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Vol. 42, No. 5, 2002

Rowe and Kahn’s Model of Successful Aging Revisited: Positive Spirituality—The Forgotten Factor

Martha R. Crowther, PhD, MPH,

Michael W. Parker, DSW,

W. A. Achenbaum, PhD,

Walter L. Larimore, MD,

and Harold G. Koenig, MD

Purpose:

We explain a new concept, positive spirituality, and offer evidence that links positive spirituality with health; describe effective partnerships between health professionals and religious communities; and summa- rize the information as a basis for strengthening the exist- ing successful aging model proposed by Rowe and Kahn.

Design and Methods:

A missing component to Rowe and Kahn’s three-factor model of successful aging is identified, and we propose strengthening the model with a fourth factor, positive spirituality.

Results:

We devel- oped an enhanced model of successful aging based on Rowe and Kahn’s theoretical framework. Evidence pre- sented suggests that the addition of spirituality to interven- tions focused on health promotion has been received positively by older adults.

Implications:

Leaders in ger- ontology often fail to incorporate the growing body of sci- entific evidence regarding health, aging, and spirituality into their conceptual models to promote successful aging. The proposed enhancement of Rowe and Kahn’s model will help health professionals, religious organizations, and governmental agencies work collaboratively to pro- mote wellness among older adults.

Key Words: Religion, Faith-based interventions,

Churches, Older adults

The spiritual dimension of older adults has not been integrated into promising intervention models that promote successful aging. The lack of interest in

issues of spirituality and aging may be analogous to the unwillingness of older people to act upon or com- ply with prescribed treatments. “As we find ways to improve the lives of older people and ameliorate the diseases which afflict them, we are also confronted by the reality that we are often unable to successfully uti- lize these discoveries” (Antonucci, 2000, p. 5).

As a means of consolidating knowledge and prac- tice, the MacArthur Foundation offered a promising set of studies on successful aging. In summarizing the findings, Rowe and Kahn’s (1998) model provided scientifically grounded parameters for understanding health across the life course and goals for construct- ing a framework for interventions. However, despite the advantages of their model, it does not incorporate research in the area of spirituality and health that would strengthen it as a framework for promoting successful aging interventions. This article has two aims. First, to assert that spirituality is an important component of health and well-being outcomes among older adults. Second, to argue for interventions which incorporate spirituality with underserved populations as a guide to health professionals, religious organiza- tions, and governmental agencies.

Clarifying Concepts

Part of the problem with incorporating spirituality into scientific thinking has been the confusion associ- ated with the terms

religion

and

spirituality

(Krause, 1993). When descriptive adjectives like

intrinsic

extrinsic

are added, the problem is compounded. Re- ligious variables in early research were typically lim- ited to declarations of nominal religious affiliation or were totally excluded from consideration (Larson, Pattison, Blazer, Omran, & Kaplan, 1986). There is a need to define and distinguish spirituality and religion so that research can proceed with greater clarity and consistency. In support of this clarification, we use definitions offered by Koenig and colleagues (Koenig, McCullough, & Larson, 2000), and we define a new term—

positive spirituality

. The distinctions between

Although the views expressed in this article are the exclusive opinions of its authors, we gratefully acknowledge the assistance of The John A. Hartford Foundation’s Geriatric Social Work Faculty Scholars Program.

Address correspondence to Martha R. Crowther, PhD, MPH, The Uni- versity of Alabama, Department of Psychology, Box 870348, Tuscaloosa, AL 35487-0348. E-mail: [email protected]

Department of Psychology, The University of Alabama, Tuscaloosa.

Department of Social Work, The University of Alabama, Tuscaloosa.

College of Humanities, Fine Arts and Communication, The University of Houston, TX.

Focus on the Family, Colorado Springs, CO.

Duke University Medical Center, and GRECC, VA Medical Center, Durham, NC.

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614 The Gerontologist

religion, spirituality, and positive spirituality are de- scribed below and in Table 1.

