Efficacy-mediated effects of spirituality and physical activity on quality of life: A path analysis
© Konopack and McAuley; licensee BioMed Central Ltd 2012
Received: 11 January 2012
Accepted: 29 May 2012
Published: 29 May 2012
Physical activity has been established as an important determinant of quality of life, particularly among older adults. Previous research has suggested that physical activity’s influence on quality of life perceptions is mediated by changes in self-efficacy and health status. In the same vein, spirituality may be a salient quality of life determinant for many individuals.
In the current study, we used path analysis to test a model in which physical activity, spirituality, and social support were hypothesized to influence global quality of life in paths mediated by self-efficacy and health status. Cross-sectional data were collected from a sample of 215 adults (male, n = 51; female, n = 164) over the age of 50 (M age = 66.55 years).
The analysis resulted in a model that provided acceptable fit to the data (χ 2 = 33.10, df = 16, p < .01; RMSEA = .07; SRMR = .05; CFI = .94).
These results support previous findings of an efficacy-mediated relationship between physical activity and quality of life, with the exception that self-efficacy in the current study was moderately associated with physical health status (.38) but not mental health status. Our results further suggest that spirituality may influence health and well-being via a similar, efficacy-mediated path, with strongest effects on mental health status. These results suggest that those who are more spiritual and physically active report greater quality of life, and the effects of these factors on quality of life may be partially mediated by perceptions of self-efficacy.
Self-reported quality of life has been positively associated with measures of spirituality, such as a perceived connection with the divine  and private religious practice . It has been suggested that spirituality may confer quality of life benefits independent of other factors , but most published work has focused on spirituality’s connection with specific health outcomes rather than with global measures of quality of life. Indeed, the literature is replete with studies linking spirituality to various health outcomes. For example, it has been reported that religious individuals have a lower risk for morbidity and mortality [4, 5] and tend to perceive themselves with less disability than do less religious individuals . However, despite these findings and a growing attention to spiritual matters in healthcare, relatively little has been published on likely explanatory mechanisms underlying such relationships.
Self-efficacy is a construct that has been suggested as a mediator of the relationship between spirituality and well-being. It has been speculated that spirituality may help some individuals to “gain a sense of control over their lives” . The possibility of mediation by self-efficacy or control constructs in general has long been supported, even if implicitly, in the literature [1, 8–10] and echoes the ideas of spiritual modeling and “partnered proxy agency” suggested by Bandura , yet empirical investigation of this hypothetical association is lacking. Efficacy-mediated models have been empirically tested and validated in another context, however.
Research published by McAuley, Konopack, Motl, Morris, Doerksen, and Rosengren  demonstrated support for a model in which self-efficacy mediated physical activity’s effects on quality of life. In their study, McAuley et al.  operationalized mental and physical health status as proximal indicators of global quality of life. They found that the direct relationship between physical activity and health status was rendered non-significant when self-efficacy was introduced into the model, thereby demonstrating mediation by self-efficacy. Subsequent research has found support for a similar efficacy-mediated model of the relationship between physical activity and quality of life . Thus, evidence exists to support self-efficacy as a reliable mediator of physical activity’s influence on quality of life.
When examining the relationship between spirituality and quality of life, others have positioned health status as a mediating variable . Although the authors cited others’ work with factors such as health behaviors and self-care agency in the context of their discussion of the spirituality-quality of life relationship, that study did not include specific measurement of these constructs. Thus, there is theoretical support in the literature for self-efficacy as a mediator of both physical activity’s and spirituality’s effects on quality of life, but this relationship has yet to be explicitly tested.
To address this question in the present study, we attempted to replicate the model of the physical activity and quality of life relationship first published by McAuley and colleagues , expanded here to examine self-efficacy as a mediator of the association between spirituality and quality of life. For both physical activity and spirituality, the influences on quality of life were hypothesized to operate through both self-efficacy and physical and mental health status.
