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 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 14-20

Religiosity and religious coping among outpatients with schizophrenia: Association with severity of illness and psychosocial functioning

1 Department of Internal Medicine, Federal Medical Centre, Owerri, Owerri, Imo State, Nigeria
2 Department of Mental Health, Faculty of Medicine, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
3 Department of Clinical Services, Federal Neuropsychiatric Hospital, Enugu, Nigeria

Date of Submission10-Jul-2021
Date of Acceptance18-Apr-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Justus U Onu
Department of Mental Health, Faculty of Medicine, Nnamdi Azikiwe University, Awka, Anambra State 420211
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnam.jnam_2_21

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Background: There are burgeoning data on the beneficial and deleterious effects of religion on health, especially, mental health worldwide. This complex relationship between religious variables and outcome in patients with schizophrenia is yet to be robustly explored among Africans. This study aimed to determine the relationship between religious variables (i.e., religious coping and orientation) and outcome variables (e.g., disease severity and psychosocial functioning). Materials and Methods: The study was a cross-sectional study done at the Federal Neuropsychiatric Hospital, Enugu, Nigeria. A total of 422 outpatients who met the stringent criteria for schizophrenia were recruited into the study over a study period of 18 weeks. Standard instruments were used to measure religious coping (Brief Religious Coping-Brief—RCOPE), religious orientation (Religious Orientation Scale-Revised—ROS-R), disease severity (The Brief Psychiatric Rating Scale), and psychosocial functioning (Social and Occupational Functioning Assessment Scale). A multivariate linear regression analysis was used to determine the religious variables that predicted disease severity and psychosocial functioning. Results: Religiosity and religious coping variables were not significant predictors of symptom severity among patients with schizophrenia. However, negative religious coping was a significant predictor of poor psychosocial functioning (t = −2.23, P = 0.02, β = −0.28), whereas high score in intrinsic religiosity was a predictor of good psychosocial functioning (t = 3.32, P = 0.001, β = 0.27). Conclusion: Findings from this study support the vast majority of research that suggests that religiosity and religious coping have diverse effects on clinical and functional outcomes.

Keywords: Functioning, Nigeria, religious coping, religious orientation, schizophrenia, symptom severity

How to cite this article:
Inechi MC, Onu JU, Achor JU, Ubochi VN. Religiosity and religious coping among outpatients with schizophrenia: Association with severity of illness and psychosocial functioning. J Niger Acad Med 2022;1:14-20

How to cite this URL:
Inechi MC, Onu JU, Achor JU, Ubochi VN. Religiosity and religious coping among outpatients with schizophrenia: Association with severity of illness and psychosocial functioning. J Niger Acad Med [serial online] 2022 [cited 2023 Jan 30];1:14-20. Available from: http://www.jnam.com/text.asp?2022/1/1/14/354767

  Introduction Top

From the time of Kraepelin, schizophrenia is often conceptualized by clinicians and researchers alike as a chronic illness with persisting, relapsing, or deteriorating symptoms, with no hope for sustained remission and recovery of functioning.[1],[2],[3] However, with the increasing presence of persons with schizophrenia and the recognition that they could function to varying degrees in the society despite their illness, clinicians are now shifting their focus from symptom reduction to ensuring that patients attain a significant level of social and occupational functioning.[4]

Various sociodemographic, sociocultural, and clinical factors have been examined as potential predictors of clinical and psychosocial outcomes in patients with schizophrenia.[5],[6],[7],[8] One sociocultural factor that has been understudied in Nigeria is religiosity/spirituality variables. Religion and spirituality are considered an integral part of the lives of many individuals especially in the Nigerian context.[9],[10] Research findings show that religious healers are widely consulted in times of mental health crisis in Nigeria, in fact, more frequently than psychiatrists, and they thus constitute an important pathway to accessing mental health care to many citizens.[9],[10] With regard to the relationship between religiosity/spirituality and various domains of schizophrenia outcomes, the findings are diverse, with some reporting some beneficial effects on symptom severity and functioning,[11] whereas others suggest that increased religiosity is associated with more severe symptoms and disability.[12] However, there is evidence for the role of religion and spirituality on the manifestation and severity of psychopathology,[12] psychosocial functioning,[11] quality of life,[11] coping with illness, and help-seeking and treatment adherence.[13],[14] For example, Triveni et al.[11] reported that higher levels of religiosity and more frequent use of positive religious coping (PRC) are associated with lower levels of psychopathology, improved functioning, and better quality of life. Studies have shown that religious beliefs and practices are sources of strength and resilience and as a result enable individuals to make sense of their suffering as well as help them cope with or adapt to difficult life situations or stress.[15],[16] Hill and Pargament[17] opined that religion and spirituality exert their influence on disease outcomes through behavioral (e.g., lifestyle factors), social (e.g., social capital from the supportive network of the religious group), psychological (e.g., belief in the supernatural), and physiological mechanisms (e.g., relaxation from religious practices such as meditation).