Religion.—

“Religion is an organized system of be- liefs, practices, rituals and symbols designed (a) to fa- cilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality), and (b) to foster an understanding of one’s relation and respon- sibility to others in living together in a community” (Koenig et al., 2000, p. 18).

Spirituality.—

“Spirituality is the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship to the sa- cred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of community” (Koenig et al., 2000, p. 18).

Positive Spirituality.—

Positive spirituality involves a developing and internalized personal relation with the sacred or transcendent that is not bound by race, ethnicity, economics, or class and promotes the well- ness and welfare of self and others. Positive spiritual- ity uses aspects of both religion and spirituality. It also incorporates the work of the Fetzer work groups, which suggests that religion and spirituality are mul- tidimensional constructs (Fetzer Institute, 1999). Our focus extends the contributions of the Fetzer work groups, namely, to capture health-relevant domains of religiousness and spirituality, by focusing on

only

positive aspects of spirituality or religion within the context of a conceptual model related to successful aging. The addition of positive spirituality to Rowe and Kahn’s model of successful aging helps bridge the gap between theory and practice at a time when the Congressional and Executive branches of the gov- ernment are enacting rules for collaboration between government and the faith community in serving the poor (e.g., Personal Responsibility and Work Oppor- tunity Reconciliation Act, 1996).

To discuss more fully what we mean, it becomes necessary to address what positive spirituality is not. There

is general agreement that certain religious be- liefs and activities can adversely affect both mental and physical health (Koenig, 2001). Spirituality may be restraining rather than freeing and life enhancing (Pruyser, 1987). Religious beliefs have been used to jus- tify hypocrisy, self-righteousness, hatred, and prejudice. The aspects of spirituality or religion that separate people from the community and family (e.g., hypocrisy, self-righteousness), or that encourage

unquestioning

devotion and obedience to a single charismatic leader, or promote religion or spiritual traditions as a healing practice to the total exclusion of any medical care, are likely to adversely affect health over time. For exam- ple, we would not suggest that Reverend Jim Jones and the Guyana mass suicide of nearly 900 people, the David Koresh cult in Waco, Texas, or the terrorist attack on September 11th that destroyed the World Trade Center Towers were guided by positive spiritu- ality. Many Western and Eastern religious traditions emphasize an intimate relation with a transcendent force, place high value on personal relations, stress re- spect and value for the self, yet place emphasis on hu- mility. The resulting emphasis on relations—relation to a transcendent force, to others, and to self—may have important mental health consequences, especially in regard to coping with the difficult life circumstances that accompany poor health and chronic disability.

Positive spirituality may reduce the sense of loss of control and helplessness that accompanies illness. Positive spiritual beliefs provide a cognitive frame- work that reduces stress and increases purpose and meaning in the face of illness. Spiritual activities like prayer and being prayed for may reduce the sense of isolation and increase the patient’s sense of control over illness or disease. Public religious behaviors that improve coping during times of physical illness in- clude, but are not limited to, participating in worship services, praying with others (and having others pray for one’s health), and visits from religious leaders

Table 1. Distinctions Between Religion, Spirituality, and Positive Spirituality

Religion Spirituality Positive Spirituality

Community focused Individualistic Seeks to identify those features of religion and spirituality that have yielded or are associated with positive outcomes. The blend between community focused and individualism.

Observable, measurable, organized and/or more extrinsic

Less visible and measurable, more subjective and/or more intrinsic

Measurable, extrinsic, and intrinsic

Formal, orthodox, organized Less formal, orthodox Less formal, orthodox, and systematic Behavior oriented, outward

practices Emotionally oriented, inward directed Emotion and behavior oriented

Authoritarian in terms of behavior

Not authoritarian, little accountability Accountable to engaging in positive actions

Doctrine separating good from evil

Unifying, not doctrine oriented Unifying, promoting life enhancing beliefs

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615Vol. 42, No. 5, 2002

such as a chaplain, pastor, priest, or rabbi at home or in the hospital.

