A Transcultural Spiritually Based Program to Enhance Caregiving Self-Efficacy: A Pilot Study

10.1177/1076167502250796 D. Oman et al. Transcultural Spiritually Based Program

ARTICLE

A Transcultural Spiritually Based Program to Enhance Caregiving Self-Efficacy: A Pilot Study Doug Oman, PhD John Hedberg, MD David Downs, MD Debra Parsons, MD This study examined how training in a nonsectarian toolkit of spiritually based self-management techniques affected the caregiving self-efficacy (confidence) of health professionals, including physicians, nurses, psychologists, and chaplains. Before and after an 8week, 2-hour per week training in the meditation-based Eight Point Program of Easwaran (1978/1991b), participants (n = 14) completed a newly developed 32-item caregiving self-efficacy questionnaire. Data were also gathered regarding sociodemographic characteristics, spiritual and religious self-perceptions and practices, and program adherence. Results indicated that mean pre/post self-efficacy increases were large (Cohen’s d > 0.80), statistically significant (p < 0.01), and associated with greater use of specific program practices. Three participants reported increases in self-perceived spirituality. Selfefficacy increases were largest for participants identifying themselves as least spiritual at pretest (p < 0.05), or reporting increases in spirituality (p < 0.05). Although preliminary, these findings support using this already widely crossculturally disseminated toolkit for a variety of purposes in clinical practice, health promotion, and health professional education. Keywords: religion; wisdom; end-of-life issues; medical education; meditation

As the population grows older in the United States and worldwide, more and more persons are likely to occupy roles that involve caregiving, either professionally or with family, friends, or neighbors. Although advances in prevention and treatment might reduce the total burden of illness, many older persons, for longer or shorter periods, will nevertheless require a variety of personalized care from sources such as family members, physicians and nurses, or paid staff of long-term care facilities.

Complementary Health Practice Review, Vol. 8 No. 3, October 2003 201-224 DOI: 10.1177/1076167502250796 © 2003 Sage Publications

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According to Pearlin, Mullan, Semple, and Skaff (1990), “Whereas caring is the affective component of one’s commitment to the welfare of another, caregiving is the behavioral expression of this commitment . . . [and is] present in all relationships where people attempt to protect or enhance each other’s well-being” (p. 583). From this perspective, caregiving roles are performed not only by family members and long-term care staff but also by highly trained health professionals such as physicians or complementary and alternative health care providers. Defined in this manner, caregiving roles vary widely in their duration, interpersonal time commitment, and the technical skills that they demand. Notwithstanding such diversity, caregiving roles offer important common challenges and opportunities. First, all caregiving roles may require the caregiver to deal with ultimate human concerns regarding mortality and suffering. Not only family members but also nurses, physicians, and other health care professionals may play an important part in helping a patient marshal resources for dealing with suffering and death, as writings about “personcentered medicine” emphasize (Barnard, Dayringer, & Cassel, 1995). Second, all caregiving roles take place in the context of a web of human relationships that can impose burdens but may also offer resources, especially if such relationships are effectively maintained and positively managed. Finally, all caregiving roles are ultimately bounded: Caregivers must sometimes move out of caregiving roles to occupy other roles in life, if only for purposes of selfrenewal (e.g., sleeping or maintenance of familial or other relationships). Boundaries between caregiving and the remainder of life must be managed to avoid burnout. None of these three domains of skill is easily mastered, as is demonstrated by ongoing research for relieving distress among groups such as medical students and medical residents, as well as spouses, children, and other caregivers for family members (Knight, Lutzky, & MacofskyUrban, 1993; Shapiro, Shapiro, & Schwartz, 2000). In this article, we suggest that important clues for enhancing caregiver efficacy may come from traditional societies worldwide that have perceived religion and spirituality as central to tasks of coping with suffering, disease, mortality, and other ultimate human concerns encountered by caregivers (Smith, 1991). In the past decade, health researchers and practitioners have increasingly recognized empowering features of religion and spirituality for persons in a wide range of life situations, including both patients and caregivers (Ellison, 1993; Maton & Wells, 1995; Pargament, 1997; Sulmasy, 1999). Compared to nonreligious or nonspiritual forms of coping, for example, religion may offer special resources for the very general problem of coping with the “limits of personal powers” (Pargament, 1997, p. 310). Recent empirical evidence links personal religious involvement with a wide variety of physical and mental health benefits, including recovery from substance abuse, improved health behaviors, reduced rates of physical disability and chronic disease, better mental health, and greater longevity (Chatters, 2000; Koenig, McCullough, & Larson, 2001; McCullough, Hoyt, Larson, Koenig, & Thoresen, 2000; Oman & Thoresen, 2002; Strawbridge, Shema, Cohen, & Kaplan, 2001). In the health care context, most systems of complementary and alternative medicine directly address spirituality (Goldstein, 1999; Jonas & Levin, 1999). Similarly, as a source of meaning for many patients, religion and spirituality are seen as relevant to “person-centered medicine,” deserving of a place in medical school curricula (Barnard et al., 1995; Sierpina & Boisaubin, 2001; Sulmasy, 1999). From only 3 in 1994, the number of medical schools in the United States that include course material on religion and spirituality in their curricula has jumped to more than 60 (Koenig et al., 2001). Despite greater mention of spirituality in medical education, many experienced health professionals continue to feel inadequately trained for dealing with spiritual issues. Of fam-

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ily practice physicians responding to a recent survey, almost all (96%) reported believing that spiritual well-being was an important part of health, but most seldom discussed spiritual issues with patients, feeling that lack of training was a barrier (Ellis, Vinson, & Ewigman, 1999). A majority (53%) were concerned about projecting particularized spiritual beliefs onto patients, perhaps doubting their own ability to maintain a constructive stance, such as pluralism, toward viable spiritual diversity (Pargament, 1997; Zinnbauer & Pargament, 2000). “If there is one area that needs further research,” stated Koenig et al. (2001) in a comprehensive review, “it is how clinicians can best integrate what we have learned about the religion-health relationship into clinical practice” (p. 439). Interestingly, available empirical evidence suggests that religion and spirituality act as resources for at least some types of caregiving (Picot, Debanne, Namazi, & Wykle, 1997). Among family or partner caregivers, spiritual factors have been associated with better relationships with care recipients (Chang, Noonan, & Tennstedt, 1998), greater well-being (Rabins, Fitting, Eastham, & Zabora, 1990), and the ability to positively reframe a distressing situation (Folkman, 1997). In addition, greater religious involvement by African American caregivers has been found to mediate their perceptions of higher rewards from caregiving when compared to White caregivers (Picot et al., 1997). Some observers suggest that the caregiving efficacy of health care professionals, such as physicians and nurses, can be enhanced through spiritual or religious resources (e.g., Stein, 2001). Sulmasy (1999) offers both personal and interpersonal strategies for accessing these resources, urging physicians to draw on their own spiritual traditions and communities, but also to talk about spiritual issues with colleagues from differing spiritual traditions. Other initial evidence suggests that academic exposure of medical students to spiritual issues does enhance their intellectual openness to the topic of spirituality in medicine (Chibnall & Duckro, 2000). A complementary but more systematic approach, capable of being incorporated into professional training curricula, might be to supply health care professionals with spiritually based tools that can be integrated into their personal styles of coping and relating without challenging their or others’ personal beliefs. Such tools might empower health professionals to draw more deeply on insights of spiritual wisdom traditions for managing caregiving stresses, as well as to support patient coping efforts from an effective and respectful stance, such as constructivism or pluralism (see Zinnbauer & Pargament, 2000). To explore the value of such an approach, we studied how training in a set of spiritually based self-management tools affected the caregiving self-efficacy of a group of health care professionals. Our final section suggests how our intervention might be applied to health care practice.

