frequency of specific, common experiences through which spiritual feelings and inner experiences occur in everyday life. Items were designed to capture DSE for ordinary people from a variety of religious and cultural groups. The scale measures key spiritual experiences, including feelings of connection and support from others, gratitude, compassion, guidance, and inner peace. To appeal to the broadest population, instructions state, “A number of items use the word ‘God.’ If you are uncomfortable with this, please substitute the name you use for the Divine or the Holy for you.”

The DSES includes 16 items, 15 of which are scored on a 6-point Likert scale (where 1 = many times a day and 6 = never or almost never). The scale has adequate internal consistency (Cronbach's α = 0.94) and construct validity (3). Scores range from 18–85, with lower scores reflecting more frequent DSE.

Two additional questions on spirituality were included in the survey. These questions were for frequency analysis only and were not included in the DSES multivariate analysis. These questions queried the extent to which patients “Trusted or relied on God” and “Accepted help from God and others to deal with something.” Items were scored on a 6-point Likert scale, with lower numbers reflecting greater trust or reliance.

Energy and fatigue.

Energy and fatigue were assessed using a measure adapted for use with individuals with chronic diseases from the vitality domain of the Medical Outcomes Study Short Form 36 (19). This measure has been demonstrated to have adequate internal consistency (r = 0.89) and test–retest reliability (r = 0.85) (19). The scale consists of 5 items that assess 2 dimensions (energy and fatigue) and are scored from 0–5. Higher energy scores reflect feelings of having adequate energy; higher scores on the fatigue subscale reflect feeling less worn out or tired (19).


Pain was assessed using an 11-point visual numeric (Likert) scale (where 0 = none and 10 = severe) developed by the Stanford Patient Education Research Center. Test–test reliability (r = 0.91) and internal consistency (r = 0.88) have been shown to be high (19).


Depressive symptoms were assessed using the Patient Health Questionnaire-Mood, a 9-item self-administered questionnaire that has been demonstrated to be a reliable (Cronbach's α = 0.86–0.89) and valid (sensitivity and specificity = 88%) indicator of depressive symptom severity in primary care settings (20, 21). Scores from 0–4 reflect minimal or no depression, 5–9 are indicative of mild symptoms, 10–14 reflect moderate depression, and ≥15 indicate moderate to severe depression.

Health perceptions.

Self-perceptions of health were assessed using a question from the National Health Interview Survey (“In general, would you say your health is …”) (22). Self-rated health has been demonstrated to be an excellent predictor of future health and this question has been shown to have high reliability (r = 0.92) (19). Scores range from 1 = excellent to 5 = poor.

Statistical analysis.

Descriptive statistics including means and proportions were calculated for variables of interest. Differences between men and women as well as those with and without arthritis were evaluated using t-tests and chi-square analyses. Pearson's product-moment correlation coefficient and Spearman's correlation were used to test associations among variables. Multiple regression models were used to assess the independent relationship between spirituality and outcomes of interest (general health, energy, fatigue, and depression), while controlling for the effects of age, race, sex, and number of comorbid conditions. Statistical analyses were performed using SPSS software, version 14 (SPSS, Chicago, IL).


  1. Top of page
  2. Abstract
  8. Acknowledgements

Of the 110 patients who were approached to participate, 99 completed this survey. Among those who declined, 2 had an acute illness and were therefore ineligible, 4 disliked the mandatory Institutional Review Board consent form clause describing confidentiality limitations, 1 was “too busy,” 1 did not like the spirituality focus, and 3 offered no reason.

As shown in Table 1, the subjects were primarily women (62%), married or living with a partner (64% of men, 58% of women), and had a mean ± SD age of 65.8 ± 9.6 years. Approximately 50% were African American, and the most common comorbid conditions in the sample were hypertension (74%), arthritis (54%), and heart disease (of any kind) (27%).

Table 1. Baseline characteristics of participants by sex*
 Men (n = 38)Women (n = 61)P
  • *

    Values are the percentage unless otherwise indicated.

  • Lower scores reflect more frequent spiritual experiences.

