The distinct roles of spirituality and religiosity in physical
and mental health after collective trauma: a national longitudinal
study of responses to the 9/11 attacks
Daniel N. McIntosh•Michael J. Poulin•
Roxane Cohen Silver•E. Alison Holman
Received: May 28, 2010/Accepted: February 9, 2011
? Springer Science+Business Media, LLC 2011
of religiosity and spirituality but have rarely addressed
differences between these dimensions. The associations of
religiosity and spirituality with physical and mental health
were examined in a national sample (N = 890) after the
September 11, 2001 terrorist attacks (9/11). Health infor-
mation was collected before 9/11 and health, religiosity,
and spirituality were assessed longitudinally during six
waves of data collection over the next 3 years. Religiosity
(i.e., participation in religious social structures) predicted
higher positive affect (b = .12), fewer cognitive intrusions
(b = -.07), and lower odds of new onset mental (inci-
dencerate ratio [IRR] = .88)
(IRR = .94) ailments. Spirituality (i.e., subjective com-
mitment to spiritual or religious beliefs) predicted higher
positive affect (b = .09), lower odds of new onset infec-
tious ailments (IRR = 0.83), more intrusions (b = .10)
and a more rapid decline in intrusions over time (b =
-.10). Religiosity and spirituality independently predict
health after a collective trauma, controlling for pre-event
Researchers have identified health implications
status; theyare notinterchangeableindices
Mental health ? Post-traumatic stress ? Intrusions ?
Positive affect ? Terrorism
Religion ? Spirituality ? Physical health ?
Spirituality and religiosity have been positively associated
with physical and mental health (Koenig et al. 2001; Oman
and Thoresen 2005; Seybold and Hill 2001). Substantial
variability exists in findings across studies, however,
pointing to the importance of examining how different
aspects of religious experience relate to specific health
outcomes (Hackney and Sanders 2003). One recurring
question is whether spirituality and religiosity have distinct
associations with health (Seybold and Hill 2001).
Spirituality and religiosity are substantively related to
each other, as both are connected to the idea of the sacred
(i.e., things set apart from the ordinary, connected to the
divine; Pargament 1997; Pargament et al. 2005); nonethe-
less, useful distinctions can be drawn. Although definitions
vary, spirituality is typically aligned with subjective, per-
sonal beliefs, whereas religiosity is identified with tradi-
tional, institutionally related practices and behaviors (Hill
and Pargament 2003; Koenig 2009). Spirituality occurs
both within and separate from religious institutions (Hill
and Pargament 2003). To examine their separate associa-
tions with health, we focused on the commonly identified
differences between them; we define religiosity as partici-
pation in religious social structures and spirituality as the
subjective, individual, lived-out commitment to spiritual or
D. N. McIntosh (&)
Department of Psychology, University of Denver,
2155 S. Race St., Denver, CO 80208, USA
M. J. Poulin
Department of Psychology, University at Buffalo,
State University of New York, Buffalo, NY, USA
R. C. Silver
Departments of Psychology and Social Behavior and Medicine,
University of California, Irvine, CA, USA
E. A. Holman
Program in Nursing Science, University of California, Irvine,
J Behav Med
There is some evidence that spirituality and religiosity
associate with different outcomes. For example, among
bereaved parents, religious participation relates to greater
perceived social support and meaning, whereas importance
of religion relates to cognitive processing and finding
meaning (McIntosh et al. 1993; see also Jansen et al. 2010;
Markides et al. 1987). One way to study differences in the
roles of spirituality and religiosity in health is to examine
them in a group of people coping with a singular stressful
event. Examining outcomes after a negative event is
especially pertinent, as spirituality and religiosity may help
people manage such experiences, which in turn can influ-
ence health (e.g., Hackney and Sanders 2003; Koenig et al.
2001; McIntosh et al. 1993; Pargament 1997; Park 2005).
The present study used the context of the September 11,
2001 terrorist attacks against the United States (9/11) to
examine similarities and differences in how spirituality and
religiosity are related to physical and mental health in a
large national sample. Moreover, we used a longitudinal
design with pre-event health information. There is little
longitudinal research examining links between religiosity,
spirituality and health. This aspect of the present design
allowed investigation of changes in levels and relations of
variables, including new onset ailments, as the coping
process unfolds. By following respondents for 3 years after
a fixed, collective event that generated notable distress
nationwide (Silver et al. 2002), we were able to determine
whether spirituality and religiosity differentially predicted
physical and mental health over time.
Mental health and adjustment
Most studies find less depression and anxiety among reli-
gious individuals, though findings are mixed (Koenig et al.