METHODS Intervention To provide training in a spiritually based set of self-management tools, we used a wellestablished nonsectarian program developed by Easwaran (1978/1991b). Only slightly capitalized on by health care to date, the program is usable by health professionals as well as the lay public and has several integrative strengths as an adjunct to standard professional training. Completely nonsectarian, it can be practiced within the context of any major religion or outside of all religions. The program nevertheless systematically engages practitioners in drawing deeply on core ideas from the “wisdom traditions” within the major religions

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(Baltes & Staudinger, 2000; Brown, 2000; Smith, 1991). This combination of features appears unique to the program, perhaps partly accounting for its international dissemination by mutually independent publishers in more than 20 European, Asian, and Middle Eastern languages,1 subsequent to the program’s introduction to the United States 40 years ago (Hedberg, Bowden, & Oman, 2001; Oman, 2000; Oman & Thoresen, 2001b). In English, more than two dozen book-length commentaries describe how to use the program to manage stress or how to implement Eastern or Western wisdom teachings in daily life (e.g., Easwaran, 1989, 1994, 1996, 1977/1998). Recently, an adaptation of the program specifically aimed at promoting effective coping with chronic diseases was taught to thousands of persons across the United States with success (Flinders, Gershwin, & Flinders, 1994). The original core program consists of the eight practices or “points” that are displayed in Figure 1. Each point in this Eight-Point Program (EPP) is described elsewhere in greater depth (Easwaran, 1978/1991b) and corresponds more or less not only to practices indigenous to major religious traditions (Walsh, 1999) but also to previously studied health care interventions (Hedberg et al., 2001; Oman & Thoresen, 2001b). For example, Points 3 and 4 (slowing down and one-pointed attention), which we will refer to as “mindfulness practices,” are similar to practices taught in many forms of mindfulness meditation (e.g., Kabat-Zinn, 1994). In the EPP, to slow down means to guard against hurry and the attendant stress by setting priorities and refraining from filling time with more than what can be done. One-pointed attention means giving full concentration to the matter at hand and not “multitasking.” In accord with many other systems of meditation and contemplative prayer from many cultures, the goal of this program may be seen as, “in essence, the effort to retrain attention” (Goleman, 1988, p. 169). A noteworthy but less common feature of the EPP is that when meditating, practitioners concentrate on a memorized “inspirational passage” drawn from scriptures or great mystics of all major religious traditions, such as represented in Figure 2. By selecting particular passages for meditation and by making choices in implementing Points 2 and 8 (holy name/ mantram and spiritual reading), practitioners can emphasize the most congenial traditions2 and the most inspiring features of these traditions while avoiding any features that conflict with their beliefs. Through several mechanisms, systematic use of the EPP might be expected to enhance a person’s ability to practice caregiving skills. Like other forms of meditation, the EPP would be expected to promote relaxation and facilitate stress management (Shapiro et al., 2000). Like religious involvement, use of the EPP could be expected to help caregivers to constructively reframe their situation, form positive appraisals, and have greater faith in successful outcomes (Pargament, 1997; Picot et al., 1997). By helping practitioners to internalize common teachings of wisdom traditions regarding compassion and coping with suffering, the EPP may enhance a caregiver’s ability to listen, understand, empathize, and wisely help suffering care recipients to mobilize their own resources to deal with ultimate concerns (see Oman & Thoresen, 2001b, for discussion of hypothesized mechanisms specific to EPP). Such enhanced empathy and listening skills could be expected to facilitate good relationships by promoting positive relationship-focused coping strategies (Kramer, 1993). Consistent with such possible mechanisms, previous research on the EPP has associated it with reduced stress, specific improved health behaviors, enhanced well-being, and psychosocial adjustment to HIV (Earl et al., 1994; Flinders, Cohn, et al., 1994; Winzelberg & Luskin, 1999). The present study reports on an adaptation of the program that emphasized application to difficult issues, including end of life, for caregivers and health care professionals. The main

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1. Passage Meditation Memorize an “inspirational passage” such as displayed in Figure 2. Meditate for a half hour each day, preferably in the morning. Meditate by sitting with back straight, eyes closed, and reciting the passage slowly in the mind with concentration. Focus the mind as completely as possible on the words of the passage; when distractions come, do not resist them but give more attention to the words of the passage. If the mind strays from the passage entirely, bring it back gently to the beginning and start again. When the passage is completed, begin another memorized passage or slowly and silently repeat the same passage until the time for meditation is completed. 2. Repetition of a Holy Word or Mantram Silent repetition in the mind of a single chosen Holy Name or hallowed phrase from a great religious tradition. Practiced whenever possible throughout the day or night (e.g., when walking, waiting, or doing mechanical chores like dishwashing—see Easwaran, 1998/1977). Suitable words or phrases include “Jesus”, “Ave Maria”, “Om mani padme hum” (Buddhist, refers to the “jewel in the lotus of the heart”), “Barukh attah Adonai” (means “Blessed art thou, O Lord” in Jewish tradition), “Allah”, or “Rama” (Mahatma Gandhi’s mantram). 3. Slowing Down Guard against hurry and attendant stress by simplifying life and refraining from filling time with more than what can be done. If speeding up, repeat holy word as aid to slowing down. 4. Focused or One-Pointed Attention Do only one activity at a time. Everything we do benefits from receiving our full attention. For example, refrain from driving and dictating or calling at the same time. Multi-tasking drains energy and leads to mistakes, whereas one-pointed attention conserves energy, leading to efficiency and poise. 5. Training the Senses Overcoming conditioned habits and learning to enjoy what is beneficial. 6. Putting Others First Gaining freedom from selfishness and separateness; finding joy in helping others. 7. Spiritual Association Spending time regularly with others following the EPP for mutual inspiration and support. 8. Inspirational Reading Drawing inspiration from writings by and about the world’s great spiritual figures and from the scriptures of all religions. Figure 1.