Age, mean ± SD years67.76 ± 8.0864.46 ± 10.090.096
Race  0.200
 African American42.159.0 
 American Indian5.31.6 
Work status  0.013
Marital status  0.859
 Married/living with partner63.856 
Education  0.958
 High school49.949.3 
 Graduate school15.811.5 
No. of comorbid conditions, mean ± SD2.92 ± 1.403.16 ± 1.680.458
Daily spiritual experiences, mean ± SD   
 All (n = 99)45.8 ± 17.537.3 ± 15.00.012
 White (n = 44)52.2 ± 19.140.5 ± 16.70.013
 African American (n = 53)38.1 ± 11.535.9 ± 13.60.253


On average, participants reported frequent DSE. The mean ± SD DSES score was 40.6 ± 16.5 (range 18–85). As shown in Table 1, on average, women reported more DSE than men (mean ± SD 37.3 ± 15.0 versus 45.8 ± 17.5; P = 0.012), with lower DSES scores associated with more DSE. African American women reported the most frequent DSE (mean ± SD 35.9 ± 13.6) and white men reported the fewest (mean ± SD 52.2 ± 19.1). DSES scores were not associated with age, education, or employment status. Higher numbers of comorbid conditions were associated with lower DSES scores (i.e., more frequent DSE; r = −0.295, P = 0.003).

The type and frequency of spiritual experiences are listed in Table 2. Themes that were endorsed by ≥80% of individuals included gratitude, appreciation, closeness, acceptance, and finding strength and comfort from spiritual sources most days to many times a day.

Table 2. Type and frequency of spiritual experiences reported by all participants (n = 99)*
 Most days to many times a day, %
  • *

    The survey directions stated, “A number of items use the word ‘God.’ If you are uncomfortable with this, please substitute the name you use for the divine or the holy for you.”

  • All questions except these are part of the Daily Spiritual Experiences Scale.

Thankful for blessings95.9
Touched by the beauty of creation88.8
Desire to be closer to God or in union81.6
Accept others, even when they do things that are wrong80.6
Find strength in religion/spirituality79.6
Find comfort in religion/spirituality79.6
Trust or rely on God to get through something79.6
Accept help from God or others to deal with something79.6
Feel God's love directly79.6
Experience a connection to all of life77.6
Feel “very close” or “as close as possible” to God76.5
Ask for God's help76.5
Feel God's presence74.5
Experience joy when connecting that lifts me out of daily concerns74.5
Feel God's love through others74.5
Feel a selfless caring for others74.5
Experience deep inner peace or harmony72.4
Feel guided by God69.4

DSE and health.

Next, we evaluated the relationship between DSE and specific aspects of health. In bivariate analyses, a higher pain score was modestly associated with lower DSES scores (more frequent DSE; ρ = −0.241, P < 0.016). Lower DSES scores (more frequent DSE) were associated with lower depression scores (ρ = 0.282, P < 0.007), but were not reliably associated with energy, fatigue, or health perceptions.

DSE scores were not reliably associated with any chronic illnesses except arthritis. Patients with arthritis reported significantly lower DSE scores (reflecting more frequent DSE) than patients without arthritis (mean ± SD 35.2 ± 12.1 versus 47.1 ± 18.6; P < 0.001). Because of the differences in total DSE scores between patients with and without arthritis, we performed further analysis on these 2 groups.

DSE and arthritis.

As compared with patients without arthritis, those with arthritis were older (mean ± SD 63.4 ± 9.4 versus 67.7 ± 9.5 years; P = 0.027) and reported more comorbid conditions (mean ± SD 2.3 ± 1.3 versus 3.9 ± 1.5; P < 0.001). However, there were no significant differences in sex, race, education, or employment status between the 2 groups (data not shown).

There were no differences in religious affiliations or frequency of attendance at religious services by arthritis status (Table 3). Compared with those without arthritis, patients with arthritis were significantly more likely to report finding strength and comfort in their religion/spirituality (P = 0.016) and to trust or rely on (P = 0.005), accept help from (P = 0.001), and feel close to their spiritual source (P = 0.018).