Demographic data from the study sample
M (SD) or category
After signing an institutionally-approved informed consent form, participants completed the following measures:
Quality of life
Quality of life was assessed using the Satisfaction with Life Scale (SWLS) , a 5-item scale developed to assess global life satisfaction across various age groups. Each scale item is rated on a 7-point scale from strongly disagree (1) to strongly agree (7), with higher scores representing greater life satisfaction. This instrument has been used as a quality of life measure in a number of investigations involving physical activity and older adults [12, 17].
The 12-Item Short Form Survey (SF-12) , a shortened version of the Medical Outcomes Study SF-36 Health Survey , was developed out of a need for brevity in large-scale health studies that could not be met with the larger SF-36. In the current study, the Mental Health and Physical Health summary scores were used as measures of mental and physical health status, respectively.
Social support was measured using an abbreviated version the Social Provisions Scale , which assesses 6 different social provisions in accordance with previous work on the subject by Weiss : attachment (i.e., emotional support), social integration (i.e., existing social network), reassurance of worth reliable alliance (i.e., tangible aid), guidance, and opportunity for nurturance.
The Lifestyle Physical Activity Self-Efficacy Scale (LSE)  was designed to assess confidence in one’s ability to accumulate 30 minutes of physical activity on 5 or more days of the week for incremental one-month periods, from one month to six months. In the present study, the LSE was used as a measure of self-efficacy specific to physical activity.
The Self-Care Self-Efficacy Scale (SCSE)  assesses an individual’s confidence in his or her ability to cope with self-care challenges due to a situation such as illness. With the permission of the developer (Dr. Lev), the scale was modified for use in the current study by replacing language specific to illness with language referring to the aging process in general. The original measure has demonstrated evidence of validity in previous studies .
Physical activity data were collected using the Actigraph portable accelerometer (Actigraph, LLC, Pensacola, FL). The Actigraph accelerometer has been shown to provide valid assessments of physical activity level in adult men and women during treadmill walking, running and daily activity [24, 25]. Previous work has demonstrated that the Actigraph accelerometer accurately predicts energy expenditure and demonstrates superior reliability when compared with other accelerometers [26, 27]. Actigraph data in the present study are reported as the total number of activity counts per day, averaged across a three-day period.
Spirituality and religiousness
Measurement of spirituality and religiousness in the current study was accomplished using two items selected from the Overall Self-Ranking dimension of the Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS) , an instrument that showed evidence of reliability and validity when psychometrically evaluated in the 1998 General Social Survey . In the current investigation, participants indicated the extent to which they considered themselves “spiritual” or “religious” by selecting a response along a 4-point Likert-type scale for each of the following questions: “To what extent do you consider yourself a religious person?” and “To what extent do you consider yourself a spiritual person?”
A model in which spirituality, social support, and physical activity influenced hierarchical quality of life in a parallel fashion was specified in a path analysis using Mplus version 3.21 covariance modeling software . Model-to-data fit in the current study was evaluated using the chi-square test  and root mean square error of approximation (RMSEA)  statistics in combination with the comparative fit index (CFI) and standardized root mean square residual (SRMR), which are accepted indicators of model-data fit [30, 33]. The strength of relationships between study variables was estimated using standardized path coefficients.
Mediation by self-efficacy
Physical activity, social support, and spirituality each accounted for significant variance in associated self-efficacy constructs, with standardized path coefficients (βs) of .34, .48, and .16, respectively. These efficacy constructs, in turn, accounted for significant variance in mental and physical health status, confirming initial study hypotheses. These results were similar to those observed by McAuley and colleagues , with the exception that physical activity self-efficacy was moderately associated with physical health status (β = .38) but not mental health status (β = .10).
The efficacy-mediated influence of spirituality was observed to be stronger for mental health status (β = .42) than for physical health status (β = .18). Thus, more spiritual individuals reported greater self-care self-efficacy, which, in turn, was associated with more positive health status. This association was stronger with mental health status than with physical health status. In addition to its effects on self-efficacy, social support was observed to maintain a statistically significant direct relationship with global quality of life (standardized path coefficient = β = 44), indicating the quality of life benefits derived from social provisions, above and beyond the effects of physical activity and spirituality.
