“I am spiritual, but not religious”: Does one without the other protect against adolescent health-risk behaviour?

“I am spiritual, but not religious”: Does one without the other protect against adolescent... Objectives Spirituality and religious attendance (RA) have been suggested to protect against adolescent health-risk behaviour (HRB). The aim of this study was to explore the interrelatedness of these two concepts in a secular environment. Methods A nationally representative sample (n = 4566, 14.4 ± 1.1 years, 48.8% boys) of adolescents participated in the 2014 Health Behaviour in School-aged Children cross-sectional study. RA, spirituality (modified version of the Spiritual Well-Being Scale), tobacco, alcohol, cannabis and drug use and the prevalence of sexual intercourse were measured. Results RA and spirituality were associated with a lower chance of weekly smoking, with odds ratios (OR) 0.57 [95% confidence interval (CI) 0.36–0.88] for RA and 0.88 (0.80–0.97) for spirituality. Higher spirituality was also associated with a lower risk of weekly drinking [OR (95% CI) 0.91 (0.83–0.995)]. The multiplicative interaction of RA and spirituality was associated with less risky behaviour for four of five explored HRB. RA was not a significant mediator for the association of spirituality with HRB. Conclusions Our findings suggest that high spirituality only protects adolescents from HRB if combined with RA. Keywords Health-risk behaviour  Adolescence  Religious attendance  Spirituality  HBSC study Introduction health-risk behaviours (Hansen et al. 2010) and is often a predictor of adult health-risk behaviour (Grant et al. 2006; Adolescent health-risk behaviour attracts the attention of Virtanen et al. 2015). Similarly, an early initiation of researchers worldwide, because it can leave a lasting effect sexual life is associated with other risk factors (Lara and over the whole life course. The earlier onset of substance Abdo 2016). use, for example, is associated with engaging in multiple With regard to prevalence, both gender differences (MacArthur et al. 2012; Saewyc et al. 1998; Wang et al. 2010) and country differences (Inchley et al. 2016) exist in Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00038-018-1116-4) contains adolescent health and health-risk behaviour. For example, supplementary material, which is available to authorized users. Department of Health Psychology, Faculty of Medicine, & Klara Malinakova University of Pavol Jozef Safarik Kosice, Tr. SNP 1, klara.malinakova@oushi.upol.cz 040 11 Kosice, Slovak Republic OUSHI - Olomouc University Social Health Institute, Department of Social Medicine and Public Health, Faculty of Palacky University Olomouc, Univerzitni 244/22, Medicine and Dentistry, Palacky University Olomouc, 771 11 Olomouc, Czech Republic Olomouc, Czech Republic Department of Community and Occupational Health, Institute of Active Living, Faculty of Physical Culture, University Medical Center Groningen, University of Palacky University Olomouc, Trida Miru 115, Groningen, Ant. Deusinglaan 1, 9713 AV Groningen, The 771 11 Olomouc, Czech Republic Netherlands Graduate School Kosice Institute for Society and Health, University of Pavol Jozef Safarik Kosice, Tr. SNP 1, 040 11 Kosice, Slovak Republic 123 K. Malinakova et al. in the 2005/2006 Health Behaviour in School-aged Chil- deeply religious attitude; however, recently, it is often also dren (HBSC) survey, the frequency of drunkenness understood as a more subjective search for peace, harmony, increased by an average of 40% in all participating eastern meaning in life and connection with the sacred (Koenig European countries compared to the 1997/1998 HBSC 2008). The above-mentioned heterogeneity hinders com- survey, but decreased by an average of 25% in 13 of the 16 parison of the various studies. Though both religiousness Western European and North American countries included and spirituality emphasize a search for the sacred, people in the study. An increasing trend in the Czech Republic, who are religious or spiritual might differ in the means they Bulgaria, Croatia and Hungary was reported also in the use to find this. In the absence of religious commitment, an study of Kuntsche et al. (2011), which further pointed out individual could actually even use alcohol, tobacco, hal- that the prevalence remained stable or even decreased in lucinogens or sexual intercourse, etc., as means to discover countries such as Finland, Iceland and Norway. This meaning, purpose and connectedness with the self, others finding shows the importance of the wider cultural and or the transcendent (Burris et al. 2011). economical context and probably also reflects an effect of However, other explanations may also hold for the different policies in this area. From this perspective, the varying associations of religiosity and spirituality. One of search for possible protective factors in adolescent health- them is the degree of internalization of religious attitudes risk behaviour remains an urgent need in the Czech (Powell et al. 2003), i.e., the inner content and experience Republic. According to the last published HBSC survey of one’s faith. This aligns with the spirituality level; (2013/2014) (Inchley et al. 2016), the prevalence of therefore, it may be informative not only to analyse spiri- drunkenness decreased significantly between the years tuality and religiosity separately, but also jointly, and to 2010 and 2014. However, the Czech Republic still holds its check a possible mediation effect. For the purpose of this position in the most unfavourable third of the countries article, we chose religious attendance as the external with data on adolescent weekly drinking, in the unfa- dimension of religiosity, and spirituality as the internal vourable half regarding weekly smoking and recent can- dimension. In our study, spirituality is understood in the nabis use and in the least favourable ten per cent regarding broader sense: as the internal individual contentedness, early sexual intercourse. one’s perceived closeness to God, one’s sense of meaning Religiosity and spirituality have often been studied as of life and of spiritual well-being (Ellison 1983). protective factors in adolescent health-risk behaviour, Thus far, most studies on the relationship between including the prevention of smoking (Nonnemaker et al. religiosity/spirituality and adolescent health-risk behaviour 2006), alcohol (Piko et al. 2012) and cannabis use (Gmel have been conducted outside of Europe (Nonnemaker et al. et al. 2013) and sexual behaviour (Hardy and Raffaelli 2006; Rew and Wong 2006), and only a very few within Central Europe (Brassai et al. 2015; Piko et al. 2012 2003; Nonnemaker et al. 2003). In a systematic review, ; Pitel Rew and Wong (2006) concluded that most studies (84%) et al. 2012). With regard to religious affiliation, the Czech showed that higher religiosity/spirituality was related to Republic is a specific case in Central Europe. This might be less health-damaging attitudes and behaviours. However, a the consequence of the historical development of the minority of studies came to at least partially different country, as the anticlerical attitudes that were already conclusions. Burris et al. (2011) found religiosity to be present were further