Despite the thinking that sociocultural norms (e.g., religion/spirituality) may explain the prevailing view that the outcome of schizophrenia in the developing countries is better than the developed world, the relationship between religious variables and various outcome measures in patients with schizophrenia has been understudied in Nigeria. Few studies in Nigeria highlighted the usefulness of religious variables in coping with depression in patients with diabetes and medication adherence in HIV-treated persons.[18],[19] There is paucity of data on the relationship between religiosity, severity of symptoms, and psychosocial functioning among stable patients with schizophrenia in Nigeria. Based on this, this study sought to answer the following questions:

  1. What is the relationship between religiosity/spirituality variables and severity of psychopathology in stable patients with schizophrenia?

  2. What is the relationship between religiosity/spirituality variables and psychosocial functioning in stable patients with schizophrenia?

  Subject and Methods Top

Study design and population

This was a cross-sectional study carried out among stable outpatients with schizophrenia at Psychiatric Hospital in Enugu, South-Eastern, Nigeria. The hospital provides mental health services to all age groups and in the various branches of psychiatric services. Outpatient clinics are run 4 days every week in the hospital. About 150 patients attend the clinic each day. An average of 40 patients with the diagnosis of schizophrenia is seen per clinic irrespective of the consulting units. Participants were recruited in 6-month period spanning from March 2018 to August 2018.

Sample selection

Consecutive individuals who presented with schizophrenia that appear to have been in a stable clinical condition were recruited into the study. Stable participants were those are conscious and able to follow the interview without a need for emergency care. Participants were aged 18–60 years and had a diagnosis of schizophrenia made at least 1 year and without other psychiatric or chronic medical conditions.

In computing the required sample size for the study, we used the finding from Pieper[20] on the prevalence of religious coping among patients with schizophrenia. Based on his finding that the proportion of patients with schizophrenia that used religious coping was 50%, the sample size was computed using Cochran formula for single proportion (z2pq/d2) and arrived at 422 after adjusting for nonresponse.

Using the case records, consecutive attendees were evaluated on the basis of the study inclusion and exclusion criteria. Individuals who qualified for the study were approached for recruitment and those who agreed to participate were enlisted. Of the 615 outpatients with a diagnosis of schizophrenia who were brought to the attention of the researcher, 53 were unable to follow the interview process because of florid-positive symptoms and were excluded. Another 68 who had comorbid physical conditions or other severe mental illnesses or substance-use disorders were excluded after a detailed medical history and physical examination, whereas 72 declined to participate in the study because of the extra time taken to conduct the research interview.

Ethical consideration

The ethical approval was obtained from the Ethical Committee of the Federal Neuropsychiatric Hospital, Enugu, Nigeria with reference number FNHE/HTR/REA/VOL.11/334. International ethical norms and standards were strictly adhered to; written informed consent was obtained from all the participants. Participation was voluntary.


Obtaining consent

The aim, objectives, and implications of this study were explained to the participant. He/she was assured that there is no risk participating in the study and that information gotten during the interview shall remain confidential and used only for the purpose of the research. He/she was made to understand that he/she can withdraw from the study at any point in the study if he/she so wishes and that they were not to suffer any consequences for choosing not to participate. After these explanations, each participant freely signed or thumb-printed on the consent form.

Diagnostic interview

Participants who met the inclusion criteria were enrolled into the study after consultation. On getting informed consent, the researcher administered to the consenting participant the psychosis module of the Mini International Neuropsychiatric Interview (M.I.N.I) to confirm the diagnosis. Participants whose diagnoses were confirmed with the M.I.N.I (psychosis module) as schizophrenia completed the study. Those who did not meet the criteria were continued on their routine outpatient consultation. Thereafter, using the screening version of the other modules of the M.I.N.I, the presence of comorbid major mental disorders was excluded.

Administration of questionnaires

After a detailed medical history of the participants whose diagnosis had been confirmed by the M.I.N.I, the principal investigator carried out a full physical examination (including neurological examination) to exclude the presence of comorbid physical conditions. For those with comorbidities, adequate counseling was given and the managing teams were alerted for further action(s). The sociodemographic questionnaire was then used to obtain sociodemographic information. Thereafter, the Religious Orientation Scale-Revised (ROS-R) and Brief Religious Coping Scale (RCOPE) were administered one after the other to elicit relevant information regarding religiosity/spirituality and religious coping. The severity of psychopathology and psychosocial functioning was assessed using the Brief Psychiatric Rating Scale (BPRS) and Social and Occupational Functioning Scale (SOFAS), respectively.