2001), and differ depending on what aspect of religion is
assessed (Hackney and Sanders 2003; Shreve-Neiger
2004). Specific to coping, religion is related to greater
positive affect and less dysphoria following stressful events
(McIntosh et al. 1993; Pargament 1997; Park and Cohen
1993). These outcomes may result from individuals’
internalized religious beliefs: spirituality may provide an
interpretive framework that aids adjustment to an event
(McIntosh 1995). Adjustment to negative events may also
result from social aspects of religious involvement: reli-
gious service attendance increases exposure to social sup-
port, thus promoting well-being (Ellison and George 1994;
Koenig and Larson 2001). Because they may operate via
different mechanisms, spirituality and religiosity may
relate independently to positive affect, anxiety and
depression following a collective stressor.
Adjustment following a traumatic event is reflected in
more than affect, anxiety and depression. It also involves
attempts to cognitively process or make sense of the event
(Greenberg 1995; Tait and Silver 1989). Traumatic events
often lead to struggles to reconcile the experience of the
event with beliefs about the world (Janoff-Bulman 1992;
Park and Folkman 1997). This process can be manifest
through involuntary, intrusive thoughts of the event
(Horowitz 1997; Lepore et al. 1996; Silver et al. 1983).
Ongoing intrusions often indicate that the individual has
not been able to integrate the event successfully, and thus
may signal and cause continued distress (Silver et al. 1983;
Tait and Silver 1989). However, early processing may
allow people to successfully integrate the event, thus
facilitating adjustment (e.g., Davis et al. 1998; Lepore et al.
1996; McIntosh et al. 1993; Silver et al. 1983; Taylor
1983). Spirituality may provide schemata that help indi-
viduals more easily assimilate events into their worldviews,
facilitating shorter, more effective processing of traumatic
events (McIntosh 1995; Siegel et al. 2001). This would be
reflected by a more rapid decline in intrusions as the event
is integrated, a pattern suggested by prior research
(McIntosh et al. 1993). Religiosity may facilitate inter-
pretation and assimilation of traumatic events because
social interactions, especially in religious contexts (Ladd
and McIntosh 2008), can offer opportunities to interpret
traumatic events collaboratively (Lepore et al. 1996;
Pennebaker and Harber 1993; Tait and Silver 1989).
Spirituality and religiosity may affect physical health by
improving health behaviors, providing social resources, or
changing psychological responses, especially when dealing
with stress (Flannelly et al. 2004; Oman and Thoresen
2005). Spirituality is likely to affect health through psy-
chological processes, such as altering cognitive appraisals
of events (Newton and McIntosh 2009, 2010), decreasing a
need for control, or enhancing a sense of control (McIntosh
and Spilka 1990) or coherence (cf. George et al. 2002) that
may decrease stress, and thus improve health outcomes
(Koenig et al. 2001; Oman and Thoresen 2005). Religiosity
may provide social support via clergy, support groups, and
integration in a social network (George et al. 2002; Ladd
and McIntosh 2008). Because social support enhances
health (Cohen 2004; House et al. 1988; Krause 2006),
religiosity should predict better physical health outcomes.
Given the importance of stress to theorized mechanisms,
we examined ailments likely to be linked to the experience
of stress. Extreme stress, such as 9/11, can trigger a neu-
rohormonal cascade of events that may support coping in
the short run, but can threaten health if it does not abate
(McEwen 1998, 2008). This stress can impair immune
function, leading to higher incidence of infection (Kemeny
and Schedlowski 2007). To the extent that spirituality and
religiosity decrease stress, they should predict lower rates
J Behav Med
of infectious ailments after a stressful event (Koenig et al.
2001). Consistent with this, religious service attendance is
associated with enhanced immune function (Lutgendorf
et al. 2004). In addition, persistent exposure to cortisol and
other stress hormones may lead to negative effects on bone
density, can increase blood pressure, promote atheroscle-
rotic changes in arteries, and increase the risk of myocar-
dial infarction (Brown et al. 2004). Musculoskeletal
ailments have also been associated with another form of
allostatic load (hypothalamic–pituitary–adrenal or HPA
axis hyporesponsiveness), wherein low cortisol responses
to stress allow increased secretion of inflammatory cyto-
kines that promote autoimmune and other inflammatory
diseases, many of which can affect the musculoskeletal
system (Boscarino 2004; McEwen 1998). Based on these
physiologic mechanisms, any factors that reduce stress
should reduce cardiovascular and musculoskeletal ail-
ments. As spirituality and religiosity are hypothesized to
decrease stress, they should each lead to reduced cardio-
vascular and musculoskeletal ailments in the context of
extreme stress. However, the evidence is not conclusive.
Lower levels of religious service attendance have been
related to higher rates of death from circulatory disease
(e.g., Oman et al. 2002), but recent work indicates that
spirituality and religiosity do not relate to cardiovascular
morbidity and mortality (Feinstein et al. 2010; Schnall
et al. 2010). Little work has examined musculoskeletal
ailments and religious variables. Links between spiritual-
ity, religiosity, and these ailments may be most evident in
stressful contexts. This study examines these connections
in the context of a collective trauma.