reinforced by the 40 years of the associated with less underage alcohol use, while spirituality communist re´gime (Nesporova and Nespor 2009). was associated with more, and also described a similar According to the Pew Research Center (2014), it is the pattern regarding adolescent sexual behaviour (Burris et al. country with the highest percentage (76.4%) of religiously 2009). unaffiliated people in the world, meaning that three-quar- The differences may be partly explained by the fact that ters of the population do not affiliate themselves to any both spirituality and religiosity are multidimensional con- organized church, though they might have some kind of structs that include attitudes, behaviours and beliefs personal belief. This very specific setting may affect the (Hooker et al. 2014). Nevertheless, many studies assess protective role of religiosity and spirituality regarding both only one or two dimensions. Originally, the term religion physical and mental health (Hayward and Elliott 2014). included both individual and institutional dimensions (Hill Therefore, the aim of this study is to explore the asso- and Pargament 2003); however, later it started to be more ciation of spirituality and religious attendance with ado- associated with religious institutions, prescribed theology lescent health-risk behaviour in a highly secular and rituals and institutional beliefs and practices, such as environment and to explore whether spirituality modified church membership or attendance (Zinnbauer et al. 1997). the association of religious attendance, or religious atten- In contrast, spirituality was originally used to describe a dance mediated that of spirituality. 123 ‘‘I am spiritual, but not religious’’: Does one without the other protect against adolescent… churches/denominations; therefore, the participants who Methods reported attending religious sessions at least once a week were dichotomized as attending. Participants and procedure Spirituality was measured using the modified shortened version of the Spiritual Well-Being Scale (SWBS) (Cotton We obtained data on a nationally representative sample of et al. 2005; Malinakova et al. 2017), measuring the overall Czech boys and girls from the 2014 HBSC study. This spiritual well-being. Response possibilities for all seven cross-sectional WHO collaborative study focuses on health items regarded a 6-point scale that ranged from ‘‘strongly and health-related behaviour and their socio-economic disagree’’ (1) to ‘‘strongly agree’’ (6), leading to scores determinants in 11-, 13-, and 15-year-old children. More from 7 to 42. A higher score represented greater spiritual detailed information about the survey can be found in well-being. In the analyses, spirituality was used as a Roberts et al. (2009). Schools were selected randomly after continuous variable, but for the purpose of dichotomization stratification by region, school size and type of school for a sensitivity analysis, participants with a score of 34 or (primary schools vs. secondary schools). Out of 243 con- higher (upper quartile of the score) were considered as tacted schools, 242 agreed to participate (response rate spiritual, and the rest as non-spiritual. Cronbach’s alpha 99.6%). Then, classes from the fifth, seventh and ninth was 0.81 in our sample. grades, in general corresponding to age categories of 11-, Tobacco use was measured by the question: ‘‘How often 13- and 15-year-olds, were selected at random, one from do you smoke tobacco at present?’’ Respondents reported each grade per school. their experience with smoking as follows: (1) every day; Data from 14,539 pupils were obtained (response rate (2) at least once a week, but not every day; (3) less than 89.2%). Most non-response was due to illness or other once a week; (4) I do not smoke. Following the HBSC reasons, for example, sports or academic competitions dichotomization (Currie et al. 2012), respondents who (10.6%), and 30 children refused to participate in the sur- smoked at least once a week were classified as smokers, the vey (0.2%). The spirituality questionnaire was included rest as non-smokers. only in the surveys of half of the 13- and 15-year-old Alcohol use was assessed by the question: ‘‘At present, adolescents, so the dataset comprised 4889 adolescents. Of how often do you drink anything alcoholic, such as beer, these, 564 (11.5% of the sample) had not responded to at wine or spirits?’’ Respondents reported frequency of least one of the seven SWBS items. We used a multiple alcohol consumption for five types of alcohol drinks with imputation to estimate values for the respondents who had the answers: (1) every day; (2) every week; (3) every responded to the majority of the SWBS items. The month; (4) rarely; (5) never. Following the HBSC remaining participants—who had not responded to four or dichotomization (Currie et al. 2012), individuals were more SWBS items—were excluded from the study classified as alcohol consumers if they reported consump- (n = 323). The final analytic sample thus included 4566 tion of any alcohol drink at least each week. respondents (mean age = 14.4, SD = 1.09, 48.8% boys). Cannabis use was assessed only in the 15-year-old For a graphical illustration of the preparation of the sample, respondents. They were asked the question: ‘‘Have you see Fig. 1. taken cannabis (grass) in the last 30 days?’’ with the pos- Data were collected between April and June 2014. The sible answers (1) never; (2) 1–2 days; (3) 3–5 days; (4) questionnaires were distributed by trained administrators 6–9 days; (5) 10–19 days; (6) 20–29 days; (7) 30 days with no teachers present in the classroom in order to reduce (and more). Following the HBSC dichotomization (Currie information bias. The consent to carry out the study was et al. 2012), respondents who answered ‘‘never’’ were obtained through school management at all the schools classified as cannabis non-users, the rest of the respondents involved in the survey. Participation in the survey was as users. anonymous and voluntary, and the parents of the pupils Experience with drug use was measured on 15-year-old were informed about the survey. respondents with the question ‘‘Have you ever taken one or several of these drugs in your life?’’ Respondents reported Measures their lifetime experience with five kinds of drugs (ecstasy, pervitin, glue or solvents, LSD and a non-existing drug, Religious attendance was measured by the question: ‘‘How netalin), with the same answers and dichotomization as for often do you go to church or to religious sessions?’’ with cannabis use. The respondents who reported an experience possible answers: several times a week/approximately once with netalin were not included in the analyses of lifetime a week/approximately once a month/a few times a year/ drug use. exceptionally/never. Sunday attendance is a matter of Early sexual intercourse was measured only among obligation in most of the Christian 15-year-old respondents by the question: ‘‘Have you ever 123 K. Malinakova et al. Imputation of missing values (MAR only) for RA/spirituality and HRB 4,182 respondents with complete responses (includes 2,091 respondents with Original sample non-MAR values for HRB)* Sample for analysis n = 4,889 387 respondents with some n = 4,566 missing responses on items for RA/spirituality and HRB (MAR) Exclusion of respondents with missing responses on a majority of the items for RA/spirituality n = 323 Fig. 1 Preparation of the sample (Czech Republic, 2014). Note: *Items included only for the 15-year-old respondents; RA religious attendance, MAR values missing at random, HRB health-risk behaviour had sexual intercourse (sometimes this is called ‘‘making multilevel modelling. We assessed the associations of only love’’, ‘‘having sex’’, etc.)