Rowe and Kahn’s Model of Successful Aging and Positive Spirituality

In their original model, Rowe and Kahn (1987) de- fined successful aging as the avoidance of disease and disability. More recently they have expanded their model to include maintenance of physical and cogni- tive function and engagement in social and produc- tive activities (Rowe & Kahn, 1997, 1998), making it ready for future intervention studies (Riley, 1998). However, their notion of successful aging has not been without criticisms.

Rowe and Kahn’s (1998) model has been criticized for not emphasizing biological research (Masoro, 2001) and for not including social structure and self- efficacy (Riley, 1998). We argue that the social and bi- ological components to aging successfully are portrayed adequately within the existing model as “avoidance of disease and disability” and “active engagement with life” (Rowe & Kahn, 1998, p. 39). Additionally, we agree with Rowe and Kahn (1998) that self-efficacy, as a psychological construct, properly rests within their original conceptualization of cognitive and men- tal fitness, and that it does not represent a separate, distinct component to successful aging.

Although we maintain that Rowe and Kahn’s (1998) synthesis of the literature addresses these crit- icisms adequately without necessary modification of their framework, their model falters systemically on two counts. First, their work does not endorse the growing body of research examining the relation be- tween spirituality and health outcomes (see reviews by Levin, 1996; Matthews & Larson, 1995). Spiritu- ality has been associated with an improvement in sub- jective states of well-being (Ellison, 1991), a reduc- tion in levels of depression and distress (Williams, Larson, Buckler, Heckmann, & Pyle, 1991), a reduc- tion in morbidity, and an increase in life span (Levin, 1996). Second, their neglect of spirituality as a major construct handicaps their call for efficacious applica- tions with their model. National surveys have consis- tently shown that the vast majority of older Ameri- cans, in particular ethnic and minority elders, report a religious or spiritual component to their lives (Prince- ton Religious Research Center, 1987, 1994).

In the following section, we introduce positive spir- ituality into Rowe and Kahn’s (1998) model, as illus- trated in Figure 1. We maintain that this expanded model will enhance the percentage of older adults who age successfully by affirming an important and positive aspect in the lives of many older Americans, while in no way disenfranchising those to whom spir- ituality is not important. Furthermore, the theoretical incorporation of spirituality into models of successful aging represents an important scientific acknowledge- ment of the research findings of the past four decades. Rowe and Kahn’s model has three components: (a) minimizing risk and disability, (b) engaging in active life, and (c) maximizing physical and mental activi-

ties. The three components of the model have the fol- lowing characteristics: (a) each is a part of an overall system and each is therefore temporally related to the others, (b) the variables are activating characteristics that describe both weaknesses and strengths, and (c) each must consider both individual characteristics as well as contextual factors. We argue that positive spir- ituality is the missing component in the model; it ad- dresses the interrelatedness between the older adults’ beliefs and values, the community, and the efficacy of interventions focused on successful aging.

Rowe and Kahn (1997) indicated that the stage is set for intervention studies to identify effective strate- gies that enhance wellness among older adults. We maintain, with our broadened Rowe and Kahn model, that aging is multifaceted and consists of interdepen- dent biological, psychological, social, and

spiritual

processes. Further, we assume that lives are lived within a social and historical context, and that the re- lation between individuals and society is multidimen- sional and interactive. For example, positive spirituality fosters active engagement in life, through religious and/ or community activities, prayer, meditation, and other practices. In addition, the literature has found an association between spiritual and/or religious ac- tivities and the reduction in disability and disease, thus allowing seniors to remain actively engaged.

The intellectual acceptance of spirituality as a major facet of life will help reopen doors of opportu- nity with groups who have avoided or become reluc- tant recipients of traditional health promotion in- terventions. A person’s spirituality is not bound by race and socioeconomic status, and its acceptance in theory will provide gerontologists the option of considering spiritual tools and paradigms in design- ing efficacious, evidence-based health promotion in- terventions that cut across traditional racial, ethnic, and economic boundaries.