Brief Description of the Eight-Point Program (EPP) of Easwaran (1978/1991b)

instructor was a seasoned professional caregiver (a physician) with substantial personal experience in using the tools. Additional presentations were given by four other instructors, (including two health professionals, both physicians) all of whom had personally used the tools. Program classes met weekly for 2 hours over 8 weeks and included time for presentation, discussion, a break, and a group meditation. In the first session, the program was discussed as, among other things, a toolkit to foster concentration and gain control over intrusive thoughts, thus resolving the “problem of the mind.” Each of the first 6 weekly sessions focused on one or two of the eight points, taught slightly out of numerical order as follows: 1, 4, 2, 3, 5 and 8, and 6 and 7. Between meetings, participants were assigned tasks such as reading background concepts and program instruction chapters in Easwaran (1978/1991b), memorizing an inspirational passage of their

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choice (from Easwaran, 1982/1991a), or practicing and/or experimenting with specific program tools (e.g., training the senses). Subsequent sessions began with small-group discussions of the previous week’s experiments, experiences, and/or readings. These small discussions permitted instructors to offer individualized corrective feedback, as well as allowing course participants to function as models for each other (see Oman & Thoresen, in press-a). The seventh meeting included extensive discussion of how to apply EPP tools in health care settings, and the final session included a course summary and large-group discussion. Each meeting closed with a group meditation that lasted 10 minutes in the first session and was progressively increased in later sessions to 30 minutes. Sample Participants were recruited from an EPP class that was taught, as outlined above, during October and November 2000 through a Veterans Administration (VA) facility in Colorado. Advertised through flyers and word of mouth, the course was open to both VA staff and outsiders. Publicity described a meditation-based course designed to help health care professionals enhance their abilities to meet the needs of patients in crises such as the end of life and to stay calm in the midst of suffering. Publicity also mentioned applications to restoring personal vitality and experiencing growth in the final stage of life. Except for the Thanksgiving holiday, the class met on consecutive Thursdays. All but two of the enrolled students agreed to participate in the present study (n = 14). Measures Self-efficacy. Self-efficacy, which may be defined as a person’s confidence that he or she is able to perform a certain kind of action, is a widely studied construct in the social sciences (Bandura, 1997). Self-efficacy is typically among the strongest predictors of objective performance for any type of activity and is increasingly used to evaluate programs for education, training, and behavioral modification. According to Bandura (1997), self-efficacy is not a generalized personality trait but is domain specific, and separate questionnaires must be designed to measure self-efficacy in each domain of skill. Self-efficacy questionnaires have been constructed for many skills relevant to health, including adhering to positive health behaviors; succeeding in health education coursework; acting as a perinatal nurse, pediatric nurse, or hospital social worker; or acting as a caregiver for a spouse with Alzheimer’s disease (Becker, Stuifbergen, Oh, & Hall, 1993; Craven & Froman, 1993; Denney, 1994; Holden, Cuzzi, Rutter, Rosenberg, & Chernack, 1996; Murphy & Kraft, 1993). Among family caregivers of frail and/or cognitively impaired elders, higher self-efficacy has been associated with greater life satisfaction, less distress, less subjective caregiver burden, and less depression (Haley, Levine, Brown, & Bartolucci, 1987; Zeiss, Gallagher-Thompson, Lovett, Rose, & McKibbin, 1999). In the present study, self-efficacy was measured with a scale developed to emphasize dimensions of caregiving that might benefit from training in spiritually based self-management tools. Initial item development was conducted by several experienced primary care health professionals, mainly nurses, in consultation with one of the present authors. To guide this process in its initial stages, a set of demonstration questions was developed that exemplified the confidence-oriented format required for self-efficacy items (Bandura, 1997) and contained plausibly suggestive content obtained from conversations with experienced EPP

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teachers and from studying program materials (such as Easwaran, 1978/1991b). In light of the initial demonstration questions or drafts-in-progress of the self-efficacy scale once available, health professionals who had used the EPP themselves were asked to generate completely realistic scale items. They were asked for items reflecting skills that are (a) important and necessary for many caregivers and (b) likely to be affected by the use of spiritually based self-management tools, especially the EPP. Some items were generated in solitary reflection and others in the context of individual meetings with the participating author, who sometimes offered prompting questions such as “How can that be turned into a skill question?” “Would that skill also be important for dealing with others besides coworkers?” and “Do you think that’s a practical issue for many caregivers?” In this manner, a series of five or six drafts was prepared and circulated among participating health professionals for criticism and improvement. The final scale emphasized primarily common caregiving skills, described above, that are relevant across a wide variety of caregiving roles: managing personal relationships, managing boundaries, and dealing with ultimate concerns such as suffering and mortality. In the present study, self-efficacy change was prospectively measured by administering a 32-item version of the self-efficacy scale at the first pretest class session and last posttest class session. Each item required responses on a scale from 0 (cannot do at all) to 10 (certain can do). Whenever scale items were personally irrelevant, participants were instructed to indicate that the item did not apply (e.g., if the participant did not have a supervisor). Adherence. Participants’ usage of the eight intervention practices was assessed at posttest. Adherence was measured by one question for each of the eight practices and an additional question regarding their adherence to the program’s “practices as a whole.” In these nine questions, participants rated their adherence over the past 2 weeks by circling a number on a continuously coded 5-point scale, where 1 = not at all, 2 = a little bit, 3 = somewhat, 4 = quite a bit, and 5 = consistently. Covariables. Also at the time of the posttest, participants were given a questionnaire that assessed several sociodemographic characteristics, including gender, age, occupation, years of education, and ethnicity. Because many Americans presently practice nontraditional forms of spirituality (Wuthnow, 1998), we also assessed what might be called participants’ “spiritual identities” by inquiring whether their beliefs were best described as “religious,” “spiritual but not religious,” or “neither” (question adapted from Newport, 1999). Other questions regarding religion and spirituality were drawn from the 1998 General Social Survey (Fetzer Institute/National Institute on Aging Working Group, 1999). These included a question regarding to what extent participants considered themselves to be spiritual (with response categories very spiritual, moderately spiritual, slightly spiritual, and not spiritual at all) and a similar question regarding the extent of being a religious person. Prior experience suggested that the intervention might enhance some participants’ spirituality and religiousness. We therefore desired to assess spirituality and religiousness at both pretest and posttest. Due to delays in obtaining human subjects approval, direct measures of spirituality and religiousness could not be conducted at pretest. At posttest, we therefore retrospectively assessed several spiritual variables by prefacing questions with the phrase “When class began on October 5. . . .” Contemporaneous (posttest) assessments began with the phrase “At the present time. . . .” Both retrospective (pretest) and contemporaneous (posttest) assessments were made of spiritual identity (“religious” vs. “spiritual but not religious” vs. “neither”), the extent to which each participant was a religious person, and the