The present study
We examined the association of spirituality and religiosity
with mental (anxiety and depression, positive affect, cog-
nitive intrusions) and physical (i.e., infectious disease,
cardiovascular ailments, musculoskeletal ailments) health
in the years following the 9/11 attacks, a collective trau-
matic experience (Schlenger et al. 2002; Silver et al. 2002),
and one for which religion was a common way of coping
(Ai et al. 2005; Schuster et al. 2001). We were able to
obtain health information collected before 9/11, and we
assessed physical and mental health, spirituality, and reli-
giosity longitudinally during six waves of data collection
over the next 3 years. By employing a longitudinal design,
an early assessment of response, pre-event data for some
key variables, and a large, nationally representative sam-
ple, this study also addressed methodological limitations
that have plagued research on stressful events in general
(cf. Silver et al. 2006) and on religion and health in par-
ticular (see Flannelly et al. 2004; Oman and Thoreson
2005, for reviews). We hypothesized that across the 3 years
following 9/11, spirituality and religiosity would indepen-
dently predict more positive affect and less anxiety and
depression, higher initial levels and faster rate of decline of
cognitive intrusions, and lower incidence of infectious,
cardiovascular, and musculoskeletal ailments.
Participants and procedure
Data were collected through Internet-based surveys of a
large, nationally representative sample recruited following
9/11 (Silver et al. 2002; 2006) in collaboration with
Knowledge Networks Inc. (KN). KN is a survey research
organization that maintains a Web-enabled research panel
of potential respondents recruited using stratified random-
digit-dial telephone sampling. Panel members participate
in brief surveys 3–4 times a month and are compensated
with Internet access (if needed), points used to obtain
merchandise, and cash incentives for certain surveys. For
this study, participants earned the equivalent of approxi-
mately $10 per survey. KN maintains the anonymity of
panel participants. Members may leave the panel at any
time, and receipt of the Web TV and Internet access is not
contingent upon completion of any specific survey. Data
indicate that the KN panel does not respond significantly
differently over time to surveys than more ‘‘naı ¨ve’’ survey
respondents (Dennis 2001). Informed consent was obtained
for all participants, and procedures were approved by the
University of Denver and University of California, Irvine
Institutional Review Boards.
Data used in the present study were collected at several
time points (see below).1At each wave, panel members
were notified that a survey was available in their password-
protected email accounts. Surveys were confidential,
self-administered and accessible any time of day for a des-
ignated 3–4 week period. Completion times were approxi-
mately 30–45 min for each survey.
Pre-9/11 health survey
Between June 2000 and September 9, 2001, 45,938 adult
KN panelists completed an online health survey, modified
from the Centers for Disease Control’s National Center for
Health Statistics annual National Health Interview Survey
1A larger sample of the KN panel was also asked questions by
Knowledge Networks about their coping strategies and acute stress
response to the attacks approximately 9–14 days after 9/11 (see Silver
et al. 2002). Since these variables have been examined earlier and
were not of interest to the present set of analyses, we excluded that
prior wave of data collection for simplicity, and focus on the
restricted sample described herein.
J Behav Med
(U.S. Department of Health and Human Services 2000).
Respondents were asked ‘‘Has a medical doctor ever diag-
nosed you as suffering from any of the following ailments?’’
with prompts for 35 physical and mental health ailments.
Responses to this survey closely tracked prevalence esti-
mates from the 2000 National Health Interview Survey
(Baker et al. 2003). Items from this survey provided the
baseline assessments for our respondents (see below).
Assessment of psychological variables
In November and December of 2001, approximately
1,643 adults from the KN panel; 1,382 completed it (84%
participation rate). This sample consisted of a random sub-
sample of the national KN sample (n = 933), as well as an
oversample of respondents from cities that had experienced
recentcommunitytraumas(n = 449)(seeSilveretal.2006).
In March and April of 2002 (Wave 2), and again in
re-surveyed. A total of 1,141 (90% participation rate) com-
pleted Wave 2and 1,098 (79% participationrate)completed
Wave 3. Three more surveys were administered to this
subsample in March and April of 2003 (Wave 4, N = 667,
79% participation rate), September and October of 2003
(Wave 5, N = 639, 76% participation rate), and September
to November of 2004 (Wave 6, N = 695, 84% participation
rate; approximately 50% of the Wave 1 sample).
Post 9/11 health surveys
Annual health surveys, patterned after the pre-9/11 health
assessment, were administered. The first was fielded
October-December, 2002 (N = 711, 77% participation
rate), the second October, 2003-March, 2004 (N = 646,
70% participation rate), and the final one during Septem-
ber–November, 2004 (N = 843, 81% participation rate).