Positive Spirituality and Wellness

Except for the past two centuries, religion and med- icine have been closely linked for most of recorded history. Yet until nearly the end of the 20th century, science has not seriously studied the relation between measures of religion, spirituality, health, and aging (Koenig, 1999; McFadden, 1996). Because of the grow- ing recognition that religious and spiritual beliefs and

Figure 1. Revised Rowe and Kahn Model of Successful Aging.

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616 The Gerontologist

practices are widespread among the American popula- tion and that these beliefs and practices have clinical rel- evance, professional organizations are increasingly call- ing for greater sensitivity and better training of clinicians concerning the management of religious and spiritual is- sues in assessment, treatment, and research (Accredita- tion Council for Graduate Medical Education, 1994; American Psychiatric Association, 1995; American Psy- chological Association, 1992; Council on Social Work Education, 1995; The Joint Commission on the Accred- itation of Healthcare Organizations in 1996, 2001).

Positive Spirituality, Psychological, and Physical Health Outcomes

There are multiple psychological, social, behav- ioral, and physiological mechanisms by which reli- gious involvement may impact health and speed re- covery from disease. Several researchers have found that religious activity—particularly when it occurs in the setting of community such as involvement in reli- gious worship services—and related voluntary activ- ity is associated with longer life span (Glass, Mendes de Leon, Marottoli, & Berkman, 1999; Hummer, Rogers, Nam & Ellison, 1999; Oman & Reed, 1998). Additionally, several studies have shown a positive as- sociation between religious involvement and better adaptation to medical illness (Ell, Mantell, Hamo- vitch, & Nishimoto, 1989; Jenkins & Pargament, 1995; Kaczorowski, 1989) or to the burden of caring for those with medical illness (Keilman & Given, 1990; Rabins, Fitting, Eastham, & Zabora, 1990). Religious activity has also been associated with better compliance with antihypertensive therapy (Koenig, George, Cohen, et al., 1998).

Religiously committed persons are less likely to en- gage in health behaviors like cigarette smoking and excessive alcohol use (Koenig et al., 2000). In this way, religion may help to prevent the negative health consequences that follow these unhealthy behaviors. On the other hand, these persons are often involved in close family systems and supportive communities, which may have effects on health through other ex- planatory mechanisms.

Level of religious commitment also predicts speed of recovery from depression regardless of initial de- pression severity, an effect that is strongest in those with chronic physical disability that is not responding to medical therapies (Koenig, George, & Peterson, 1998). A positive association between religious in- volvement and mental health in persons with physical disability has also been found in studies of hospital- ized medical patients (Idler, 1995; Larson, 1993). Sim- ilarly, studies of mental health and substance abuse have shown that religious activity buffers against the negative effects of physical illness or stressful life events (Kendler, Gardner, & Prescott, 1997). Nearly 850 studies have now examined the relation between religious involvement and some indicator of mental health. Many of the studies have been conducted in medically ill patients or older persons suffering with chronic disability. The vast majority of such studies

do indeed find that religious involvement is associated with greater well-being and life satisfaction, greater purpose and meaning in life, greater hope and opti- mism, less anxiety and depression, more stable mar- riages and lower rates of substance abuse (Koenig, McCullough, & Larson, 2000).

Religious Coping, Psychological, and Physical Health Outcomes

In an examination of the association between reli- gious coping and depression, Koenig and colleagues (1995) found that religious coping may reduce the af- fective symptoms of depression, but appeared less ef- fective for the biological symptoms that are probably more responsive to medical treatments. More re- cently, Koenig and collaborators examined the associ- ation between 21 types of religious coping and a host of physical and mental health characteristics (Koenig, Pargament, & Nielsen, 1998). Offering religious help to others (e.g., praying for others) was one of the most powerful predictors of high quality of life, low depressive symptoms, greater level of cooperativeness, and greater stress-related growth. Other types of reli- gious coping associated with positive mental health in- cluded reappraising God as benevolent, collaborating with God, seeking a connection with God, and seek- ing support from clergy or other church members. These coping behaviors were strongly related to stress-related growth, enabling patients to experience greater psychological growth from these stressful health problems. Coping behaviors that focused pri- marily on the self (self-directed coping) without de- pending on God, were related to greater depression, lower quality of life, and significantly lower stress- related growth. Some studies show that religious cop- ing is also associated with improved attendance at scheduled medical appointments (Koenig, 1995).