? (yes, no). religious attendance (Model 1), only spirituality (Model 2), Age, gender and socio-economic status were considered of both variables jointly (Model 3) and their multiplicative as potential confounding variables. The socio-economic interaction (to assess moderation) (Model 4) with the var- status of the respondents’ families was used as a covariate ious health-risk behaviours using binary logistic regression and was assessed by the Family Affluence Scale (FAS) models. Each model was first tested as a crude one, and (Currie et al. 2014). The scale examines the number of cars then, it was adjusted for gender, age and socio-economic owned by the family, having one’s own bedroom, number status. For the sensitivity analysis using the dichotomized of computers in the household, number of foreign family spirituality, the prevalences of all types of health-risk holidays, number of bathrooms and dishwasher ownership. behaviour were compared with the proportion test. Finally, The summary score ranges from 10 to 13, and following mediation analysis was performed using the bootstrap HBSC recommendations, it was converted into a fractional approach via mediation package in R. We tested whether rank (ridit) score, leading to transformation of ordinal data religious attendance mediated the association of spirituality to an interval scale with a normalized range (from 0 to 1, with health-risk behaviour as well as whether spirituality with higher score indicating higher socio-economic posi- mediated the association of religious attendance with tion) and distribution. health-risk behaviour. All analyses were performed using the statistical software package IBM SPSS version 21. For Statistical analyses the imputation of missing data, the Hmisc package in the R software was used. As a first step, we performed a multiple imputation of missing data on item level, twenty times. It was assumed that data are missing at random (MAR). Then, we descri- Results bed the background characteristics of the sample and compared the respondents excluded from the analyses with The background characteristics of the sample are presented the remaining ones. Next, we checked the effect of in Table 1, which also describe prevalence of five kinds of ‘‘school’’, given the nested nature of the data. That showed health-risk behaviour for both attending and non-attending that the intraclass correlation between students from the respondents. Of the 4566 adolescents, 331 (7.2%) reported same school was negligible; therefore, we did not use attending church services once a week or more. Religious 123 ‘‘I am spiritual, but not religious’’: Does one without the other protect against adolescent… Table 1 Characteristics of the sample (Czech Republic, 2014) Total Religious attendance Attending (C 1/week) Non-attending (\ 1/week) Number % Number % Number % Gender Boys 2230 48.8 145 43.8 2085 49.2 Girls 2336 51.2 186 56.2 2150 50.8 Age 13 years old (seventh grade) 2291 50.2 162 48.9 2129 50.3 15 years old (ninth grade) 2275 49.8 169 51.1 2106 49.7 Health-risk behaviour Weekly smoking 487 10.7 23 6.9 464 11.0 Weekly drinking 577 12.6 33 10.0 544 12.8 Recent cannabis use (only 15-year-olds) 189 8.3 15 8.9 174 8.3 Lifetime drugs use (only 15-year-olds) 186 8.3 18 10.9 168 8.0 Early sexual intercourse (only 15-year-olds) 500 22.0 29 17.2 471 22.4 Total 4566 100 331 7.2 4235 92.8 Only numbers regarding the respondents with the occurrence of a health-risk behaviour are presented attendance and spirituality (SWBS scale) were moderately attendance and spirituality (Model 4) showed that a one SD correlated with Spearman’s r = 0.30 (p \ 0.01). The mean increase in spirituality for attending respondents was SWBS score was 22.15 (SD = 7.61) with minimum 7 and associated with 40% decrease in the odds of weekly maximum 42 (median 21). The SWBS was non-normally smoking, 31% decrease in the odds of weekly drinking, distributed, with skewness of 0.528 (SE = 0.036) and 51% decrease in the odds of recent cannabis use and 52% kurtosis of 0.063 (SE = 0.072). Of the highly spiritual decrease in the odds of lifetime drug use. With regard to respondents, i.e., those in the upper quartile of a score, early sexual intercourse, the result was significant only for 54.0% were boys and mean age was 14.31 (SD = 1.12). Of the crude model (33% decrease in the odds), but not for the these, 61.9% were attending religious sessions at least once adjusted one. a week. Of the participants, 1202 (26.3%) were involved in The sensitivity analysis using the dichotomized spiritu- at least one kind of health-risk behaviour, with the fre- ality (Fig. 2) compared the prevalences of health-risk quency being higher for non-attending (26.8%) than for behaviour in respective groups with the proportion test. attending (19.9%) respondents (p \ 0.05). Compared to Non-spiritual attending group (NSA) was considered ref- included respondents, those excluded (n = 323) were erence group for these comparisons in order to allow a prevalently boys (p \ 0.05), were slightly older (p \ 0.01) more detailed assessment of the dissonance of religious attendance and spirituality. *p \ 0.05, **p \ 0.001. and had a higher prevalence of recent cannabis (p \ 0.05) and drugs use (p \ 0.001), but did not differ significantly Comparison of prevalences of health-risk behaviour in regard to other health-risk behaviours. (Fig. 2) showed that there were no significant differences Table 2 shows the associations of religious attendance, in the prevalence of smoking and weekly drinking in the spirituality and their interaction with various health-risk respective groups. The recent cannabis use had signifi- behaviours, adjusted for gender and age. Attending cantly higher prevalence in the NSA (13.5, 95% CI respondents were less likely to be involved only in weekly 9.6–17.4%) than the non-spiritual non-attending group smoking, and the other associations were not statistically (NSNA) (8.1, 7.2–9.0%). The lifetime drug use had sig- significant (Model 1). Similarly, a one SD increase in nificantly higher prevalence in the NSA (17.4, 13.1–21.7%) spirituality was associated with a 12% decrease in the odds than all other groups: the NSNA (7.9, 7.0–8.8%), the of weekly smoking and a 9% decrease in the odds of spiritual non-attending group (11.8, 8.6–15.0%), and the weekly drinking (Model 2). When religious attendance and spiritual attending group (2.7, 0.0–8.5%). On the other spirituality were both added to the model (Model 3), nei- hand, the prevalence of sexual intercourse in the NSA ther of them was statistically significant for any type of group was significantly lower (18.8, 14.3–23.3%) than in health-risk behaviour. The interaction of religious the NSNA (25.5, 21.2–29.8%). 