Mental health status At each health survey, physician-
diagnosed Anxiety Disorder and Depression were used to
compute an index of physician-diagnosed mental health
ailments (0 = none, 1 = Anxiety Disorder or Depression,
2 = both).
intrusions were measured with other clusters of posttrau-
matic stress symptoms (numbing/avoidance and hyper-
arousal). These were assessed at Waves 1 and 2 using the
Impact of Events Scale-Revised (IES-R; Weiss and Marmar
1997). Internal consistencies at both waves for all subscales
were very good (as .84–.89). At Waves 3 through 6, 9/11-
related intrusions and other posttraumatic stress symptoms
were measured using the conceptually similar PTSD
Checklist (PCL; Blanchard et al. 1996) in order to make
assessments of posttraumatic stress more consistent with
DSM-IV criteria for probable posttraumatic stress disorder.
Internal consistencies for this measure were good at all
waves for all subscales (as .81 to .89); mean scores were
computed as an index of cognitive intrusions of the attacks.
Positive affect At each wave, participants reported the
frequency of experiencing eight different positive emotions
(affection, joy, love, happiness, contentment, caring, pride,
and fondness) within the past week (cf. Diener et al. 1995).
Internal consistency in this sample was excellent at all
waves (as[.91); the mean score was computed as an
index of positive affect.
Physical health status A physician used the International
Classification of Diseases Version 9 (ICD-9) standards
(World Health Organization 1999) to classify the 35 Health
Survey ailments into ICD-9 disease system categories.
Individual variables representing the total count of the
separate ICD-9-based categories of infectious (e.g., physi-
cian-diagnosed hepatitis or herpes), musculoskeletal (e.g.,
physician-diagnosed arthritis or back pain), and cardio-
vascular (e.g., physician-diagnosed hypertension or heart
problems) ailments were created.
Primary predictor variables: religiosity and spirituality
Religiosity As noted above, religiosity was defined as
participation in religious social structures. In this study, it
was operationalized as attendance at religious services. To
assess attendance before 9/11, respondents answered the
question, ‘‘Before the events of September 11th, how often
did you attend services or meetings of a spiritual or reli-
gious organization?’’ using a 5-point scale (1 = ‘‘Never,
3 = ‘‘Sometimes,’’ 5 = ‘‘All the time’’).
Spirituality Spirituality was defined as the subjective,
individual, lived-out commitment to spiritual or religious
beliefs. In this study, it was assessed using a modified two-
item Intrinsic subscale of the 9-item Religious Orientation
Scale (Gorsuch and McPherson 1989): ‘‘My whole
approach to life is shaped by my spiritual or religious be-
liefs’’ and ‘‘I try hard to live all my life according to my
religious or spiritual beliefs’’), assessed on a 5-point scale
ranging from 1 ‘‘strongly disagree’’ to 5 ‘‘strongly agree.’’
This scale exhibited excellent reliability (a = .83).
Demographics KN provided age, gender, marital status,
ethnicity, education, and household income. KN imputed
J Behav Med
missing values for income with mean income scores for
respondent’s census block.
9/11-related exposure At Wave 1, participants reported
their experiences related to the 9/11 attacks. Using this
information, we coded their 9/11 exposure on a scale from
0 to 2, where 0 represented indirect exposure following the
attacks (e.g. via non-live or print media), 1 represented
indirect exposure via live media coverage, and 2 repre-
sented being directly exposed to the attacks.
Stressful events Lifetime exposure to stressful events
was assessed at Wave 1 by asking participants whether
they had ever experienced each of 37 negative events (e.g.,
natural disaster, child abuse) and the age(s) at which they
occurred. From these data, an index of the total number of
stressful events individuals experienced was calculated.
Health risk factors and somatization Smoking and body
mass index (BMI) were assessed in the pre-9/11 health
survey as general risk factors for morbidity. At each wave
of health data collection, individual differences in reporting
physical symptoms were assessed in two ways. First, the
total number of physician-diagnosed physical health ail-
ments was computed. Second, respondents completed the
somatization subscale from the 18-item Brief Symptom
Inventory (BSI-18; Derogatis 2001). Reliability was
excellent for all assessments (all as[.80).
Analyses were conducted using Stata 9.0 (Stata Corp.
College Station, TX). Analyses of the associations of
religiosity and spirituality with mental and physical health
outcomes were done using multilevel regression models
(mixed effects or hierarchical linear models; Singer and
Willett 2003). Multilevel modeling provided an efficient
way to examine whether religiosity and spirituality would
predict outcomes across multiple waves without increasing
Type I error. It also allowed for the prediction of change in
cognitive intrusions in the form of the interaction between
time (months since 9/11) and spirituality and religiosity.