Table 3. Selected spiritual and religious characteristics of patients by arthritis status
No, % (n = 43)Yes, % (n = 54)
Religious affiliation  0.469
 Not affiliated4.41.9 
Frequency of attending religious services  0.360
 Several times per week or daily26.623.1 
 Several times per month35.642.3 
 Several times per year15.621.2 
 Once per year6.7 
 Rarely or never15.613.5 
Feel close to God  0.018
 As close as possible17.828.3 
 Very much44.460.4 
 Not at all2.21.9 
Find strength in my religion or spirituality  0.016
 Every day53.381.1 
 Most days11.111.3 
 Some days15.63.8 
 Once in a while11.11.9 
 Never/almost never8.91.9 
Find comfort in my religion or spirituality  0.015
 Every day51.177.4 
 Most days13.315.1 
 Some days15.63.8 
 Once in a while15.61.9 
 Never/almost never4.41.9 
Trust God/rely on God to get through  0.005
 Every day51.186.8 
 Most days15.63.8 
 Some days15.63.8 
 Once in a while6.71.9 
 Never/almost never11.13.8 
Accept help from God and others to get through  0.001
 Every day42.286.8 
 Most days24.43.8 
 Some days28.95.7 
 Once in a while4.4 
 Never/almost never3.8 

Patients with arthritis reported significantly higher levels of pain compared with those without arthritis (mean ± SD 5.5 ± 2.7 versus 2.6 ± 2.5; P < 0.001). No significant differences in mood or health perceptions were observed between patients with and without arthritis in bivariate analyses (data not shown). However, as shown in Table 4, after adjustment for age, race, sex, pain, and comorbid conditions, DSE were modestly associated with having more energy and less depression.

Table 4. Unadjusted and adjusted associations between Daily Spiritual Experiences Scale score and selected variables in arthritis patients (n = 54)
  • *

    Adjusted for age, race, sex, pain, and number of comorbid conditions.

  • In the past 2 weeks, using an 11-point Likert scale (0 = no pain, 10 = severe pain).

No. of comorbid conditions0.2950.003  
Depressive symptoms0.1670.1020.2820.007


  1. Top of page
  2. Abstract
  8. Acknowledgements

The primary findings of this study are that older adults with chronic health challenges report frequent DSE. Approximately 80% of participants reported having many spiritual experiences most days to many times each day. Similar to the findings of other studies (5, 6), we found that DSE were more frequent among African Americans, especially African American women, and least frequent among white men. The most common types of DSE that patients reported included themes of acceptance, gratitude, and finding comfort and strength from their spiritual source.

Another important finding of this study was that DSE are especially common among people living with arthritis. More than 50% of the individuals in this study reported having arthritis and reported significantly more frequent DSE than those with other chronic illnesses. One reason for this may be that arthritis is an illness that is characterized by pain, whereas other chronic conditions such as hypertension or diabetes are more silent in presentation. Other studies of patients with arthritis have suggested that spirituality may be an important coping mechanism. In a study of 35 patients with RA, Keefe et al (23) found that patients who reported more frequent DSE also had higher levels of positive effects. Bartlett et al (8) also found that patients with RA with higher levels of spirituality reported more positive effects and enhanced self-ratings of health, even after controlling for disease activity, functional status, depression, and age. Studies of African Americans with sickle cell disease, another disease characterized by pain, have noted that religion/spirituality played a significant role in both coping with and modulating the experience of pain (24, 25). Results from the current study suggest that more frequent spiritual experiences are also associated with fewer depressive symptoms and higher levels of energy.

How might DSE help patients? Perhaps DSE serve as an inner resource and means to actively cope with pain. Approximately 80% of patients with arthritis in this study reported turning directly to their religion/spirituality every day for comfort and strength. Other studies have also found that anywhere from 38–92% of individuals with arthritis reported using prayer to cope with their arthritis (26–28). Finally, spirituality may increase the ability to find meaning and purpose in living with a disease and increase self-esteem through the belief that a spiritual source created them and considers that individual to be unique and valuable. For many, spirituality also helps shape their perspective toward having gratitude, can provide social support through attendance at a church, temple, or mosque (29), and may foster a greater sense of connection to all.

This study extends findings of others, evaluating pathways through which spirituality may affect health. Studies evaluating the association between spirituality and health are often confounded by factors such as social support, bias (one must be relatively healthy to leave home for church), and positive health behaviors advocated by many religions. We chose to assess DSE of the individual rather than beliefs or behaviors, using a measure designed to be independent of any specific religion. Although for many religion (a system of worship and philosophy shared by a group) and spirituality are synonymous, a distinction can be made between religiosity and spirituality, which can be present in the absence of religious participation (3).