123 K. Malinakova et al. Table 2 Associations of adolescent weekly smoking, weekly drinking, recent cannabis use, lifetime drugs use and early sexual intercourse with religious attendance, spirituality (standardized to z-scores), their joint association and their interaction, adjusted for age, gender and socio-economic status (FAS) (odds ratios, OR, and 95% confidence intervals, CI) (Czech Republic, 2014) Weekly smoking Weekly drinking Recent cannabis use Lifetime drugs use (15 years Early sexual intercourse (15 years old) old) (15 years old) Crude Adjusted Crude Adjusted Crude Adjusted Crude Adjusted Crude Adjusted Model 1: religious attendance Non-attending 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) Attending 0.61 0.57 0.75 (0.52– 0.74 (0.51– 1.08 (0.62– 1.03 (0.59– 1.40 (0.84– 1.39 (0.83– 0.72 (0.48– 0.67 (0.44– (0.39–0.94)* (0.36–0.88)* 1.09) 1.08) 1.88) 1.80) 2.34) 2.32) 1.09) 1.01) Model 2: spirituality 0.84 0.88 0.91 0.91 0.93 (0.80– 0.91 (0.78– 1.05 (0.90– 1.06 (0.91– 0.98 (0.88– 0.95 (0.85– (per SD) (0.76–0.92)*** (0.80–0.97)* (0.83–0.996)* (0.83–0.995)* 1.09) 1.07) 1.22) 1.24) 1.08) 1.05) Model 3: religious attendance and spirituality mutually adjusted Attending versus 0.75 (0.48–1.18) 0.64 (0.40– 0.84 (0.57– 0.82 1.22 1.19 1.39 1.35 0.71 0.68 non-attending 1.02) 1.24) (0.55–1.23) (0.67–2.23) (0.65–2.16) (0.78–2.45) (0.76–2.38) (0.46–1.10) (0.44–1.07) Spirituality (per SD) 0.86 (0.77– 0.91 0.93 0.92 0.91 0.90 1.007 1.02 1.01 0.98 0.95)** (0.82–1.01) (0.84–1.02) (0.84–1.02) (0.77–1.08) (0.76–1.07) (0.85–1.19) (0.86–1.21) (0.90–1.13) (0.88–1.10) Model 4: interaction Attendance versus 1.10 (0.68–1.80) 0.96 1.18 1.17 2.00 (1.08– 1.88 (1.01– 2.54 (1.34– 2.54 (1.34– 1.04 0.96 non-attendance (0.58–1.60) (0.75–1.87) (0.73–1.88) 3.72)* 3.53)* 4.82)** 4.83)** (0.61–1.78) (0.56–1.66) Spirituality (per SD) 0.89 (0.80– 0.95 0.96 0.96 1.01 0.99 1.10 1.12 1.05 1.02 0.995)* (0.85–1.06) (0.87–1.06) (0.86–1.06) (0.84–1.20) (0.82–1.18) (0.92–1.31) (0.94–1.34) (0.93–1.18) (0.90–1.14) Religious attendance 0.61 (0.43– 0.60 (0.41– 0.69 (0.50– 0.69 (0.50– 0.47 (0.29– 0.49 (0.30– 0.50 (0.30– 0.48 (0.29– 0.67 (0.46– 0.70 0.87)** 0.87)** 0.95)* 0.95)* 0.78)** 0.82)** 0.82)** 0.80)** 0.98)* (0.47–1.02) 9 spirituality (per SD) *p \ 0.05; **p \ 0.01; ***p \ 0.001; Those with p-values below 0.05 are considered significant and are shown in bold; SD standard deviation Model 3: logit(Health-risk behaviour) = a ? b *RA ? b * spirituality ? b * gender ? b * age ? b * SES ? e 1 2 3 4 5 Model 4: logit(Health-risk behaviour) = a ? b *RA ? b * spirituality ? b * RA * spirituality ? b * gender ? b * age ? b * SES ? e 1 2 3 4 5 6 ‘‘I am spiritual, but not religious’’: Does one without the other protect against adolescent… Discussion 25% Weekly smoking Religious attendance The aim of this study was to assess the relationship of non-attending religious attendance, spirituality and their interaction with 20% attending health-risk behaviour among adolescents in a highly sec- 15% ular environment. The results showed that mere religious attendance and spirituality were associated with only one 10% or two kinds of health-risk behaviour, but their multi- 11.0% 9.9% 10.9% 5% plicative interaction was associated with four of the five n=434 n=16 n=30 4.1% behaviours examined. Attending respondents and spiritual n=7 0% no yes respondents were less likely to be regular smokers, and Spirituality spiritual adolescents were less likely to overuse alcohol. The associations were not significant for cannabis, drug use and early sexual intercourse. We also found that religious 25% Weekly drinking Recent cannabis use attendance and spirituality were not associated with health- risk behaviour in case of mutual adjustment. Moreover, 20% with the exception of smoking, the religious attendance and 15% spirituality were not mediators for each other for the association with health-risk behaviour. 10% 15.9% The association of religious attendance and spirituality 13.5% 12.4% n=44 12.6% 10.8% n=13 n=500 n=20 5% with less risk behaviour as we found in our study is con- 7.6% 8.1% n=11 n=163 n=13 2.7% sistent with previous findings of other authors (Kub and n=2 0% Solari-Twadell 2013; Rew and Wong 2006). Religious no yes no yes Spirituality attendance and spirituality may influence risk behaviour via several pathways. First, religious systems generally Lifetime drug use Sexual intercourse emphasize one’s responsibility to care for health and dis- 25% courage behaviours that could harm the body (Koenig 2012). Second, parents of religious respondents show a 20% stronger parental monitoring of adolescents’ behaviour 15% (Mahoney 2010), which may to a certain degree prevent 25.5% 22.2% n=26 the occurrence of unwanted behaviours. Third, religious n=445 10% * 18.8% 17.4% n=18 15.1% organizations offer different leisure-time activities, which n=16 11.8% n=11 n=12 5% 7.9% may also serve as a prevention of some risk behaviours n=156 2.7% (Adamczyk and Felson 2012). It requires further analysis ** n=2 * 0% no yes no yes which would include also the additional variables to dis- Spirituality criminate between these explanations. However, we also found that the interaction of a low Fig. 2 Prevalence of adolescent weekly smoking, weekly drinking, level of spirituality and religious attendance was associated recent cannabis use, lifetime drugs use and early sexual intercourse in with an increased level of health-damaging behaviours, groups with different combinations of spirituality and religious attendance; *p \ 0.05; **p \ 0.001 (Czech Republic, 2014) which differs from the findings of Pitel et al. (2012). This study dealt with a similar issue in Slovak adolescents, but found the religious/non-spiritual group not to be so distinct Religious attendance was not a significant mediator for from the other groups as we found. An explanation could the association of spirituality with health-risk behaviour be the different cultural contexts of Slovakia and the Czech (p [ 0.10 for all types of health-risk behaviour). On the Republic—religiosity is distinctly more prevalent in Slo- other hand, spirituality was a significant mediator for the vakia (85.3% Christian) than in the Czech Republic (23.3% association of religious attendance with smoking only Christian) (Pew Research Center 2014). A second expla- (p = 0.03); it was not a significant mediator for religious nation may be the different way of assessing spirituality, attendance with other types of health-risk behaviour i.e., using a question on the importance of faith by Pitel (p [ 0.10 for all types of health-risk behaviour except for et al. (2012) versus using the spirituality questionnaire as smoking). we did, with the latter probably being a stronger measure. Prevalence of health-risk behaviour K. Malinakova et al. Our finding of a higher prevalence of some risk beha- adolescents’ behaviour and attitudes. Therefore, a useful viours among adolescents who attend but are not spiritual strategy to prevent adolescent health-risk behaviour might raises important questions about this specific group, which be to create an environment where spiritual values are has rarely been studied. Some adolescents may attend shared and respected by the whole group, for example, in church services without an adequate internal conviction. scout and other organizations, or different