The Religious Orientation Scale

The ROS-R, also called the Intrinsic/Extrinsic (I/E) scale (revised), is a 14-item scale that measures intrinsic and extrinsic dimensions of religiosity, respectively. The original ROS was developed by Allport and Ross in 1967 but revised by Gorsuch and McPherson in 1989 and known as ROS-R (or I/E revised).[21],[22]

It assesses specific religious behavior categorized into an intrinsic behavior subscale and extrinsic behavior subscale. These two subscales look at religion as a motivational construct and scored on a five-point Likert-type scale (1 = strongly disagree to 5 = strongly agree). Reliability estimates were: for intrinsic (I)-revised, 0.83; extrinsic personal (Ep)-revised, 0.57; extrinsic social (Es)-revised, 0.58; and extrinsic (E)-revised, 0.65.[23] Both subscales have high internal consistency (for intrinsic scale, alpha equals 0.85 and for extrinsic scale, alpha ranges between 0.70 and 0.75).[24] Its psychometric properties as an assessment tool for measuring religious orientation for Nigerian population have also been established to reflect similar alpha values.[25]

The Brief Religious Coping Scale

The Brief RCOPE (B-RCOPE) is a 14-item scale assessing religious coping in the form of two factors, i.e., positive (PRC) and negative religious coping (NRC).[26] PRC reflects a secure relationship with a transcendent force, a sense of connectedness with others, and benevolent world view, whereas NRC reflects underlying spiritual tensions and struggles within oneself, with others, and with the divine. The items are scored on a four-point Likert scale ranging from “0 = not at all” to “3 = a great deal.” The total score ranges from 0 to 21 for each subscale; the higher the score, the stronger the PRC and NRC, respectively. The validity and reliability of the B-RCOPE have been supported by studies.[27]

The Brief Psychiatric Rating Scale

The BPRS is a widely used instrument for assessing the severity of positive, negative, general, and affective symptoms of individuals who have severe mental disorders, especially schizophrenia.[28] The BPRS consists of 18 symptom constructs and takes 20–30 minutes for the interview and scoring. It is rated on a Likert scale of 1 (not present) to 7 (extremely severe) or 0–6 in the new version. We used the 1–7 scale rating.

Social and Occupational Functioning Scale

The SOFAS is a clinician-rated scale for the assessment of current functioning. It is derived from Global Assessment Scale, which measures the overall severity of psychiatric disturbance.[29] It is neither directly influenced by the overall severity of the individual’s psychological symptoms nor the effects of lack of opportunity and other environmental limitations. It has excellent interrater reliability (ICC = 0.83).[30] The SOFAS considers social and occupational functioning in a continuum, from excellent functioning to grossly impaired functioning. Its scores range from 0 to 100, with lower scores representing lower functioning. Each interview lasted for no more than 45 minutes to 1 hour.

Data analysis

Data were analyzed using the International Business Machine-Statistical Package for Social Sciences (IBM-SPSS) version 20. Categorical variables were described using frequency counts and percentages. The association between sociodemographic variables and severity of psychopathology and psychosocial functioning was done using Mann-Whitney U-test or Kruskal-Wallis test as appropriate. The relationship of religious variables with the severity of psychopathology and psychosocial functioning was analyzed using partial correlation while controlling for covariates such as age at the onset of the disease and the duration of illness. Multivariate linear regression was used to identify the potential predictors of the severity of symptoms and psychosocial functioning.

  Results Top

The participants were mostly young adults (mean age of 36 years), males (52.1%), and with more than 6 years of formal education (80.1%). The median age at the onset and the duration of illness were 26 years and 2 years, respectively, as shown in [Table 1]. [Table 2] shows that the employment status was significantly associated with the severity of psychopathology and psychosocial functioning (P < 0.001), whereas marital status was significantly associated with psychosocial functioning (P = 0.006) but was a trend for the severity of psychopathology (P = 0.05). The relationship between religious variables, severity of psychopathology, and psychosocial functioning is shown in [Table 3]. PRC and intrinsic religiosity negatively correlated with the severity of psychopathology but positively correlated with psychosocial functioning, whereas the NRC had a positive correlation with the severity of psychopathology but negative correlation with psychosocial functioning. Religious variables were not significant predictors of symptom severity after controlling for potential confounders. However, intrinsic religiosity was a significant predictor of good psychosocial functioning, whereas NRC was a predictor of poor psychosocial functioning [Table 4].
Table 1: Sociodemographic and clinical characteristics of the study participants