This study has limitations. Our data are cross-sectional, which does not allow us to infer causality. For example, more frequent DSE may reduce depressive symptoms; conversely, depression may negatively impact the frequency of DSE. DSE should not be viewed as a proxy for overall level of spirituality, but rather as a set of experiences that may play an important role for some. Our sample consisted mostly of individuals who were well-educated, married, and Christian, and may not be representative of older outpatients in other primary care settings.

How might clinicians use these findings to help their patients? Arthritis is the leading cause of disability in the US and in 1 study was the second most common diagnosis in older adults (30). In our study, >50% of the patients reported having arthritis. It is important to identify cost-effective solutions to help patients cope with the long-term pain of arthritis, especially with the increasing safety concerns of many nonsteroidal medications. This study and others have found that spirituality is an important and effective approach that many patients may use to cope with their pain.

Currently, studies suggest that few clinicians incorporate discussions about spirituality into their care of patients, while conversely many patients want spirituality considered in their health care options (31). In a study of 1,413 patients, 83% showed that they could name medical situations where a discussion of spirituality was important. The most important reason, listed by >80%, was a desire for more patient-physician understanding. Included in this understanding was discussing the influence of spiritual beliefs on dealing with sickness and the decision-making process (31).

Professional organizations such as the American College of Physicians and Surgeons endorse spiritual history taken as part of a comprehensive patient psychosocial evaluation (32). Spiritual practices vary in frequency and intensity over time for many individuals (23). Patients may indicate an interest in spirituality by wearing religious medals, being observed reading spiritual books, or by using certain words in conversation (i.e., blessed). Patients may also mention that spiritual experiences have helped them in the past. In these instances, clinicians might encourage interested patients to explore the potential therapeutic benefit of using spiritually based strategies to help with day-to-day coping of health challenges with their spiritual counselors.


  1. Top of page
  2. Abstract
  8. Acknowledgements

Dr. Bartlett had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study design. McCauley, Tarpley, Haaz, Bartlett.

Acquisition of data. McCauley, Tarpley, Bartlett.

Analysis and interpretation of data. McCauley, Haaz, Bartlett.

Manuscript preparation. McCauley, Tarpley, Haaz, Bartlett.

Statistical analysis. Haaz, Bartlett.


  1. Top of page
  2. Abstract
  8. Acknowledgements

The authors would like to thank Harold G. Koenig, MD for his substantive contributions on this project and Lynn Underwood, PhD for her help with the DSES.