activities in We could argue that their religious practice is more the youth centres. result of external pressure, usually from the family. Thus, Our results also show that the available evidence on the experienced discrepancy could result in a desire to rebel religiosity and spirituality should be interpreted with cau- in some way, for example, by health-damaging behaviour. tion. It is important to keep in mind the multidimension- In addition, this discrepancy may lead to substantial exis- ality of both constructs and the consequent ambiguity in tential distress, causing individuals to regulate their emo- definitions and methods of measurement. A group of ‘‘re- tions in maladaptive ways, for example, through alcohol or ligious respondents’’ may include participants with differ- drug use (Aldwin et al. 2014). At the same time, higher ent levels of spirituality, which could lead to spirituality was associated with less likely weekly smoking misinterpretation of results. Future research on this topic and drinking, but not with the other risk behaviours. and on the causal pathway is therefore recommended. Therefore, the popular being ‘‘spiritual, but not religious’’ might have only a limited impact on someone’s behaviour, Conclusion as some other authors also concluded (Jang and Franzen 2013). Our findings suggest that religious attendance or spiritu- ality separately have only limited impact on adolescent Strengths and limitations health-risk behaviour. Spirituality may only protect against health-risk behaviour if combined with religious atten- This study has several important strengths, the most dance, and if not the reverse holds true for attendance important being its large and representative sample and its without being spiritual. Thus, this study shows the impor- high response rate. It is also the first study that uses the tance of the internalization of adolescent religious values shortened version of the SWBS in the Czech environment. with and its impact on health-risk behaviour, inviting for However, the high proportion of non-attending respondents more attention for research on this theme. (92.8%) and the correspondingly low number of attending Acknowledgements This study was supported by the Grant Agency respondents represent a limitation of our study, as it of the Czech Republic project Spirituality and Health among Ado- decreased the power of the study in particular regarding lescents and Adults in the Czech Republic (Grant No. 15-19968S) and moderation. Another limitation might be information bias, by the Czech Ministry of Education, Youth and Sports (MEYS) as our data were based on self-reports of adolescents, (Grant Nos. LG14042 and LG 14043). which can be influenced by social desirability. A third limitation is the cross-sectional design of the study which Compliance with ethical standards does not allow us to make conclusions on causality. Conflict of interest The authors declare that they have no conflict of interest. Implications Ethical statement The Czech HBSC study was conducted under Our findings suggest that taking care of the spiritual and auspices of Ministry of Education, Youth and Sports of the Czech Republic and the World Health Organization Country Office in the religious needs of adolescents may affect their risk beha- Czech Republic. The study design was approved by the Ethics viours. Such care could include, for example, family and Committee of the Faculty of Physical Culture, Palacky University in school education as well as pastoral care focussing on Olomouc (No. 17/2013) and conducted in accordance with the ethical promoting the process of finding one’s own identity and the requirements formulated by the Convention on Human Rights and Biomedicine (40/2000 Coll.). healthy spirituality of the adolescent. We found that, in particular, religious attendance without strong spirituality Open Access This article is distributed under the terms of the Creative may not be protective or can even increase the likelihood Commons Attribution 4.0 International License (http://creative commons.org/licenses/by/4.0/), which permits unrestricted use, dis- of health-risk behaviour. This could lead to educating tribution, and reproduction in any medium, provided you give parents on the deleterious effects of forcing adolescents to appropriate credit to the original author(s) and the source, provide a attend church without internal spiritual drive. Alterna- link to the Creative Commons license, and indicate if changes were tively, our results support the idea that the more effective made. interventions would be the ones that lead to internalization of the spiritual values. 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“I am spiritual, but not religious”: Does one without the other protect against adolescent health-risk behaviour?

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Abstract

Objectives Spirituality and religious attendance (RA) have been suggested to protect against adolescent health-risk behaviour (HRB). The aim of this study was to explore the interrelatedness of these two concepts in a secular environment. Methods A nationally representative sample (n = 4566, 14.4 ± 1.1 years, 48.8% boys) of adolescents participated in the 2014 Health Behaviour in School-aged Children cross-sectional study. RA, spirituality (modified version of the Spiritual Well-Being Scale), tobacco, alcohol, cannabis and drug use and the prevalence of sexual intercourse were measured. Results RA and spirituality were associated with a lower chance of weekly smoking, with odds ratios (OR) 0.57 [95% confidence interval (CI) 0.36–0.88] for RA and 0.88 (0.80–0.97) for spirituality. Higher spirituality was also associated with a lower risk of weekly drinking [OR (95% CI) 0.91 (0.83–0.995)]. The multiplicative interaction of RA and spirituality was associated with less risky behaviour for four of five explored HRB. RA was not a significant mediator for the association of spirituality with HRB. Conclusions Our findings suggest that high spirituality only protects adolescents from HRB if combined with RA. Keywords Health-risk behaviour  Adolescence  Religious attendance  Spirituality  HBSC study Introduction health-risk behaviours (Hansen et al. 2010) and is often a predictor of adult health-risk behaviour (Grant et al. 2006; Adolescent health-risk behaviour attracts the attention of Virtanen et al. 2015). Similarly, an early initiation of researchers worldwide, because it can leave a lasting effect sexual life is associated with other risk factors (Lara and over the whole life course. The earlier onset of substance Abdo 2016). use, for example, is associated with engaging in multiple With regard to prevalence, both gender differences (MacArthur et al. 2012; Saewyc et al. 1998; Wang et al. 2010) and country differences (Inchley et al. 2016) exist in Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00038-018-1116-4) contains adolescent health and health-risk behaviour. For example, supplementary material, which is available to authorized users. Department of Health Psychology, Faculty of Medicine, & Klara Malinakova University of Pavol Jozef Safarik Kosice, Tr. SNP 1, klara.malinakova@oushi.upol.cz 040 11 Kosice, Slovak Republic OUSHI - Olomouc University Social Health Institute, Department