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extent to which each participant was a spiritual person. No changes in any of these variables were recalled by participants, except for the last variable (“extent spiritual”), as noted below. Finally, purely retrospective assessments were made of three additional religious variables: how frequently participants attended religious services, whether they practiced an organized religion, and, if so, which religion or denomination. Hypotheses Our primary a priori hypothesis was that self-efficacy would increase over the course of the training. This primary hypothesis was tested fully prospectively using data that were gathered, as noted above, at the first and last class sessions. We also tested a second a priori hypothesis: that such increases would be mediated by overall program adherence. Additional analyses of a more exploratory nature assessed how self-efficacy changes might relate to participants’ retrospectively assessed sociodemographic and spiritual characteristics or to adherence to individual program practices. Statistical Analyses Sample sociodemographic, spiritual, religious, and program adherence characteristics were computed through unadjusted means and percentages. Principal components factor analyses were used to examine the factor structure of self-efficacy scores at pretest and posttest. Scree tests were used to determine the number of factors for extraction. Internal reliability was assessed through Cronbach’s alpha statistic. To handle “does not apply” responses by some participants on some of the 32 self-efficacy items, self-efficacy scores were calculated in two ways: unadjusted and adjusted. First, for each participant, unadjusted self-efficacy scores were calculated as the mean response on items that had been answered at both pretest and posttest. Unadjusted change scores were computed as the difference between the unadjusted pretest and posttest scores, and a twotailed t statistic was used to test for a nonzero population mean change (thereby providing an unadjusted test of the major study hypothesis). Mean change was divided by the pooled standard deviation to calculate Cohen’s effect size statistic (Cohen, 1988). Second, adjusted pretest self-efficacy scores were computed that used all available numerical responses and adjusted for the difficulty level of questions left unanswered by an individual participant. These adjusted pretest scores were computed using a linear regression that modeled each of the 14 × 32 item responses as the sum of an overall intercept, a participant effect, a question effect, and an error term. Responses of “does not apply” (hereafter called “missing”) were imputed as the regression predictions, and adjusted pretest efficacy scores were computed as the average of the 32 actual or imputed item responses. Adjusted posttest efficacy scores were similarly computed via a wholly separate regression. To perform a test of the major study hypotheses (self-efficacy increase over time) that adjusted for missing values, we used linear mixed-model regressions. A mixed model generalizes the standard linear model by allowing for data to be generated from several sources of variation. Mixed models are the preferred tool for analyzing repeated measures with small sample sizes and missing data, and these models adjust for missing data rather than deleting all participants’scores when missing data are found. We computed self-efficacy change over time from mixed-effect regressions that modeled all item responses at both time points and adjusted for possible sources of random variation associated with individual participants and individual questions (see further details in Table 1 note). Efficacy change was statistically

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Examples of Meditation Passages

Source. Drawn from Easwaran (1982/1991).

tested for a difference from zero by using a two-tailed t test obtained from regression software (SAS PROC MIXED, SAS Institute, Cary, NC). Mixed linear regressions were also used to explore relationships of self-efficacy with covariates. Associations of pretest, posttest, and self-efficacy change scores—with sociodemographic, spiritual, religious, and program adherence measures and with pretest self-efficacy (a potential effect-modifier), were obtained by including additional terms for each covariate and/or its interaction with time. Similar mixed models were also used to examine the effects of program adherence on self-efficacy changes. Overall program adherence, hypothesized to have a positive effect on efficacy, was examined with a one-tailed t test. Because individual participants experiencing difficulties might have greater recourse to some program practices (e.g., spiritual association), which could produce inverse associations with efficacy changes, the efficacy effect of each of the individual practices was examined through a two-tailed t test, using a Bonferroni adjustment for multiple tests of hypotheses. Finally, the interrelationships among measures of adherence were calculated with unadjusted correlations and exploratory factor analyses. Linear regressions were used to examine associations between adherence and sociodemographic, religious, and spiritual variables.

RESULTS Analyses revealed a sample with moderate diversity in occupation, gender, and spiritual variables. Self-efficacy questions loaded consistently on a single factor that displayed a large and statistically significant increase from pretest to posttest. These prospectively measured self-efficacy increases were correlated with program adherence, and several participants retrospectively reported increases in spirituality.

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Sample Characteristics Of the 14 class members who agreed to participate, men (n = 8) slightly outnumbered women (n = 6). Participants ranged in age from 40 to 71, and all but 2 were married. All identified themselves as non-Hispanic White, except for 1 reporting Asian descent. Years of education ranged from 14 to 25, with a median of 20.5. Reported occupations were heterogeneous and included 3 physicians, 3 nurses, 3 psychologists, 2 chaplains, 1 laboratory-based health researcher, 1 writer, and a very active elderly hospital volunteer. Two participants, the researcher and the writer, did not regularly interact with patients. Two other participants were in training: a psychology resident and a retired hospital administrator interning as a chaplain. The majority of participants described themselves as religious (n = 8), with the remainder describing themselves as “spiritual but not religious” (n = 6). Of the 8 religious participants, 4 identified themselves as Lutheran, and 1 each was Jewish, Episcopalian, Presbyterian, and Hindu. Five of the participants (all self-identified as “religious”) attended religious services every week, 3 attended between one and three times per month, and the remainder (n = 6, 5 of whom were “spiritual but not religious”) attended less than once a month. On average (retrospectively at pretest), participants reported higher levels of being “spiritual” than being “religious” (e.g., 7 participants were “very spiritual” vs. 4 “very religious”), with participants being slightly less religious but more spiritual than a representative sample of the U.S. population (Fetzer Institute/National Institute on Aging Working Group, 1999, p. 93; full data in Oman, Hedberg, Downs, & Parsons, 2001). Informal assessment suggested that most participants had prior exposure to at least one type of meditation. Self-Efficacy Factor Structure The majority (n = 9) of participants gave numerical responses to all 32 self-efficacy questions for both pretest and posttest. At pretest or posttest, 4 participants indicated that some questions did not apply (see Oman et al., 2001). Overall, numerical responses were available for 93.2% of the 14 × 32 × 2 = 896 efficacy items, and unadjusted pre-post change scores were available for 90.2% of the 14 × 32 = 448 potentially available differences. At both pretest and posttest, scree tests suggested extraction of a single underlying factor that accounted for more than half the variance of the efficacy responses. Most questions at pretest and all questions at posttest loaded highly (0.60 or larger) on this factor, which could perhaps be called relational caregiving self-efficacy to distinguish it from efficacy in the more technical skills demanded by some types of caregiving (e.g., properly administering medications). We therefore computed self-efficacy scores as the unweighted average of all responses. Internal reliability for this measure was high (α > 0.95 at both pretest and posttest, regardless of whether participants with missing values were dropped). Three quarters of the questions correlated highly (0.60 or larger) with the total scores at both pretest and posttest, and the eight remaining questions correlated highly (0.50 or higher) on one of the two tests. Self-Efficacy Scores Unadjusted pretest self-efficacy scores ranged from 4.27 to 8.47, with a mean of 6.68. Unadjusted posttest scores averaged a point higher, ranging from 5.25 to 9.59, with a mean of 7.66. Changes in individual self-efficacy ranged from a loss of 0.27 to a gain of 2.73, with a mean increase of 0.99 (95% confidence interval [CI] = 0.45 to 1.53, p < .01), which resulted