Several studies report an association between reli- gious involvement and immune system function. Dull and Skokan (1995) developed a cognitive model to explain the relation between spirituality and the im- mune system. In their model they posit that spiritual- ity is a complex system of beliefs that can have an im- pact on all aspects of an individual’s daily life. Spiritual practices may affect a person’s cognitions and subsequently impact health practices and out- comes. For example, a cancer patient with spiritual beliefs may assign a larger meaning to the illness, thus reducing the negative effects of stress on health.

Investigations in patients with AIDS show that those who are more involved in religious activities have measurably stronger immune function (Woods, Antoni, Ironson, & Kling, 1999). Likewise, studies at Stanford University in patients with breast cancer show better immune functioning among women with greater religious expression (Schaal, Sephton, Thore- son, Koopman, & Spiegel, 1998). The findings pre- sented above suggest a positive association between re- ligion and reduced levels of psychological stress and could point to physiological consequences that impact physical health as well. However, this research is in its

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earliest stages, with the results highly preliminary and not definitive. Prospective studies and clinical trials are needed to determine the order of the effects.

The Role of Positive Spirituality in Health Promotion

Health promotional efforts are designed to trans- form the more traditional biomedical models that ac- centuate the physician’s responsibility to treat disease, to an ideal in which individuals are increasingly respon- sible for optimizing their health by attending to the quality of their self-care. Hooyman and Kiyak (1999) suggest that health promotion makes “explicit the im- portance of people’s environments and lifestyles as determinants of their health status” (p. 117). As a re- flection of and in reaction to the aging demography of America and the world, the American Association for World Health (1999) has adopted the theme, “Healthy Aging, Healthy Living—Start Now.” Prac- titioners have not used specified exercises for self- care consistently in the development of innovative wellness initiatives (Prochaska & DiClemente, 1984; Prochaska, Velicer, DiClemente, & Rossi, 1993). Only rarely and recently are the implications of these re- search domains considered in the development of well- ness and health promotion programs (Parker, Fuller, Koenig, Bellis, Vaitkus, & Eitzen, 2001).

The National Academy on an Aging Society (2000) has released information that portrays the health pro- motional challenge with seniors. Almost all of the at- risk conditions are associated with chronic illnesses such as hypertension, heart disease, diabetes, cancer, and stroke. Though many older people are at risk for chronic conditions because of genetic predisposition, gender and age, many risk factors are related to mod- ifiable health behaviors.

Can religious and spiritually minded organizations participate more actively in these efforts? Can they help fill the void in funding of intervention initiatives? We offer evidence to support these assertions. The role religious organizations can play and have played in providing support for aging members in the com- munity and hospital has often been overlooked or not acknowledged in the literature on successful aging. Religious communities have the most valuable re- source in society—people. By supporting community- dwelling older adults and their caregivers, religious communities could potentially reduce both the length and frequency of hospital admissions and perhaps delay nursing home placement. Religious denominations, spiritually minded nonprofit organizations, ecumenical groups, churches, synagogues, and other religious in- stitutions represent viable sources that can be engaged in partnerships that provide health promotional and prevention opportunities to groups that are more diffi- cult to reach (Parker et al., 2000; Parker et al., 2002).