The results of this study provide further support for previously proposed efficacy-mediated models of physical activity and quality of life [12, 13]. More importantly, the results reported here provide initial evidence for the extension of McAuley et al.’s  hierarchical, social cognitive model to understanding the association between spirituality and quality of life. Specifically, our data suggest that spirituality may exert an influence on health and well-being in a path that, like physical activity, is mediated by self-efficacy.
In our best-fitting model, spirituality exhibited a stronger connection with mental health status than with physical health status. These results are similar to the findings of Sawatzky and colleagues , who, in their study of spirituality among adolescents, also found mental health status to mediate the association between spirituality and quality of life. Our data suggest that spirituality’s influence on quality of life operates largely through mental health status, and physical activity’s influence on quality of life is chiefly through physical health status. Although previous research has certainly supported physical activity as a mental health determinant, there is also evidence for spirituality as a determinant of physical health above and beyond the influence of psychosocial factors . Indeed, recent evidence supports our findings that physical activity’s effects on physical health status are stronger than on mental health status, and that global quality of life is more strongly influenced by mental health status . Thus, our results suggest that physical activity and spirituality are complementary determinants of quality of life, with their strongest influences on physical and mental health status, respectively.
We also observed a direct path between the provision of social support and perceptions of global quality of life that was significant above and beyond the effects on self-efficacy (β = .44), as shown in Figure 1. Others have similarly found social support to be an important variable to consider when examining the extent to which spirituality influences health outcomes. For example, an investigation of quality of life among Korean and Korean American breast cancer survivors resulted in social support for the mediating influence of spirituality, but only for Korean Americans . At present, it appears that some of the quality of life benefits derived from spirituality are due to increases in social support, yet the manner in which social support operates in a hierarchical model of quality of life may differ across populations. Certainly, social support remains an important determinant of quality of life , and future research in this area is warranted.
Programs and services designed to improve quality of life among older adults are needed as the population in the United States continues to face increasing age-related challenges to health and functioning. Targeting a modifiable construct like self-efficacy may help, in this respect . The results of the current study provide additional support for the mediating role of self-efficacy perceptions in the determination of health status and global quality of life. Our data tentatively suggest that programs designed to promote physical activity and feelings of spirituality – but not necessarily religiousness – will likely have a greater impact if they also target self-efficacy.
Mean, standard deviation, and range of observed variables
White (n = 194)
Minority (n = 24)
Satisfaction with Life
Average accelerometer counts per day
Although the path analysis reported here corroborated and extended existing research, the data were cross-sectional, thereby limiting the extent of our ability to draw causal inferences. One final question that remains is that of which efficacy measure to use. It is clear from the results in this study that religiosity was not related to self-care self-efficacy. Yet, in the religiosity literature, control constructs are repeatedly suggested to mediate the beneficial aspects of religiosity on health and well-being outcomes. If, as Bandura  suggested, this can be explained by “partnered proxy efficacy,” the question becomes: Self-efficacy with respect to what, if not self-care? The challenge remains to precisely determine which control constructs are driving the effects of spirituality on well-being.
The data presented here provide support for a hypothetical model in which self-efficacy mediates the relationship between physical activity and quality of life. Moreover, evidence was also provided for a similarly structured, efficacy-mediated path between spirituality and quality of life. Thus, it appears that control constructs such as self-efficacy account for some portion of the quality of life benefits derived from both spirituality and physical activity. Further investigation of these relationships, particularly the influence of spirituality on health and quality of life outcomes, is needed.
Funding for this study was provided by National Institute of Mental Health Pre-Doctoral Fellowship #1F31MH076460-01. Edward McAuley is supported by a Shahid and Ann Carlson Khan Professorship in Applied Health Science and a grant from the National Institute on Aging (5R01 AG20118).