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in a “large” effect size, that is, an increase equal to more than 80% of the pooled pretest/ posttest standard deviation (d > 0.80 as in Cohen, 1988). The magnitude and statistical significance of these improvements were essentially unchanged when further computations were made to adjust for missing item responses. Figure 3 displays the adjusted and unadjusted pretest and posttest values for self-efficacy for each individual participant. Pretest scores were higher among participants older than 60 years of age (p < .05). Because both personal and professional caregiving experience might naturally increase with age, this result supports the construct validity of the self-efficacy scale. Pretest and posttest scores were otherwise not significantly related to sociodemographic or spiritual variables. However, pretest to posttest changes in self-efficacy were significantly higher among participants who reported moderate or slight spirituality at pretest (+1.52 increase) than among participants who reported being very spiritual (+0.44 increase). Table 1 displays the relationships of selected sociodemographic and spiritual variables with self-efficacy scores and their changes over time. Participants reported greater confidence in response to some questions than in response to others, as reported elsewhere (Oman et al., 2001). However, none of the changes for any of the 32 individual questions was significantly different from the overall mean increase across all questions (p > .05). For each of the 32 efficacy items, Table 2 displays the average score at pretest and the average increase from pretest to posttest. Adherence to Practices At posttest, reported overall adherence ranged from 3 (somewhat) to 5 (consistent), with a mean of 3.6. Mean adherence to individual practices ranged from 3.1 (sense training) to 4.0 (meditation), but no interpretable factors could be extracted. Of the 28 intercorrelations among the eight measures of adherence to individual practices, 27 were positive, although only 3 attained statistical significance.3 Improvements in self-efficacy were associated with adherence to the first of the two mindfulness practices, slowing down (p < .005; p < .05 after adjustment for multiple comparisons). Improvements in self-efficacy were also marginally associated with overall adherence to the program (p < .10) and with adherence to one-pointed attention (the other mindfulness practice, p < .06) but not with adherence to other individual practices (p > .10). Interestingly, adherence to slowing down was significantly lower (p < .05) among participants who perceived themselves as very spiritual, very religious, or who attended religious services irregularly (once a month or more but less than weekly). Other covariates were not significantly predictive of adherence to either of the mindfulness practices or to the overall program (p > .05). Changes in Spirituality and Religiousness Three participants retrospectively reported increases in the extent to which they were spiritual persons: The only “slightly spiritual” participant became “moderately spiritual,” and 2 of 6 “moderately spiritual” participants became “very spiritual.” The prospectively measured self-efficacy increase among these 3 participants (mean = 1.98, p < .0001; SD = 0.29) was significantly larger (p < .05) than the still highly significant increase in self-efficacy reported among the other participants whose spirituality remained unchanged (mean = 0.71, p < .01; SD = 0.91, adjusted).

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Figure 3.

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Changes in Caregiving Self-Efficacy

Note. Adjusted scores are only visible when different than unadjusted scores.

DISCUSSION This study investigated the effects on caregiver self-efficacy of an 8-week, 2-hour per week training in a nonsectarian, spiritually based set of self-management tools developed by Easwaran (1978/1991b). In prospectively measured changes from pretest to posttest, partici-

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Adjusted Caregiver Self-Efficacy Scores and Score Changes by Selected Characteristics

TABLE 1.

Characteristic

n

(%)

Gender Male 8 (57) Female 6 (43) Age 40-59 9 (64) 60+ 5 (36) Religious Very 3 (79) Moderate/ slight/none 11 (21) Spiritual Very 7 (50) Moderate/slight 7 (50) Occupation Fully trained, sees patients 10 (71) In training or sees no patients 4 (29) Pretest efficacy Above mean 9 (64) Below mean 5 (36) All participants, combined 14 (100)

Pretest

Posttest

Change

Mean (SD)

Mean (SD)

Mean

(95% CI)

6.98 (1.17) 6.39 (1.23)

8.05 (1.02) 7.27 (1.27)

1.07 0.87

(0.32, 1.82) (0.01, 1.74)

6.25 (1.15) 7.59 (0.74)**

7.45 (1.20) 8.19 (1.04)

1.20 0.60

(0.53, 1.88) (–0.30, 1.50)

7.31 (1.09)

7.55 (0.48)

0.24

(–0.87, 1.36)

6.58 (1.22)

7.76 (1.30)

1.18

(0.60, 1.77)

7.25 (0.85) 6.21 (1.31)

7.70 (1.07) 7.74 (1.33)

0.44 (–0.21, 1.09) 1.52** (0.87, 2.18)

6.98 (1.17)

7.91 (1.34)

0.93

(0.26, 1.60)

6.10 (1.11)

7.23 (0.20)

1.13

(0.06, 2.20)

7.41 (0.62) 5.50 (0.90)**

8.07 (1.04) 7.08 (1.20)

0.66 1.59*

(0.03, 1.29) (0.74, 2.43)

6.73 (1.19)

7.72 (1.16)

0.98

(0.44, 1.53)

Note. CI = confidence interval. Means computed in mixed models for item responses that included fixed terms for intercept and global pretest to posttest change, as well as additional terms for random variation associated with each participant, each question, all possible two-way interactions (among time, participant, and question), and residual variance; Satterthwaite method was used for tests and confidence intervals. Standard deviations are from “adjusted” scores computed using linear regressions. *p < .10, **p < .05 for differences in group means for self-efficacy pretest or change values, for groups defined by covariates (e.g., age, spirituality, or pretest efficacy).

pants significantly increased their self-efficacy scores by more than 80% of their standard deviation, an amount that was highly statistically significant (p < .01). Approximately 20% of participants retrospectively reported increases in their level of spirituality, and none reported decreases. The largest improvements in self-efficacy were observed among participants with lower initial levels of self-efficacy, lower initial levels of spirituality, and greater use of program tools, especially mindfulness tools, and among participants who reported increases in spirituality. Together, these results suggest that this training supplied many participants with tools that enhanced their confidence in dealing effectively with several core psychosocial and relational caregiving tasks.