  1. Top of page
  2. Abstract
  8. Acknowledgements
  • 1
    DeBusk RF, West JA, Miller NH, Taylor CB. Chronic disease management: treating the patient with disease(s) vs treating disease(s) in the patient. Arch Intern Med 1999; 159: 273942.
  • 2
    Matthews DA, McCullough ME, Larson DB, Koenig HG, Swyers JP, Milano MG. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998; 7: 11824.
  • 3
    Underwood LG, Teresi JA. The daily spiritual experience scale: development, theoretical description, reliability, exploratory factor analysis, and preliminary construct validity using health-related data. Ann Behav Med 2002; 24: 2233.
  • 4
    Rhee SM, Garg VK, Hershey CO. Use of complementary and alternative medicines by ambulatory patients. Arch Intern Med 2004; 164: 10049.
  • 5
    Levin JS, Taylor RJ, Chatters LM. Race and gender differences in religiosity among older adults: findings from four national surveys. J Gerontol 1994; 49: S13745.
  • 6
    Cooper LA, Brown C, Vu HT, Ford DE, Powe NR. How important is intrinsic spirituality in depression care? A comparison of white and African-American primary care patients. J Gen Intern Med 2001; 16: 6348.
  • 7
    Koenig HG, George LK, Titus P, Meador KG. Religion, spirituality, and acute care hospitalization and long-term care use by older patients. Arch Intern Med 2004; 164: 157985.
  • 8
    Bartlett SJ, Piedmont R, Bilderback A, Matsumoto AK, Bathon JM. Spirituality, well-being, and quality of life in persons with rheumatoid arthritis. Arthritis Rheum 2003; 49: 77883.
  • 9
    Ellison CG, Levin JS. The religion-health connection: evidence, theory, and future directions. Health Educ Behav 1998; 25: 70020.
  • 10
    Mueller PS, Plevak DJ, Rummans TA. Religious involvement, spirituality, and medicine: implications for clinical practice. Mayo Clin Proc 2001; 76: 122535.
  • 11
    Oxman TE, Freeman DH Jr, Manheimer ED. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995; 57: 515.
  • 12
    Goldbourt U, Yaari S, Medalie JH. Factors predictive of long-term coronary heart disease mortality among 10,059 male Israeli civil servants and municipal employees: a 23-year mortality follow-up in the Israeli Ischemic Heart Disease Study. Cardiology 1993; 82: 10021.
  • 13
    Koenig HG, George LK, Hays JC, Larson DB, Cohen HJ, Blazer DG. The relationship between religious activities and blood pressure in older adults. Int J Psychiatry Med 1998; 28: 189213.
  • 14
    Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry 1998; 155: 53642.
  • 15
    McCullough ME, Larson DB. Religion and depression: a review of the literature. Twin Res 1999; 2: 12636.
  • 16
    Riley BB, Perna R, Tate DG, Forchheimer M, Anderson C, Luera G. Types of spiritual well-being among persons with chronic illness: their relation to various forms of quality of life. Arch Phys Med Rehabil 1998; 79: 25864.
  • 17
    Cotton SP, Levine EG, Fitzpatrick CM, Dold KH, Targ E. Exploring the relationships among spiritual well-being, quality of life, and psychological adjustment in women with breast cancer [published erratum appears in Psychooncology 2000;9:89]. Psychooncology 1999; 8: 42938.
  • 18
    Cronan TA, Kaplan RM, Posner L, Blumberg E, Kozin F. Prevalence of the use of unconventional remedies for arthritis in a metropolitan community. Arthritis Rheum 1989; 32: 16047.
  • 19
    Lorig K, Stewart AL, Ritter P, Gonzalez V, Laurent D, Lynch J. Outcome measures for health education and other health care interventions. Thousand Oaks (CA): Sage; 1996.
  • 20
    Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA 1999; 282: 173744.
  • 21
    Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16: 60613.
  • 22
    US Bureau of the Census. National Health Interview Survey. Washington (DC): Department of Commerce; 2004.
  • 23
    Keefe FJ, Affleck G, Lefebvre J, Underwood L, Caldwell DS, Drew J, et al. Living with rheumatoid arthritis: the role of daily spirituality and daily religious and spiritual coping. J Pain 2001; 2: 10110.
  • 24
    Cooper-Effa M, Blount W, Kaslow N, Rothenberg R, Eckman J. Role of spirituality in patients with sickle cell disease. J Am Board Fam Pract 2001; 14: 11622.
  • 25
    Harrison MO, Edwards CL, Koenig HG, Bosworth HB, Decastro L, Wood M. Religiosity/spirituality and pain in patients with sickle cell disease. J Nerv Ment Dis 2005; 193: 2507.
  • 26
    Bill-Harvey D, Rippey RM, Abeles M, Pfeiffer CA. Methods used by urban, low-income minorities to care for their arthritis. Arthritis Care Res 1989; 2: 604.
  • 27
    Abraido-Lanza AF, Guier C, Revenson TA. Coping and social support resources among Latinas with arthritis. Arthritis Care Res 1996; 9: 5018.
  • 28
    Arcury TA, Bernard SL, Jordan JM, Cook HL. Gender and ethnic differences in alternative and conventional arthritis remedy use among community-dwelling rural adults with arthritis. Arthritis Care Res 1996; 9: 38490.
  • 29
    Hill PC, Pargament KI. Advances in the conceptualization and measurement of religion and spirituality: implications for physical and mental health research. Am Psychol 2003; 58: 6474.
  • 30
    Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis 2001; 60: 917.
  • 31
    McCord G, Gilchrist VJ, Grossman SD, King BD, McCormick KF, Oprandi AM, et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med 2004; 2: 35661.
  • 32
    Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med 2000; 132: 57883.