- Pollner M: Divine relations, social relations, and well-being. J Heal Soc Behav 1989, 30: 92–104. 10.2307/2136915View ArticleGoogle Scholar
- Diener E, Clifton D: Life satisfaction and religiosity in broad probability samples. Psychol Inq 2002, 13: 206–209.Google Scholar
- Pargament KI: Is religion nothing but …? Explaining religion versus explaining religion away. Psychol Inq 2002, 13: 239–244. 10.1207/S15327965PLI1303_06View ArticleGoogle Scholar
- Hill TD, Angel JL, Ellison CG, Angel RJ: Religious attendance and mortality: An 8-year follow-up of older Mexican Americans. Journals of Gerontology B: Psychological Sciences and Social Sciences 2005, 60: S102-S109. 10.1093/geronb/60.2.S102View ArticlePubMedGoogle Scholar
- Koenig HG, McCullough M, Larson D: Handbook of religion and health. Oxford University Press, Oxford; 2001.View ArticleGoogle Scholar
- Idler EL: Religious involvement and the health of the elderly: Some hypotheses and an initial test. Social Forces 1987, 66: 226–238.View ArticleGoogle Scholar
- Siegel K, Schrimshaw EW: The perceived benefits of religious and spiritual coping among older adults living with HIV/AIDS. Journal for the Scientific Study of Religion 2002, 41: 91–102. 10.1111/1468-5906.00103View ArticleGoogle Scholar
- Levin JS: Religion and health: is there an association, is it valid, and is it causal? Social Science & Medicine 1994, 38: 1475–1482. 10.1016/0277-9536(94)90109-0View ArticleGoogle Scholar
- Mattis JS, Jagers RJ: A relational framework for the study of religiosity and spirituality in the lives of African Americans. Journal of Community Psychology 2001, 29: 519–539.View ArticleGoogle Scholar
- Strawbridge WJ, Shema SJ, Cohen RD, Kaplan GA: Religious attendance increases survival by improving and maintaining good health behaviors, mental health, and social relationships. Annals of Behavioral Medicine 2001, 23: 68–74. 10.1207/S15324796ABM2301_10View ArticlePubMedGoogle Scholar
- Bandura A: On the psychosocial impact and mechanisms of spiritual modeling. Int J Psychol Relig 2003, 13: 167–173. 10.1207/S15327582IJPR1303_02View ArticleGoogle Scholar
- McAuley E, Konopack JF, Motl RW, Morris KS, Doerksen SE, Rosengren K: Physical activity and quality of life in older adults: Influence of health status and self-efficacy. Annals of Behavioral Medicine 2006, 31: 99–103. 10.1207/s15324796abm3101_14View ArticlePubMedGoogle Scholar
- White SM, Wójcicki TR, McAuley E: Physical activity and quality of life in community dwelling older adults. Health and Quality of Life Outcomes 2009, 7: 10. 10.1186/1477-7525-7-10PubMed CentralView ArticlePubMedGoogle Scholar
- Sawatzky R, Gadermann A, Pescut B: An investigation of the relationships between spirituality, health status and quality of life in adolescents. Applied Research in Quality of Life 2009, 4: 5–22. 10.1007/s11482-009-9065-yView ArticleGoogle Scholar
- Pfeiffer E: A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975, 23: 433–441.View ArticlePubMedGoogle Scholar
- Diener E, Emmons RA, Larsen RJ, Griffin S: The Satisfaction with Life Scale. J Personal Assess 1985, 49: 71–75. 10.1207/s15327752jpa4901_13View ArticleGoogle Scholar
- Elavsky S, McAuley E, Motl RW, Konopack JF, Marquez DX, Jerome GJ, et al.: Physical activity enhances long-term quality of life in older adults: Efficacy, esteem, and affective influences. Annals of Behavioral Medicine 2005, 30: 138–145. 10.1207/s15324796abm3002_6View ArticlePubMedGoogle Scholar
- Ware JE, Kosinski M, Keller SD: The SF-36 Physical and Mental Health Summary Scales: A user's manual. Boston, MA. The Health Institute, New England Medical Center; 1994.Google Scholar
- Ware JE: The status of health assessment 1994. Annual Review of Public Health 1995, 16: 327–354. 10.1146/annurev.pu.16.050195.001551View ArticlePubMedGoogle Scholar