The construction of all multilevel models presented herein
involved screening two sets of control variables before
entering the variables for spirituality and religiosity. These
sets of control variables were demographic (age, gender,
ethnicity, education, income level) and trauma/mental
health history (pre-9/11 mental health, number of lifetime
stressful events, and exposure to the 9/11 attacks). In
addition, each model that examined a physical ailment
included that ailment assessed pre-9/11 in the first block,
new onset mental health ailments in the second block, and
a third block with physical health risk factors (smoking,
BMI) and somatization (total number of ailments reported,
BSI-somatization). Significant variables from each block
were retained for the final models.
Treatment of missing data
Following recruitment into the study, there was varying
attrition over time. This type of missing data is acceptable
in multilevel modeling, because individuals contribute to
estimation of the model at particular time points even if
they cannot do so at all time points (Singer and Willett
2003). Missing data on particular measures within a wave
were managed by listwise deletion of cases with missing
data on a given variable. This resulted in only small
reductions in ns, since each variable was missing data on
less than 2% of cases.
Sample demographics and characteristics
The initial sample (N = 1,382) was 71.1% White, 9.2%
African American, 10.8% Hispanic, and 8.3% other eth-
nicities (e.g., Asian American, Native American). Females
comprised 51.1% of the sample, and ages ranged from 18
to 101 (M = 48.1). Of the 1,196 respondents (86.5%) who
reported their religious identity, most respondents identi-
fied as Christian (70.7%), with 1.8% Jewish, 12.6%
‘‘other’’ (including 4 Muslims),2and 14.3% ‘‘none.’’ At
baseline, 15.2% of the sample reported a prior diagnosis of
anxiety or depression, 9.5% reported a prior doctor-diag-
nosed infectious ailment, 21.5% reported a prior doctor-
diagnosed cardiovascular ailment, and 34.8% reported a
prior doctor-diagnosed musculoskeletal ailment. During
the study, 1-year incidence for these ailment categories
averaged 14.5% for anxiety or depression, 10.0% for
infectious ailments, 27.8% for cardiac ailments, and 29.2%
for musculoskeletal ailments. Mean levels of religiosity
and spirituality, assessed on a 1–5 scale with 5 representing
highest levels, were 2.85 and 3.30, respectively. As
expected, religiosity and spirituality were highly corre-
lated, but not identical, constructs (r = .60).
Analysis of non-participants
Individuals who received but did not respond to the Wave 1
survey did not differ significantly from respondents in
terms of income, education, gender, marital status, or eth-
nicity. Respondents were, however, significantly older
(M = 48.1 years) than non-respondents (M = 40.0 years;
t (1,371) = 8.33, P\.001). Patterns of non-response after
2Given the generally representative nature of our sample, this sug-
gests that Muslims were greatly underrepresented. However, because
our surveys were conducted in the context of the 9/11 attacks, it is
possible that a larger number of our participants were Muslim but did
not want to disclose their religious identities.
J Behav Med
Wave 1 were examined using Stata’s xtgee module
(a multilevel application that allows for binomial distribu-
tions), with participation at each wave (yes/no) as the time-
varying dependent variable. At each subsequent wave,
non-participants tended to be younger (M = 43.0 years)
than those who continued to participate (M = 50.4 years;
OR = 1.02, P\.001) and reported fewer lifetime negative
events on average (7.78) than did continuing participants
(8.76; OR = 1.02, P\.05), but there were no differences
on any key study variables.
Mental health and adjustment
Multilevel regressions, fit using Stata’s xtreg module,
examined associations of spirituality and religiosity with
mental ailments (anxiety and depression) and positive
affect over the 36 months following 9/11. As shown in
Table 1, both religiosity (b = .12, P\.001) and spiritu-
ality (b = .09, P\.01) predicted higher levels of positive
affect, and religiosity, but not spirituality, predicted lower
incidence of mental ailments (IRR = 0.88, P\.05).
An additional multilevel model tested the hypothesis that
religiosityand spirituality would predict both levels and rate
of decline of cognitive intrusions. To evaluate whether
religiosity and spirituality predicted change in intrusions
over time, we tested the interactions of religiosity and
spirituality with time. The religiosity X time interaction was
not significant, and was therefore dropped from the final
model, but religiosity did predict lower overall levels of
intrusions (b = -.07, P\.05; see Table 1). The spiritual-
ity X time interaction was significant (b = -.10, P\.01),
and recentering spirituality at 1 SD above and below its
mean revealed that, consistent with our predictions, the
decline in cognitive intrusions was greater at high (b =
-.20, P\.001) versus low (b = -.14, P\.001) levels of
spirituality (see Fig. 1); combining results, it can be seen
that spirituality is associated with higher levels of intrusions
at Wave 2 and more rapid declines over time.