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Table 2: Relationship between sociodemographic and severity of symptoms and psychosocial functioning

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Table 3: Correlation of religious and clinical variables with severity of psychopathology and psychosocial functioning

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Table 4: Sociodemographic, clinical, religiosity variables as predictors of illness severity and psychosocial functioning

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  Discussion Top

This cross-sectional study aimed to determine the relationship between religious variables and various outcome indicators (i.e., psychopathological and psychosocial functioning) among a large cohort of stable patients with schizophrenia. The summary of the major findings is: (1) PRC and intrinsic religiosity positively correlated with psychosocial functioning but inversely related to the severity of psychopathology, whereas NRC positively correlated with the severity of symptoms but negatively for psychosocial functioning; (2) after controlling for sociodemographic (e.g., gender, employment status) and clinical factors (e.g., age at the onset, the type of antipsychotic medication, the duration of illness), high scores in PRC and intrinsic religiosity were the significant predictors of psychosocial functioning; and (3) religious variables did not significantly predict the severity of psychopathology.

With regard to the relationship between various aspects of religiosity with the severity of symptoms of schizophrenia, the findings are diverse from several studies.[11],[12],[13] Although some authors have reported that some religious activities and beliefs are associated with more severe psychopathology,[12] others suggest that increased religiosity or religious activities are positively correlated with the reduction of psychopathology.[11],[13] This later observation is consistent with the findings of the present study. Hence, participants who utilized more PRC (i.e., those who had more secure relationship with supernatural and a sense of connectedness with others with more optimistic view of the universe) and are of intrinsic religiosity orientation (i.e., the extent to which an individual uses religion as a pathway toward reaching goals set by the religion) had lower scores in the psychopathology scale, whereas those who used more of NRC and extrinsic religiosity orientation had high symptom severity. Triveni et al.[11] re-echoed this finding among Indian patients with schizophrenia. Both studies used similar methodology (i.e., stable patients with schizophrenia and RCOPE as the measures of religious coping). However, the usefulness of religious variables in modulating the severity of psychopathology was not significant after controlling for potential confounders such as age at the onset of illness and the duration of illness. The implication of this later finding is that religiosity factors alone may not be necessary, but when they interact with other factors, they may influence the severity of psychopathology. This may indeed be the case as some studies have postulated that the positive influence on religious variables on psychopathology may be mediated by medication adherence.[14]

Similarly, there is some evidence for the role of religion and spirituality on psychosocial functioning among patients with chronic medical conditions such as schizophrenia.[11] In the present study, PRC and intrinsic religiosity were significant predictors of improved psychosocial functioning, whereas the reverse was the case for NRC. Johnson et al.[31] and Triveni et al.[11] reported that intrinsic religiosity and PRC were associated with psychosocial adaptation and functional and social recovery among patients with schizophrenia. Elsewhere, researchers have shown that religion/religiousness in patients with schizophrenia is associated with better social integration,[32] reduced use of psychoactive substances, improved social support,[33] good medication adherence, and more adaptive lifestyle.[14] In addition, religious coping is positively correlated with psychological and existential well-being with PRC as the primary predictor of emotional well-being. These primary effects of religious variables on the various psychosocial milieu of the individual may explain its usefulness in psychosocial functioning among patients with schizophrenia.


The study was limited by the following: First, it was a hospital-based study and as such may not be a good representation of the general schizophrenia population in the community. Second, because of the cross-sectional nature of the study, causal relationship between the independent variables and outcome measures may not be inferred. Third, the participants may be particularly vulnerable to social desirability bias, especially considering the self-report nature of some of the instruments, the presupposed benefits that might come from presenting themselves as having fewer symptoms or as being particularly religious or nonreligious. This may have specifically affected their responses to the items and skewed the scores on the instruments with consequent effect on the interpretations.

Fourth, the nonprobability sampling method was also a limitation, as it may have excluded individuals from the study whose experiences might have been different. Despite this inherent limitation, it was nevertheless the most appropriate for this study setting.

  Conclusion Top

The findings of the present study support the emerging literature on the beneficial effects of some aspects of religiosity/spirituality on psychosocial functioning among stable outpatients with schizophrenia. Based on this finding, there is a need to expand the biopsychosocial model of treatment to incorporate religious concerns to harness its usefulness in recovery.

Authors’ contributions

MCI was the principal investigator. However, JUO, JUA, and VNU were also involved in the conceptualization and supervision. MCI collected the data and JUO analyzed the data. All the authors approved the final draft for submission.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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