- Russell DR, Cutrona C: The provisions of social relationships and adaptation to stress. In In Advances in personal relationships. Edited by: Jones WH, Perlman D. JAI Press, Greenwich, CT; 1984:37–68.Google Scholar
- Weiss RS: The provisions of social relationships. Prentice Hall, Englewood Cliffs, NJ; 1974.Google Scholar
- McAuley E, Jerome GJ, Marquez DX, Elavsky S, Blissmer B: Exercise self-efficacy in older adults: Social, affective, and behavioral influences. Annals of Behavioral Medicine 2003, 25: 1–7. 10.1207/S15324796ABM2501_01View ArticlePubMedGoogle Scholar
- Lev EL, Owen SV: A measure of self-care self-efficacy. Res Nurs Heal 1996, 19: 421–429. 10.1002/(SICI)1098-240X(199610)19:5<421::AID-NUR6>3.0.CO;2-SView ArticleGoogle Scholar
- Melanson EL, Freedson PS: Validity of the Computer Science and Applications, Inc: CSA) activity monitor. Medicine & Science in Sports & Exercise 1995, 27: 934–940.View ArticleGoogle Scholar
- Sirard JR, Melanson EL, Li L, Freedson PS: Field evaluation of the Computer Science and Applications, Inc. physical activity monitor. Medicine & Science in Sports & Exercise 2000, 32: 695–700.View ArticleGoogle Scholar
- Welk GJ, Blair SN, Wood K, Jones S, Thompson RW: A comparative evaluation of three accelerometry-based physical activity monitors. Medicine & Science in Sports & Exercise 2000, 32(Suppl 9):489–497.View ArticleGoogle Scholar
- Welk GJ, Schaben JA, Morrow JRJ: Reliability of accelerometry-based activity monitors: A generalizability study. Medicine & Science in Sports & Exercise 2004, 36: 1637–1645.Google Scholar
- National Institute on Aging/Fetzer Workgroup: Multidimensional measurement of religiousness/spirituality for use in health research. John E. Fetzer Institute, Kalamazoo, MI; 1999.Google Scholar
- Idler EL, Musick MA, Ellison CG, George LK, Krause N, Ory MG, et al.: Measuring multiple dimensions of religion and spirituality for health research: Conceptual background and findings from the 1998 General Social Survey. Research on Aging 2003, 25: 327–365. 10.1177/0164027503025004001View ArticleGoogle Scholar
- Muthén LK, Muthén BO: Mplus. 321st edition. Muthén & Muthén, Los Angeles; 1998.Google Scholar
- Bollen KA: Structural equations with latent variables. Wiley-Interscience, New York; 1989.View ArticleGoogle Scholar
- Browne MW, Cudeck R: Alternative ways of assessing model fit. In In Testing structural equation models. Edited by: Bollen KA, Long JS. Sage Publications, Newbury Park, CA; 1993:136–162.Google Scholar
- Hu L, Bentler PM: Fit indices in covariance structure modeling: sensitivity to underparameterized model misspecification. Psychological Methods 1998, 3: 424–453.View ArticleGoogle Scholar
- Bentler PM, Bonett DG: Significance tests and goodness of fit in the analysis of covariance structures. Psychol Bull 1980, 88: 588–606.View ArticleGoogle Scholar
- Lawler-Row KA, Elliott J: The role of religious activity and spirituality in the health and well-being of older adults. J Heal Psychol 2010, 14: 43–52.View ArticleGoogle Scholar
- Sawatzky R, Ratner PA, Johnson JL, Kopec JA, Zumbo BD: Self-reported physical and mental health status and quality of life in adolescents: a latent variable mediation model. Health and Quality of Life Outcomes 2010, 8: 17. 10.1186/1477-7525-8-17PubMed CentralView ArticlePubMedGoogle Scholar
- Lim J, Yi J: The effects of religiosity, spirituality, and social support on quality of life: a comparison between Korean American and Korean breast and gynecologic cancer survivors. Oncology Nursing Forum 2009, 36: 699–708. 10.1188/09.ONF.699-708View ArticlePubMedGoogle Scholar
- Helgeson VS: Social support and quality of life. Quality of Life Research 2003, 12(Suppl 1):25–31.View ArticlePubMedGoogle Scholar
- Motl RW, McAuley E: Physical activity, disability, and quality of life in older adults. Physical Medicine and Rehabilitation Clinics of North America 2010, 21: 299–308. 10.1016/j.pmr.2009.12.006View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.