of Social Medicine and Public Health, Faculty of Palacky University Olomouc, Univerzitni 244/22, Medicine and Dentistry, Palacky University Olomouc, 771 11 Olomouc, Czech Republic Olomouc, Czech Republic Department of Community and Occupational Health, Institute of Active Living, Faculty of Physical Culture, University Medical Center Groningen, University of Palacky University Olomouc, Trida Miru 115, Groningen, Ant. Deusinglaan 1, 9713 AV Groningen, The 771 11 Olomouc, Czech Republic Netherlands Graduate School Kosice Institute for Society and Health, University of Pavol Jozef Safarik Kosice, Tr. SNP 1, 040 11 Kosice, Slovak Republic 123 K. Malinakova et al. in the 2005/2006 Health Behaviour in School-aged Chil- deeply religious attitude; however, recently, it is often also dren (HBSC) survey, the frequency of drunkenness understood as a more subjective search for peace, harmony, increased by an average of 40% in all participating eastern meaning in life and connection with the sacred (Koenig European countries compared to the 1997/1998 HBSC 2008). The above-mentioned heterogeneity hinders com- survey, but decreased by an average of 25% in 13 of the 16 parison of the various studies. Though both religiousness Western European and North American countries included and spirituality emphasize a search for the sacred, people in the study. An increasing trend in the Czech Republic, who are religious or spiritual might differ in the means they Bulgaria, Croatia and Hungary was reported also in the use to find this. In the absence of religious commitment, an study of Kuntsche et al. (2011), which further pointed out individual could actually even use alcohol, tobacco, hal- that the prevalence remained stable or even decreased in lucinogens or sexual intercourse, etc., as means to discover countries such as Finland, Iceland and Norway. This meaning, purpose and connectedness with the self, others finding shows the importance of the wider cultural and or the transcendent (Burris et al. 2011). economical context and probably also reflects an effect of However, other explanations may also hold for the different policies in this area. From this perspective, the varying associations of religiosity and spirituality. One of search for possible protective factors in adolescent health- them is the degree of internalization of religious attitudes risk behaviour remains an urgent need in the Czech (Powell et al. 2003), i.e., the inner content and experience Republic. According to the last published HBSC survey of one’s faith. This aligns with the spirituality level; (2013/2014) (Inchley et al. 2016), the prevalence of therefore, it may be informative not only to analyse spiri- drunkenness decreased significantly between the years tuality and religiosity separately, but also jointly, and to 2010 and 2014. However, the Czech Republic still holds its check a possible mediation effect. For the purpose of this position in the most unfavourable third of the countries article, we chose religious attendance as the external with data on adolescent weekly drinking, in the unfa- dimension of religiosity, and spirituality as the internal vourable half regarding weekly smoking and recent can- dimension. In our study, spirituality is understood in the nabis use and in the least favourable ten per cent regarding broader sense: as the internal individual contentedness, early sexual intercourse. one’s perceived closeness to God, one’s sense of meaning Religiosity and spirituality have often been studied as of life and of spiritual well-being (Ellison 1983). protective factors in adolescent health-risk behaviour, Thus far, most studies on the relationship between including the prevention of smoking (Nonnemaker et al. religiosity/spirituality and adolescent health-risk behaviour 2006), alcohol (Piko et al. 2012) and cannabis use (Gmel have been conducted outside of Europe (Nonnemaker et al. et al. 2013) and sexual behaviour (Hardy and Raffaelli 2006; Rew and Wong 2006), and only a very few within Central Europe (Brassai et al. 2015; Piko et al. 2012 2003; Nonnemaker et al. 2003). In a systematic review, ; Pitel Rew and Wong (2006) concluded that most studies (84%) et al. 2012). With regard to religious affiliation, the Czech showed that higher religiosity/spirituality was related to Republic is a specific case in Central Europe. This might be less health-damaging attitudes and behaviours. However, a the consequence of the historical development of the minority of studies came to at least partially different country, as the anticlerical attitudes that were already conclusions. Burris et al. (2011) found religiosity to be present were further reinforced by the 40 years of the associated with less underage alcohol use, while spirituality communist re´gime (Nesporova and Nespor 2009). was associated with more, and also described a similar According to the Pew Research Center (2014), it is the pattern regarding adolescent sexual behaviour (Burris et al. country with the highest percentage (76.4%) of religiously 2009). unaffiliated people in the world, meaning that three-quar- The differences may be partly explained by the fact that ters of the population do not affiliate themselves to any both spirituality and religiosity are multidimensional con- organized church, though they might have some kind of structs that include attitudes, behaviours and beliefs personal belief. This very specific setting may affect the (Hooker et al. 2014). Nevertheless, many studies assess protective role of religiosity and spirituality regarding both only one or two dimensions. Originally, the term religion physical and mental health (Hayward and Elliott 2014). included both individual and institutional dimensions (Hill Therefore, the aim of this study is to explore the asso- and Pargament 2003); however, later it started to be more ciation of spirituality and religious attendance with ado- associated with religious institutions, prescribed theology lescent health-risk behaviour in a highly secular and rituals and institutional beliefs and practices, such as environment and to explore whether spirituality modified church membership or attendance (Zinnbauer et al. 1997). the association of religious attendance, or religious atten- In contrast, spirituality was originally used to describe a dance mediated that of spirituality. 123 ‘‘I am spiritual, but not religious’’: Does one without the other protect against adolescent… churches/denominations; therefore, the participants who Methods reported attending religious sessions at least once a week were dichotomized as attending. Participants and procedure Spirituality was measured using the modified shortened version of the Spiritual Well-Being Scale (SWBS) (Cotton We obtained data on a nationally representative sample of et al. 2005; Malinakova et al. 2017), measuring the overall Czech boys and girls from the 2014 HBSC study. This spiritual well-being. Response possibilities for all seven cross-sectional WHO collaborative study focuses on health items regarded a 6-point scale that ranged from ‘‘strongly and health-related behaviour and their socio-economic disagree’’ (1) to ‘‘strongly agree’’ (6), leading to scores determinants in 11-, 13-, and 15-year-old children. More from 7 to 42. A higher score represented greater spiritual detailed information about the survey can be found in well-being. In the analyses, spirituality was used as a Roberts et al. (2009). Schools were selected randomly after continuous variable, but for the purpose of dichotomization stratification by region, school size and type of school for a sensitivity analysis, participants with a score of 34 or (primary schools vs. secondary schools). Out of 243 con- higher (upper quartile of the score) were considered as tacted schools, 242 agreed to participate (response rate spiritual, and the rest as non-spiritual. Cronbach’s alpha 99.6%). Then, classes from the fifth, seventh and ninth was 0.81 in our sample. grades, in general corresponding to age categories of 11-, Tobacco use was measured by the question: ‘‘How often 13- and 15-year-olds, were selected at random, one from do you smoke tobacco at present?’’ Respondents reported each grade per school. their experience with smoking as follows: (1) every day; Data from 14,539 pupils were obtained (response rate (2) at least once a week, but not every day; (3) less than 89.2%). Most non-response was due to illness or other once a week; (4) I do not smoke. Following the HBSC reasons, for example, sports or academic competitions dichotomization (Currie et al. 2012), respondents who (10.6%), and 30 children refused to participate in the sur- smoked at least once a week were classified as smokers, the vey (0.2%). The spirituality questionnaire was included rest as non-smokers. only in the surveys of half of the 13- and 15-year-old Alcohol use was assessed by the question: ‘‘At present, adolescents, so the dataset comprised 4889 adolescents. Of how often do you drink anything alcoholic, such as beer, these, 564 (11.5% of the sample) had not responded to at wine or spirits?’’ Respondents reported frequency of least one of the seven SWBS items. We used a multiple alcohol consumption for five types of alcohol drinks with imputation to estimate values for the respondents who had the answers: (1) every day; (2) every week; (3) every responded to the majority of the SWBS items. The month; (4) rarely; (5) never. Following the HBSC remaining participants—who had not responded to four or dichotomization (Currie et al. 2012), individuals were more SWBS items—were excluded from the study classified as alcohol consumers if they reported consump- (n = 323). The final analytic sample thus included 4566 tion of any alcohol drink at least each week. respondents (mean age = 14.4, SD = 1.09, 48.8% boys). Cannabis use was assessed only in the 15-year-old For a graphical illustration of the preparation of the sample, respondents. They were asked the question: ‘‘Have you see Fig. 1. taken cannabis (grass) in the last 30 days?’’ with the pos- Data were collected between April and June 2014. The sible answers (1) never; (2) 1–2 days; (3) 3–5 days; (4) questionnaires were distributed by trained administrators 6–9 days; (5) 10–19 days; (6) 20–29 days; (7) 30 days with no teachers present in the classroom in order to reduce (and more). Following the HBSC dichotomization (Currie information bias. The consent to carry out the study was et al. 2012), respondents who answered ‘‘never’’ were obtained through school management at all the schools classified as cannabis non-users, the rest of the respondents involved in the survey. Participation in the survey was as users. anonymous and voluntary, and the parents of the pupils Experience with drug use was measured on 15-year-old were informed about the survey. respondents with the question ‘‘Have you ever taken one or several of these drugs in your life?’’ Respondents reported Measures their lifetime experience with five kinds of drugs (ecstasy, pervitin, glue or solvents, LSD and a non-existing drug, Religious attendance was measured by the question: ‘‘How netalin), with the same answers and dichotomization as for often do you go to church or to religious sessions?’’ with cannabis use. The respondents who reported an experience possible answers: several times a week/approximately once with netalin were not included in the analyses of lifetime a week/approximately once a month/a few times a year/ drug use. exceptionally/never. Sunday attendance is a matter of Early sexual intercourse was measured only among obligation in most of the Christian 15-year-old respondents by the question: ‘‘Have you ever 123 K. Malinakova et al. Imputation of missing values (MAR only) for RA/spirituality and HRB 4,182 respondents with complete responses (includes 2,091 respondents with Original sample non-MAR values for HRB)* Sample for analysis n = 4,889 387 respondents with some n = 4,566 missing responses on items for RA/spirituality and HRB (MAR) Exclusion of respondents with missing responses on a majority of the items for RA/spirituality n = 323 Fig. 1 Preparation of the sample (Czech Republic, 2014). Note: *Items included only for the 15-year-old respondents; RA religious attendance, MAR values missing at random, HRB health-risk behaviour had sexual intercourse (sometimes this is called ‘‘making multilevel modelling. We assessed the associations of only love’’, ‘‘having sex’’, etc.)? (yes, no). religious attendance (Model 1), only spirituality (Model 2), Age, gender and socio-economic status were considered of both variables jointly (Model 3) and their multiplicative as potential confounding variables. The socio-economic interaction (to assess moderation) (Model 4) with the var- status of the respondents’ families was used as a covariate ious health-risk behaviours using binary logistic regression and was assessed by the Family Affluence Scale (FAS) models. Each model was first tested as a crude one, and (Currie et al. 2014). The scale examines the number of cars then, it was adjusted for gender, age and socio-economic owned by the family, having one’s own bedroom, number status. For the sensitivity analysis using the dichotomized of computers in the household, number of foreign family spirituality, the prevalences of all types of health-risk holidays, number of bathrooms and dishwasher ownership. behaviour were compared with the proportion test. Finally, The summary score ranges from 10 to 13, and following mediation analysis was performed using the bootstrap HBSC recommendations, it was converted into a fractional approach via mediation package in R. We tested whether rank (ridit) score, leading to transformation of ordinal data religious attendance mediated the association of spirituality to an interval scale with a normalized range (from 0 to 1, with health-risk behaviour as well as whether spirituality with higher score indicating higher socio-economic posi- mediated the association of religious attendance with tion) and distribution. health-risk behaviour. All analyses were performed using the statistical software package IBM SPSS version 21. For Statistical analyses the imputation of missing data, the Hmisc package in the R software was used. As a first step, we performed a multiple imputation of missing data on item level, twenty times. It was assumed that data are missing at random (MAR). Then, we descri- Results bed the background characteristics of the sample and compared the respondents excluded from the analyses with The background characteristics of the sample are