214 TABLE 2.

D. Oman et al. Self-Efficacy at Pretest and Changes From Pretest to Posttest, by Question Mean Self-Efficacy

Question Each question prefixed by “I am confident that I can . . .” Challenges involving relationships with coworkers 1. Have good relationships with my coworkers 2. Sense the needs of other coworkers (so that I can help them without being asked) 3. Maintain my equanimity when working with difficult or argumentative coworkers 4. Support coworkers in dealing sensitively with the mental and physical disabilities of patients 5. Support coworkers in dealing sensitively with the dying process of patients 6. Recognize the good in how my coworkers organize their work and not be overly attached to my own style of working (when their style is different than mine) Challenges involving relationships with patients 7. Have good relationships with patients 8. Control my temper with patients 9. Help patients in their relationships with other persons 10. Sense the needs of patients (so that I can help them without being asked) 11. Maintain my equanimity when working with difficult, irrational, and/or argumentative patients 12. Help patients to have courage regarding their own chronic suffering 13. Support patients in (appropriately) adapting or continuing their spiritual or religious practices in their present living situation 14. (If needed) find common ground between a patient’s spiritual/religious beliefs and my own spiritual/religious beliefs 15. Remember that a patient who has poor cognition may also possess a noble spirit 16. Maintain energy and equanimity when caring for patients who very likely won’t get better (patients with incurable and irreversible illnesses or conditions) 17. Recognize valid requests and suggestions by patients and not be rigidly attached to my own preferred styles of working Challenges involving relationships with families of residents 18. Sensitively answer questions from families of patients 19. Help families of patients to deal with chronic suffering experienced by patients 20. Help families of patients to deal with the death of patients 21. Recognize valid requests and suggestions made by patients’ Relatives

Pretest

Change

8.21a

–0.21

6.96

+0.75

6.43

+1.21b

7.72a

+0.40

6.79

+0.95

6.29

+1.07b

8.47a 8.72a 7.22

+0.11 +0.32 +0.59

6.72

+1.24b

7.06

+1.06b

6.39

+1.42b

6.15

+1.43b

6.72

+1.63b

7.64

+1.25b

7.15

+0.89

6.97

+0.84

7.64

+0.71

6.88 6.52

+1.01 +1.22b

7.22

+0.74

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TABLE 2 (continued)

Mean Self-Efficacy Question Challenges involving relationships with supervisors 22. Effectively communicate my needs about my work with my supervisors 23. Maintain my equanimity when working with a difficult supervisor Challenges involving relationships in general 24. Delegate responsibilities when I need to 25. Adequately prioritize work demands 26. Gracefully set limits to work demands Challenges involving general self-management 27. Maintain equanimity under pressure at work 28. Maintain equanimity when required to complete many tasks in a limited amount of time 29. Maintain equanimity at my job even when I do not have enough time to complete all my tasks 30. Positively cope with stress on the job Challenges involving boundaries between work and personal life 31. Leave my work stress at work and not take it home with me 32. Control worries about my future so that they do not interfere unduly with my ability to contribute at work All questions combinedd Mean Standard deviation

Pretest

Change

6.36

+0.67

6.50

+0.60

6.36 6.14 5.29c

+0.71 +1.00 +1.79b

6.64

+0.71

6.36

+0.71

5.86c 5.79c

+1.29b +1.21b

5.07c

+1.79b

5.64c

+1.79b

6.75 0.84

+0.97b 0.47

Note. Mean self-efficacy represents mixed-effect regression estimates of scale responses from 0 (cannot do at all) to 10 (certain can do), modeled as the sum of fixed effects for each question and its change over time, as well as random effects for each individual participant and the interaction of participant with time (see Oman et al., 2001). a. Higher than the mean of all questions combined, p < .05 (from t tests of posterior modes in mixed regressions that included random effects for participant and question). b. Change is different than zero, p < .05 (from t tests of regression coefficients in models that included fixed terms for question and its interaction with time, as well as random effects for participant and its interaction with time). c. Lower than the mean of all questions combined, p < .05 (from t tests of posterior modes in mixed regressions that included random effects for participant and question). d. Unweighted means and standard deviations of previous rows of table.

Findings that self-efficacy improvements were greatest among participants with lower initial self-efficacy and spirituality are interpretable and merit attempts at a fully prospective replication. Participants lower in initial self-efficacy or spirituality may have had less prior exposure to spiritual self-management tools and thus stood to benefit the most by acquiring them. An analogous but nonsignificant trend was also observed toward greater self-efficacy improvement among participants with lower initial religiousness (see Table 1). Prior internalization of mindfulness-like practices and, consequently, less need for them might account for the lower self-reported adherence to these practices by participants who were very spiri-

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tual or religious. Weaker prediction of self-efficacy gain by religiousness than by spirituality may exist because, in popular usage, religious tends to connote a narrower set of more institutionally based practices than does spirituality; some participants reporting low religiousness may nevertheless have had prior familiarity with spiritual self-management skills, perhaps from what Wuthnow (1998) calls a “practice-oriented spirituality.” The strength that adherence to mindfulness practices demonstrated in predicting increases in self-efficacy may be due in part to the overwhelming time pressures that many health professionals face within present-day health care systems. Unlike several of the other six points, the two mindfulness practices are employed directly in the work environment and may therefore act as the most immediate cause of enhanced work-related efficacy. Meditation, inspirational reading, training the senses, and spiritual association are practiced largely or entirely apart from work, but their practice may nevertheless be important for supporting or perhaps enabling long-term adherence to mindfulness practices, inasmuch as they foster the overall training of attention (Goleman, 1988; see also Benson, 1993). Our finding that a single factor, relational caregiving, explained more than half the selfefficacy variance suggests that a common cluster of interrelated skills may partly underlie each of the three previously identified caregiving skills that are reflected in the self-efficacy scale: managing personal relationships, managing boundaries, and dealing with ultimate concerns. The existence of a common skill set, perhaps involving control over attention, is consistent with Baumeister and Exline’s (1999) contention that self-regulation is a single “moral muscle” underlying many of the virtues that facilitate social relationships, with Goleman’s (1988) contention that concentrated attention “amplifies the effectiveness of any kind of activity” (p. 168), and with Pollner’s (1989) observation that the processes operating in a person’s relationship with the divine source of ultimate concern can be very similar to processes that operate in relationships with other human beings. EPP supporting materials also endorse a common attentional skill set, claiming its enhancement as a major training benefit. Nevertheless, in view of our very small sample size, it seems plausible that further studies with larger samples may eventually uncover intercorrelated but distinguishable selfefficacy scale subfactors that correspond to distinct caregiving skill domains. Importance and Application to Practice Although this Eight-Point Program is less prominent in comparison with well-known programs of mindfulness meditation, in several ways, the EPP provides a more direct connection to the wisdom traditions of the great religions (Smith, 1991). In this respect, the program is similar to a Judeo-Christian form of passage meditation studied by Carlson, Bacaseta, and Simanton (1988) but carries out these authors’ recommendation that passages for meditation could be drawn from a variety of religious or spiritual traditions. By thus connecting practitioners with the cognitive content related to wisdom traditions and religious modes of coping, this program may be hypothesized to foster a more sustained ability to practice mindfulness in the long term, as well as to support wise and effective coping (Baltes & Staudinger, 2000; Benson, 1993; Brown, 2000; Pargament, 1997). For example, Oman and Thoresen (in press-a) suggest that the EPP offers tools for enhancing a practitioner’s ability to learn from persons functioning as spiritual exemplars, persons who may range from saints and divine incarnations to family or support group members and fellow professionals. Calling this process observational spiritual learning, Oman and Thoresen argue that this mode of learning is central to the transmission of spirituality and has been systematically fostered