To test the hypothesis that spirituality and religiosity would
predict decreased incidence of physical ailments, which
were count variables, multilevel Poisson regression models
were built using Stata’s xtpois module (to address over-
dispersion, negative binomial models were also examined
using Stata’s xtnbreg module; results were substantively
identical). Poisson regression models yield regression
coefficients that can be anti-logged and interpreted as
incidence rate ratios (IRRs). An IRR is the ratio by which
the predicted count of the outcome variable (e.g., number
of physical ailments) would change given a one-unit
increase in the predictor. IRRs of\1 indicate a relative
decrease in the outcome’s incidence while IRRs of[1
indicate a relative increase in the outcome’s incidence, and
IRRs = 1 indicate no association between the predictor
and the outcome. The final models, which included control
variables that significantly predicted incidence of ailment
categories in their respective screening blocks, are shown
in Table 2. Results indicated that spirituality, though not
religiosity, predicted decreased incidence of infectious
ailments (IRR = 0.83, P\.05). Conversely, religiosity
predicted decreased incidence of musculoskeletal ailments
(IRR = 0.94, P\.05), but spirituality did not. Neither
Table 1 Multilevel regression models for mental health (N = 890)
Variable New onset Mental AilmentsPositive Affect Cognitive Intrusions
IRR (95% CI)
B (95% CI)
B (95% CI)
Time (months post-9/11) 1.02 (1.01, 1.03)***-.002-0.000 (-0.001, 0.001)-.09**-0.005 (-0.008, -0.002)
Age.000 0.000 (-0.001, 0.003) .06**0.002 (0.001, 0.003)
Female gender1.87 (1.42, 2.46)*** .08** 0.11 (0.04, 0.17).11*** 0.12 (0.07, 0.17)
Hispanic ethnicity .06** 0.11 (0.03, 0.19)
Income .12*** 0.02 (0.01, 0.03)-.09***-0.01 (-0.02, -0.01)
Pre-9/11 mental ailments4.11 (3.46, 4.90)***-.15***-.21 (-0.27, -0.15).10***0.12 (0.07, 0.17)
Pre-9/11 stressful events1.01 (0.99, 1.03)
9/11 exposure.13*** 0.14 (0.09, 0.18)
Religiosity0.88 (0.79, 0.98)*.12*** 0.06 (0.03, 0.08)-.07*-0.03 (-0.06, -0.01)
Spirituality 1.04 (0.92, 1.17).09**0.05 (0.02, 0.08) .10** 0.05 (0.02, 0.07)
Spirituality X Time-.10**-0.002 (-0.003, -0.001)
IRR incidence rate ratio. N for new onset mental ailments was 785; for other models, it was 890. All models displayed significant fit (all
* P\.05 ** P\.01 *** P\.001
J Behav Med
spirituality nor religiosity was a significant predictor of the
incidence of cardiovascular ailments. Based on these
models, estimated adjusted incidence rates of infectious
and musculoskeletal ailments at high and low levels of
spirituality and religiosity are shown in Fig. 2.
This is one of the first large-scale, longitudinal studies to
examine how spirituality and religiosity independently
predict mental and physical health after a major traumatic
event. We addressed many methodological limitations of
prior research, including the need for pre-event measures of
health status, prompt assessment of outcomes post-event,
and multiple subsequent post-event assessments. The
association between spirituality, religiosity and health
outcomes were robust after controlling for confounding
factors (age, gender, ethnicity, education, marital status,
income, pre-9/11 health, smoking, BMI, stressful event
history, and 9/11 exposure). This significantly strengthens
the evidence for the influence of spirituality and religiosity
on health. In addition, by controlling for somatization, we
minimized the likelihood that our measures of physical
health ailments were confounded by respondents’ tendency
Religiosity was associated with more positive affect,
lower incidence of mental ailments, fewer cognitive intru-
sions, and decreased incidence of musculoskeletal ailments
during 3 years following 9/11. It was not associated with
infectious or cardiovascular ailments or a reduction in
cognitive intrusions across time. In contrast, spirituality was
associated with more positive affect, fewer infectious ail-
ments, higher levels of cognitive intrusions, and a steeper
decline in intrusions. It was not associated with mental,
musculoskeletal, or cardiovascular ailments. Finding that
spirituality and religiosity independently associate with
different outcomes, combined with studies also suggesting
they function separately (e.g., Jansen et al. 2010; Markides
et al. 1987; McIntosh et al. 1993), indicates that despite
their association spirituality and religiosity are distinct
phenomena. The influence of each on health and stress
processes needs to be examined individually.