Models of Intervention That Incorporate Positive Spirituality

The African American religious community has helped establish the connection between health pro-

motion and spirituality. In their 20-year review of lay health advisor programs among African Americans, Jackson and Parks (1997) reviewed the growing lay health advisor movement. Among their findings was the recommendation that professional educators should rely on the collective wisdom of the commu- nity to identify, recruit, select, and train lay health ad- visors, and they cite a number of studies that confirm the value of seeking the collective wisdom of the Afri- can American religious community in health promo- tional outreach programs.

Smith, Merritt, and Patel (1997) examined the im- pact of education and support provided by African American churches in encouraging health promotion activities for blood pressure management. In a related program, Kong (1997) described a community-based program, which included churches, that played a valuable role in increasing the number of African American hypertensives that received treatment. There is also evidence that supports the role of minis- ters in providing assistance for African Americans (Okwumabua & Martin, 1997; Neighbors, Musick, & Williams, 1998).

Jackson and Reddick (1999) describe the Health Wise Church Project, a community outreach initiative between a diverse group of African American churches and a university health education program. The pri- mary objective was to develop early detection and ill- ness prevention networks among older church mem- bers. Their four-stage model for the establishment of academic–church collaborations is similar to a model used by Parker and colleagues (2000, 2001), which adopted the Rowe and Kahn model of successful ag- ing with the addition of positive spirituality. As illus- trated in Figure 2, we have taken the Parker and col- leagues model and adapted it for use with faith-based and non–faith-based organizations. This model is a unifying theoretical framework that fosters interdisci- plinary thinking as well as program development and research in the area of health promotion. The model demonstrates how prevention information can be dis- seminated to older adults by gaining access to com- munity organizations. The inclusion of both faith and non–faith-based organizations captures older persons who consider themselves spiritual but do not associ- ate with organized religion.

The model considers a variety of social, biological, cultural, and economic factors that influence health and health behavior. Experts recommend diet and ex- ercise to alter individual health practices, to create healthier environments, and to enlighten attitudes and expectations toward health (Rowe & Kahn, 1998). By interacting with older adults through faith and non–faith-based organizations as proposed in the model, the more traditional biomedical models that accentuate the physician’s responsibility to treat dis- ease are transformed to an ideal in which individuals are increasingly responsible for optimizing their health by attending to the quality of their self-care (Hooyman & Kiyak, 1999).

Faith and non–faith-based organizations can work across denominational and racial boundaries

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Figure 2. Proposed model for community-level health promotion for seniors.

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in conjunction with public and private health care providers and academia and research organizations to forge partnerships. These partnerships can provide the impetus and resources necessary for communities to organize conferences, programs, or workshops that promote successful aging. This model symbolizes the potential of community partnerships in address- ing institutional forms of diversity that limit outreach with disadvantaged groups. The unifying framework proposed marks a needed reversal in the trend towards separation of spirituality, organized religion, non– faith-based institutions, academia, and health care pro- fessionals that has occurred over the past several years.

Conclusion

We have briefly reviewed studies exploring the spirituality–health connection and its impact on suc- cessful aging. This research is in its very earliest stages, with the results highly preliminary and not de- finitive. Results suggest an association; however, pro- spective studies and clinical trials are needed to deter- mine the direction of effects. In an effort to build on Rowe and Kahn’s (1998) model of successful aging, we offer evidence to include a conceptually distinct category—positive spirituality. The incorporation of positive spirituality into Rowe and Kahn’s model of successful aging helps underscore the importance of this area in self-health care. We maintain that all in- terventions should be sensitive to the diversity of Americans’ religious and spiritual beliefs, attitudes, and practices, and spiritual or religious interventions should only be offered with permission, respect, and sensitivity. Any intervention using positive spirituality should be patient- and not caregiver-centered. The health care provider must honor the patient’s auton- omy, follow the patients’ lead and needs, and use per- mission, respect, wisdom, and sensitivity. We look for- ward to the continued growth of research as well as more fine-tuning of the implications for interventions.

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Received September 5, 2001 Accepted April 15, 2002 Decision Editor: Laurence G. Branch, PhD

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