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by religious traditions throughout history (see also Bandura, in press; Oman & Thoresen, in press-b).4 Especially in light of such theoretical considerations, our participants’ large gains in caregiving self-efficacy suggest that the EPP could make important and perhaps distinctive contributions to health professional training and education, in which heightened incorporation of spirituality is an ongoing concern, partly because of mandates from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (Barnard et al., 1995; Ethics Network News Editor, 1998; Narayanasamy, 1999; Sierpina & Boisaubin, 2001). For example, other health care organizations and professional groups might follow the Association of American Medical Colleges and a large Colorado-based health care system, Exempla Healthcare, each of which has offered continuing education credits for physicians and nurses who receive EPP training (Fetzer Institute, 2002; Hedberg et al., 2001). Individual health care professionals may also study EPP tools in printed form or online and by attending ongoing workshops for further training (Hedberg et al., 2001).5 Our effect modification findings imply that EPP in-service training, although likely to benefit all organizations, may especially strengthen an individual or a professional staff that lacks the highest initial levels of spirituality and/or self-efficacy. Although preliminary, our findings support the EPP as a tool for achieving several personcentered health care training objectives (Barnard et al., 1995). Each of the three generic caregiving skills identified earlier—managing personal relationships, managing boundaries, and dealing with ultimate concerns—was represented among self-efficacy items that demonstrated statistically significant training increases (e.g., Table 2, Items 3, 20, 26). Regardless of whether further studies with larger samples reveal separate self-efficacy subfactors, the strong theoretical basis for the EPP suggests that it will enhance each corresponding professional skill. Furthermore, our finding that caregiving self-efficacy increases were significantly associated with mindfulness practices suggests that future EPP training for health professionals should not de-emphasize these two points, perhaps specifically sensitizing trainees to these points’ proximate roles in producing workplace benefit. Other EPP points may proximally mediate other beneficial outcomes unmeasured by this study. Addressing medical educators, Hedberg et al. (2001) offer fuller descriptions of several educationally relevant processes by which EPP training may have caused the skill enhancements observed in the present study. For example, the EPP’s comprehensiveness and systematic inclusion of cognitive material from spiritual wisdom traditions (e.g., Figure 2) may foster a “practical spiritual multilingualism”: Experience suggests that using the EPP can greatly assist health professionals in recognizing the practical dynamics and common elements of spiritual practices from a wide range of religious traditions. (Hedberg et al., 2001, p. 24)

Hedberg and colleagues (2001) also suggest that directly sharing portions of the EPP with patients may sometimes be appropriate, although it is best done cautiously because of power imbalances and other problematic features of relationships between health professionals and patients (Post, Puchalski, & Larson, 2000). “In as much as the EPP can be validly conceptualized as a toolkit consisting of several interrelated techniques for managing stress and gaining control over the mind,” they suggest, “sharing elements of the EPP may to some extent be governed by the same principles that govern the sharing of any other technique in a clinical setting” (Hedberg et al., 2001, p. 25). They urge professionals to maintain an ongoing aware-

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ness of alternative techniques that may be more appropriate for accomplishing particular objectives, as well as the knowledge and emotional detachment necessary to select the most appropriate technique. In many situations (e.g., for patients with severe pain or low levels of functioning), the most easily shared part of the EPP may be Point 2, the repetition of a mantram/holy word, a practice long known in both Eastern and Western spiritual traditions (Bernardi et al., 2001; Easwaran, 1977/1998; Oman & Thoresen, 2001a; see Oman & Driskill, 2003, for discussion of psychological mechanisms, historical background, and research needs). “Appropriately and ethically offering Point 2 of the EPP,” noted Hedberg and colleagues (2001), “demands many of the same skills in relating to patients and clients as is demanded by offering the recent version of Benson’s form of meditation” (p. 25) in which the focus of meditation is a word or phrase adopted from a person’s own spiritual tradition (Benson, 1993). Furthermore, as an ill or distressed person who uses the mantram/holy word breaks cycles of rumination and psychological distress and gains wellness, EPP materials can offer a smooth transition to integrating additional EPP tools into a personal repertoire of effective living strategies (Easwaran, 1977/1998). Finally, it should be noted that the present study expands the available empirical support for the EPP’s usefulness for a diverse range of populations and outcomes (e.g., beyond earlier findings by Earl et al., 1994; Flinders, Cohn, et al., 1994; Winzelberg & Luskin, 1999). The program’s flexibility and diverse appeal suggest that health promotion organizations might study the usefulness of offering facilities for learning and applying the EPP. In wellness-oriented health promotion settings, where staff professionals increasingly assist clients in formulating and pursuing personalized health/fitness goals, the EPP and supporting materials may offer a particularly rich and flexible approach to smoothly combining broader efficacy goals, or even spiritual goals, with a health focus. For example, a client might draw on EPP ideas and writings about Point 5, training the senses, to (a) formulate a specific goal for improving a health behavior such as diet, (b) identify a set of strategies for success that draw in part from the full EPP attentional retraining toolkit, and (c) receive onsite social support for implementing that strategy (e.g., Point 7). Similar steps might be applied to wellness goals related to exercising, managing stress, or enhancing personal concentration or caregiving skills. Future Research The major findings of this study are highly encouraging, but future research on this program must include larger samples and expanded study designs. Our posttest occurred at the beginning of the Christmas holiday season, often a time of distress that is unlikely to spuriously enhance self-efficacy (Lee et al., 1998). Nevertheless, studies that include control groups will be needed to rule out seasonal effects as an explanation for observed improvements in self-efficacy. Concurrent rather than retrospective measures of pretest spirituality (and other sociodemographic and spiritual variables) are needed to rule out recall biases, and consequently our findings regarding pretest spirituality must be regarded as provisional. The psychometric properties of the self-efficacy scale are promising but need further study. Testretest reliability should be assessed. Although the statistical tests for self-efficacy increases took sample size into account, future research should clearly aim to recruit larger numbers of participants. Larger samples are needed for additional statistical power to detect self-efficacy subfactors, as well as to guide construction of briefer versions of the scale. Studies could also beneficially include more ethnic and religious diversity and wider age ranges.