Fig. 1 Change in cognitive intrusions over the 3 years post-9/11,
graphed by level of spirituality. For the graph, high and low values of
spirituality are one standard deviation above and below the sample
mean, respectively. The total range of the cognitive intrusions scale
was 1–5, but 85% of individuals in this sample scored between 1 and 2
Table 2 Multilevel poisson regression models for incidence of physical ailments (N = 785)
Variable Infectious IRR (95% CI) Cardiovascular IRR (95% CI)Musculoskeletal IRR (95% CI)
Time (months post-9/11)1.02 (1.00, 1.03)* 1.01 (1.00, 1.02)**1.06 (0.87, 1.76)***
Pre-9/11 infectious ailments4.91 (3.21, 7.53)***
Pre-9/11 cardiac ailments2.90 (2.52, 3.35)***
Pre-9/11 musculoskeletal ailments1.31 (1.05, 1.07)***
Age in years 1.03 (1.02, 1.03)*** 1.01 (1.21, 1.42)***
Female gender 0.95 (0.64, 1.42)1.14 (0.97, 1.33)
African American ethnicity1.24 (0.87, 1.76) 0.66 (0.45, 0.97)*
New onset mental ailments 1.23 (0.96, 1.58)0.98 (0.84, 1.15) 0.91 (0.81, 1.01)
Pre-9/11 stressful events 1.02 (0.99, 1.06)1.00 (0.99, 1.02)1.01 (0.99, 1.02)
Smoking1.43 (0.89, 2.30)
BMI 1.01 (0.99, 1.03)
Total past year physical diagnoses1.09 (1.06, 1.12)*** 1.16 (1.13, 1.18)***
Somatization 1.10 (0.76, 1.61)
Religiosity 1.05 (0.88, 1.25)1.04 (0.96, 1.13) 0.94 (0.88, 0.99)*
Spirituality 0.83 (0.69, 0.99)*0.99 (0.90, 1.09) 1.04 (0.97, 1.12)
IRR incidence rate ratio. All models displayed significant fit (all Ps\.001)
* P\.05 ** P\.01 *** P\.001
J Behav Med
Mental health and adjustment
Both religiosity and spirituality predicted greater positive
affect. As religious variables are consistently associated
with positive affect (Loewenthal et al. 2000), research
should focus on how they enhance positive emotions and
the effects of this.
Spirituality and religiosity differed in their relation to
cognitive intrusions of the attacks. Religiosity predicted
fewer intrusions over time, whereas spirituality predicted
both more intrusions and a more rapid decline across the
3 years. This pattern reinforces earlier work examining
religion and cognitive processing after a traumatic loss
(McIntosh et al. 1993). It further supports the interpretation
that high levels of spirituality may be related to amplified
processing of a traumatic event, and that such processing
leads to less need for processing with time. Why the dif-
ference between spirituality and religiosity? Perhaps peo-
ple high in spirituality are especially focused on beliefs or
have a greater need to integrate events into their belief
systems, regardless of their degree of religious participa-
tion. These individuals may engage in more thought about
disturbing events that facilitates more effective integration
of the events. Religiosity, reflecting greater social partici-
pation, may provide social pressure or resources that
decrease the need or ability to engage in as much cognitive
processing. Further work should examine potential differ-
ences in the motivation for meaning or understanding in
spirituality and religiosity, and consider differences in
health and coping outcomes.
Greater religiosity predicted fewer reports of physician-
diagnosed mental health ailments (anxiety, depression), but
there was no association with spirituality. One possibility is
that for these specific disorders, the social aspect of reli-
gion, perhaps via social integration or support, provides the
most protection. However, a meta-analysis suggested that
institutional religion (which included attendance) predicted
more distress (which included depression and anxiety), and
personal devotion (which included intrinsic religion) pre-
dicted less distress, with generally larger effects for per-
sonal devotion (Hackney and Sanders 2003). One question
for future research to address is whether the relation of
spirituality and religiosity to mental health outcomes
depends on whether they are measured in a stressful con-
text. Perhaps the social support from religion has a stress-
buffering, rather than a direct, effect on mental health.
Regarding physical health, neither spirituality nor religi-
osity predicted cardiovascular ailments. The absence of a
relation is similar to two recent studies (Feinstein et al.
2010; Schnall et al. 2010), and extends the null result to the
context of a collective trauma. The variability across
studies and the difficulty in finding an association suggest
that if there is any effect on cardiovascular ailments, it may
be specific to religious or spiritual variables not measured
in these studies, or that there is a moderating factor that
needs to be identified.
Religiosity, but not spirituality, predicted fewer mus-
culoskeletal ailments. This suggests that the social aspect
of religion is associated with fewer problems with these
ailments. Perhaps frequent social and physical activity
associated with religious service attendance is protective of
the development of musculoskeletal ailments. Although
reverse influence is also possible (those who have muscu-
loskeletal ailments may have difficulty attending services),
the fact that religiosity at Wave 1 predicted new onset
ailments presents a strong case that attendance is protec-
tive. Especially given the relative absence of other work
Fig. 2 Panel A Estimated incidence of new onset infectious ailments
in the 3 years post-9/11, adjusted for model variables (see Table 2)
and graphed by high and low levels of spirituality and religiosity.