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Longer follow-up periods would allow study of the sustainability of self-efficacy gains and of whether long-term self-efficacy gains are mediated by assimilation of spiritual modeling material from wisdom traditions. Also worth investigating are effects on external measures, such as patient satisfaction, and objective or other-rated job performance. Several of these design features have been included in a randomized, waitlist controlled study of the EPP recently funded by the Fetzer Institute (2002). In conclusion, the findings reported here suggest that the Eight-Point Program, or other similar nonsectarian spiritually based programs, holds promise for enhancing caregiving self-efficacy among several types of health professionals. Increases in self-efficacy were demonstrated among both men and women in a population whose spiritual identities ranged from “spiritual but not religious” to adhering to several traditional religious faiths. Available data suggest that benefits are largest for professionals with lower initial spirituality and lower initial self-efficacy. If future studies confirm these findings, such programs could make important contributions to educating, supporting, and empowering health care professionals and perhaps other types of caregivers.

NOTES 1. Languages of independent publication include Bahasa Indonesian, Chinese (PRC), Chinese (Taiwan), Dutch, English, French, German, Greek, Hebrew, Hungarian, Italian, Japanese, Korean, Lithuanian, Malayalam (India), Marathi (India), Portuguese, Russian, Slovenian, Spanish, and Telugu (India). Works published independently in multiple languages include more than one dozen supportive texts in addition to the basic instructional text (Easwaran, 1978/1991b). All original program materials were developed by the late Eknath Easwaran (1911-1999), recently described by a preeminent publishing journal as “one of the most powerful . . . teachers lecturing and writing in America” (Carrigan, 1996). 2. The compatibility of the program with orthodox Western religious practice is reflected in remarks by prominent Roman Catholic theologian Henri Nouwen (1992) that “Easwaran showed me the great value of learning a sacred text by heart and repeating it slowly in the mind, word by word, sentence by sentence. In this way, listening to the voice of love becomes not just a passive waiting, but an active attentiveness to the voice that speaks to us through the words of the Scriptures” (p. 64). 3. Of the 28 intercorrelations among the eight measures of adherence to individual practices, 3 were large and significant (0.5 < r, p < .05), 10 were moderate (0.3 < r < 0.5), 7 were small (0.1 < r < 0.3), and 8 were negligible (–0.1 < r < 0.1). Intercorrelations between Points 2, 4, and 5 (mantram, one-pointedness, and sense training) were each large and significant (0.5 < r, p < .05); Point 4 (one-pointedness) was also marginally significantly associated with Points 1 and 3 (meditation and slowing down, 0.1 < r < 0.3, p < .10). 4. According to Bandura’s social cognitive theory, four processes underlie all observational learning, including observational spiritual learning: attention, retention, reproduction, and motivation (Bandura, 1997, in press; Oman & Thoresen, in press-a). The Eight-Point Program (EPP) appears to facilitate each of these four observational spiritual learning processes. For example, by memorizing and meditating on the words of spiritual exemplars who have composed such passages (Point 1), practitioners give attention to pertinent modeling information (i.e., information about the lives and thought processes of the authors of the passages). Meditating on the information in these passages fosters its retention, thereby facilitating its reproduction in behavior later during the day (e.g., when a meditator remembers St.

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Francis’s words “where there is hatred let me sow love”). Recommended meditation passages (Easwaran, 1982/1991a) emphasize positive rewards and benefits of spiritual living and should therefore inspire and motivate. Other components of the EPP, such as spiritual fellowship (Point 7), spiritual reading (Point 8), and frequent repetition of a holy word or mantram (Point 2), are also likely to foster observational spiritual learning either by providing additional and perhaps complementary modeling information (Oman & Thoresen, in press-b) or by facilitating its assimilation. 5. We have found particularly useful the publications and workshops for general audiences provided in many cities by the Blue Mountain Center of Meditation (http:// www.nilgiri.org), a nonprofit organization founded in 1961 by the developer of the EPP.

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Zeiss, A., Gallagher-Thompson, D., Lovett, S., Rose, J., & McKibbin, C. (1999). Self-efficacy as a mediator of caregiver coping: Development and testing of an assessment model. Journal of Clinical Geropsychology, 5(3), 221-230. Zinnbauer, B. J., & Pargament, K. I. (2000). Working with the sacred: Four approaches to religious and spiritual issues in counseling. Journal of Counseling & Development, 78(2), 162-171. Acknowledgments. Work by the first author in preparation of this article was (partially) supported by Training Grant T32 HL07365-21 from the U.S. National Heart, Lung, and Blood Institute. We especially benefited from the assistance of Susan Wallace, RN, and Marcy Messe, RN, in developing the self-efficacy scale. We also appreciate critical readings of an earlier version of the manuscript by members of the Behavioral Factors Seminar at UC Berkeley, especially Beverly A. Davenport, William Klitz, and S. Leonard Syme. We are grateful to Deborah Nickloy for permission to reproduce the drawing of the Native American; several other images are copyright ©2001-2003 by www.arttoday.com. Biographical Data. Doug Oman, PhD, obtained his doctorate in biostatistics from the University of California at Berkeley, where he is presently a lecturer, having recently concluded a postdoctoral fellowship studying relationships between psychosocial factors and health. He is currently or recently has been principal investigator on two grants, one from the National Institute of Aging to examine the positive effects of volunteer work on physical health and the other from Fetzer Institute to conduct a randomized waitlist controlled study of the Eight-Point Program. He has studied relationships between spirituality, religion, and health since 1997. John Hedberg, MD, MA, earned a master’s degree in medical anthropology and his MD from the University of Minnesota in Minneapolis. He is a clinical assistant professor of medicine at the University of Colorado Medical School and in the private practice of internal medicine in the Denver area. David Downs, MD, received his medical degree from the University of Colorado. He is board certified in internal medicine and is in private practice in Denver. He is currently a clinical assistant professor of medicine at the University of Colorado School of Medicine and is the president of the Denver Medical Society. Debra Parsons, MD, FACP, received her medical degree from the University of Colorado and is board certified in internal medicine and geriatrics. She is the associate program director for the Internal Medicine Residency at Exempla St. Joseph Hospital, where she is also the section chief of general internal medicine. She is an associate clinical professor in the Department of Medicine at the University of Colorado. Address correspondence to: Doug Oman, PhD, School of Public Health, 140 Warren Hall #7360, University of California, Berkeley, CA 94720-7360; e-mail: [email protected].