Panel B Estimated incidence of new onset musculoskeletal ailments
in the 3 years post-9/11, adjusted for model variables (see Table 2)
and graphed by high and low levels of spirituality and religiosity. For
the graphs, high and low values of spirituality and religiosity are one
standard deviation above and below the sample mean, respectively
J Behav Med
exploring religiosity, spirituality, and diagnosis of muscu-
loskeletal ailments, future work should explore the con-
sistency, and then possible mechanisms, responsible for
Finally, spirituality, but not religiosity, predicted fewer
infectious ailments in the 3 years following 9/11. This is
consistent with work showing that religion predicts immune
system functioning beyond social support (Lutgendorf et al.
with fewer reported illnesses (McIntosh and Spilka 1990).
The specific relationship with spirituality suggests that
psychological resources such as control (McIntosh and
Spilka 1990), coherence and meaning (George et al. 2002;
Park 2005), and alterations in cognitive appraisal (Newton
and McIntosh 2009, 2010) may be particularly relevant in
decreasing stress-related immunosupressive outcomes.
Limitations and future directions
Several limitations of this study point to areas for future
research. First, there may be self-report biases related to
spirituality, religiosity, and the outcomes. However, the
pattern would need to be specific, as the association of
spirituality and religiosity varied by ailment, and somati-
zation was controlled; further, any bias in a specific ailment
would need to be altered by 9/11 or the passage of time, as
a consistent bias would be controlled by the baseline.
Additionally, our health measure had been benchmarked
against the National Health Interview Survey, which itself
has been validated against medical records (U.S. Depart-
ment of Health and Human Services 1994). Nonetheless,
self-report measures of physician-diagnosed ailments are
subject to recall biases and may reflect the respondents’
interpretations of their medical encounters. Without med-
ical record corroboration, we cannot assume that all indi-
viduals reporting physician-diagnosed ailments had true
disease, nor that all true disease was reported. Future
research should confirm self-reports using medical records.
A second set of limitations involve our measures of
religiosity and spirituality. Religiosity was assessed with
self-reported attendance at religious services. Participation
in a religious social structure may involve more than this
(e.g., study or prayer groups) and social integration and
interaction can vary within the same level of attendance.
Similarly, there are many definitions of spirituality. By
focusing solely on internalization, the content of beliefs,
for example, was omitted. Future work should incorporate
more complete measures of both constructs. However, we
share Koenig’s (2009) concern to avoid operationalizations
of spirituality that include components (e.g., existential
well-being, meaning) that may themselves be indicators of
good mental health. In both cases, measures of the content
of the beliefs, or the rituals and attitudes of the religious
social context, would be helpful; the association of religion
and well-being may differ across faith groups (Park et al.
1990), and people of different faiths appraise stressful
events differently (Newton and McIntosh 2009). Finally,
religiosity and spirituality were assessed post-9/11. Stron-
ger inferences can be made when investigating the role of
spirituality and religion in adjustment to stress if these are
measured before the onset of the stressor.
Third, we cannot rule out potential biases in our sample
due to attrition, and thus decreasing representativeness over
time. However, retention rates were relatively high, rang-
ing from 76 to 90% from wave to wave, and with
approximately 50% of the original sample retained after
3 years. In addition, our analyses of non-respondents at
each wave indicated that they differed from respondents
only by age and number of lifetime traumas, not by reli-
giosity, spirituality, nor any health outcome. Nonetheless,
we welcome future epidemiological research conducted
with even more rigorous panel methods.
Across 3 years, with numerous controls, religiosity and
spirituality were independently and differentially related to
mental and physical health. Both predicted positive affect,
and neither predicted cardiovascular ailments. Religiosity
alone predicted fewer mental health ailments and lower
levels of cognitive intrusions. Spirituality alone predicted
fewer infectious ailments, more cognitive intrusions and a
faster decline in intrusions. As these findings focused on
responses to a collective trauma, our outcomes are tied to
stress and coping processes. Other avenues through which
spirituality and religiosity may influence health may lead to
different patterns. Future work should compare their
influence on health across a variety of indicators and
contexts. The resulting patterns will illuminate processes
through which spirituality and religiosity together and
separately influence mental and physical health.
Foundation grants BCS-9910223, BCS-0211039, and BCS-0215937
to Roxane Cohen Silver. The authors would like to thank Virginia
Gil-Rivas and Judith Andersen for their assistance with the study
design and data collection, and the Knowledge Networks Govern-
ment, Academic, and Non-profit Research team of J. Michael Dennis,
William McCready, Kathy Dykeman, Rick Li, and Vicki Pineau for
providing access to data collected on KN panelists, for preparing the
Web-based versions of our surveys, for creating the data files, for
general guidance on their methodology, and for their survey research
and sampling expertise.
Project funding provided by National Science
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