presented the remaining ones. Next, we checked the effect of in Table 1, which also describe prevalence of five kinds of ‘‘school’’, given the nested nature of the data. That showed health-risk behaviour for both attending and non-attending that the intraclass correlation between students from the respondents. Of the 4566 adolescents, 331 (7.2%) reported same school was negligible; therefore, we did not use attending church services once a week or more. Religious 123 ‘‘I am spiritual, but not religious’’: Does one without the other protect against adolescent… Table 1 Characteristics of the sample (Czech Republic, 2014) Total Religious attendance Attending (C 1/week) Non-attending (\ 1/week) Number % Number % Number % Gender Boys 2230 48.8 145 43.8 2085 49.2 Girls 2336 51.2 186 56.2 2150 50.8 Age 13 years old (seventh grade) 2291 50.2 162 48.9 2129 50.3 15 years old (ninth grade) 2275 49.8 169 51.1 2106 49.7 Health-risk behaviour Weekly smoking 487 10.7 23 6.9 464 11.0 Weekly drinking 577 12.6 33 10.0 544 12.8 Recent cannabis use (only 15-year-olds) 189 8.3 15 8.9 174 8.3 Lifetime drugs use (only 15-year-olds) 186 8.3 18 10.9 168 8.0 Early sexual intercourse (only 15-year-olds) 500 22.0 29 17.2 471 22.4 Total 4566 100 331 7.2 4235 92.8 Only numbers regarding the respondents with the occurrence of a health-risk behaviour are presented attendance and spirituality (SWBS scale) were moderately attendance and spirituality (Model 4) showed that a one SD correlated with Spearman’s r = 0.30 (p \ 0.01). The mean increase in spirituality for attending respondents was SWBS score was 22.15 (SD = 7.61) with minimum 7 and associated with 40% decrease in the odds of weekly maximum 42 (median 21). The SWBS was non-normally smoking, 31% decrease in the odds of weekly drinking, distributed, with skewness of 0.528 (SE = 0.036) and 51% decrease in the odds of recent cannabis use and 52% kurtosis of 0.063 (SE = 0.072). Of the highly spiritual decrease in the odds of lifetime drug use. With regard to respondents, i.e., those in the upper quartile of a score, early sexual intercourse, the result was significant only for 54.0% were boys and mean age was 14.31 (SD = 1.12). Of the crude model (33% decrease in the odds), but not for the these, 61.9% were attending religious sessions at least once adjusted one. a week. Of the participants, 1202 (26.3%) were involved in The sensitivity analysis using the dichotomized spiritu- at least one kind of health-risk behaviour, with the fre- ality (Fig. 2) compared the prevalences of health-risk quency being higher for non-attending (26.8%) than for behaviour in respective groups with the proportion test. attending (19.9%) respondents (p \ 0.05). Compared to Non-spiritual attending group (NSA) was considered ref- included respondents, those excluded (n = 323) were erence group for these comparisons in order to allow a prevalently boys (p \ 0.05), were slightly older (p \ 0.01) more detailed assessment of the dissonance of religious attendance and spirituality. *p \ 0.05, **p \ 0.001. and had a higher prevalence of recent cannabis (p \ 0.05) and drugs use (p \ 0.001), but did not differ significantly Comparison of prevalences of health-risk behaviour in regard to other health-risk behaviours. (Fig. 2) showed that there were no significant differences Table 2 shows the associations of religious attendance, in the prevalence of smoking and weekly drinking in the spirituality and their interaction with various health-risk respective groups. The recent cannabis use had signifi- behaviours, adjusted for gender and age. Attending cantly higher prevalence in the NSA (13.5, 95% CI respondents were less likely to be involved only in weekly 9.6–17.4%) than the non-spiritual non-attending group smoking, and the other associations were not statistically (NSNA) (8.1, 7.2–9.0%). The lifetime drug use had sig- significant (Model 1). Similarly, a one SD increase in nificantly higher prevalence in the NSA (17.4, 13.1–21.7%) spirituality was associated with a 12% decrease in the odds than all other groups: the NSNA (7.9, 7.0–8.8%), the of weekly smoking and a 9% decrease in the odds of spiritual non-attending group (11.8, 8.6–15.0%), and the weekly drinking (Model 2). When religious attendance and spiritual attending group (2.7, 0.0–8.5%). On the other spirituality were both added to the model (Model 3), nei- hand, the prevalence of sexual intercourse in the NSA ther of them was statistically significant for any type of group was significantly lower (18.8, 14.3–23.3%) than in health-risk behaviour. The interaction of religious the NSNA (25.5, 21.2–29.8%). 123 K. Malinakova et al. Table 2 Associations of adolescent weekly smoking, weekly drinking, recent cannabis use, lifetime drugs use and early sexual intercourse with religious attendance, spirituality (standardized to z-scores), their joint association and their interaction, adjusted for age, gender and socio-economic status (FAS) (odds ratios, OR, and 95% confidence intervals, CI) (Czech Republic, 2014) Weekly smoking Weekly drinking Recent cannabis use Lifetime drugs use (15 years Early sexual intercourse (15 years old) old) (15 years old) Crude Adjusted Crude Adjusted Crude Adjusted Crude Adjusted Crude Adjusted Model 1: religious attendance Non-attending 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) Attending 0.61 0.57 0.75 (0.52– 0.74 (0.51– 1.08 (0.62– 1.03 (0.59– 1.40 (0.84– 1.39 (0.83– 0.72 (0.48– 0.67 (0.44– (0.39–0.94)* (0.36–0.88)* 1.09) 1.08) 1.88) 1.80) 2.34) 2.32) 1.09) 1.01) Model 2: spirituality 0.84 0.88 0.91 0.91 0.93 (0.80– 0.91 (0.78– 1.05 (0.90– 1.06 (0.91– 0.98 (0.88– 0.95 (0.85– (per SD) (0.76–0.92)*** (0.80–0.97)* (0.83–0.996)* (0.83–0.995)* 1.09) 1.07) 1.22) 1.24) 1.08) 1.05) Model 3: religious attendance and spirituality mutually adjusted Attending versus 0.75 (0.48–1.18) 0.64 (0.40– 0.84 (0.57– 0.82 1.22 1.19 1.39 1.35 0.71 0.68 non-attending 1.02) 1.24) (0.55–1.23) (0.67–2.23) (0.65–2.16) (0.78–2.45) (0.76–2.38) (0.46–1.10) (0.44–1.07) Spirituality (per SD) 0.86 (0.77– 0.91 0.93 0.92 0.91 0.90 1.007 1.02 1.01 0.98 0.95)** (0.82–1.01) (0.84–1.02) (0.84–1.02) (0.77–1.08) (0.76–1.07) (0.85–1.19) (0.86–1.21) (0.90–1.13) (0.88–1.10) Model 4: interaction Attendance versus 1.10 (0.68–1.80) 0.96 1.18 1.17 2.00 (1.08– 1.88 (1.01– 2.54 (1.34– 2.54 (1.34– 1.04 0.96 non-attendance (0.58–1.60) (0.75–1.87) (0.73–1.88) 3.72)* 3.53)* 4.82)** 4.83)** (0.61–1.78) (0.56–1.66) Spirituality (per SD) 0.89 (0.80– 0.95 0.96 0.96 1.01 0.99 1.10 1.12 1.05 1.02 0.995)* (0.85–1.06) (0.87–1.06) (0.86–1.06) (0.84–1.20) (0.82–1.18) (0.92–1.31) (0.94–1.34) (0.93–1.18) (0.90–1.14) Religious attendance 0.61 (0.43– 0.60 (0.41– 0.69 (0.50– 0.69 (0.50– 0.47 (0.29– 0.49 (0.30– 0.50 (0.30– 0.48 (0.29– 0.67 (0.46– 0.70 0.87)** 0.87)** 0.95)* 0.95)* 0.78)** 0.82)** 0.82)** 0.80)** 0.98)* (0.47–1.02) 9 spirituality (per SD) *p \ 0.05; **p \ 0.01; ***p \ 0.001; Those with p-values below 0.05 are considered significant and are shown in bold; SD standard deviation Model 3: logit(Health-risk behaviour) = a ? b *RA ? b * spirituality ? b * gender ? b * age ? b * SES ? e 1 2 3 4 5 Model 4: logit(Health-risk behaviour) = a ? b *RA ? b * spirituality ? b * RA * spirituality ? b * gender ? b * age ? b * SES ? e 1 2 3 4 5 6 ‘‘I am spiritual, but not religious’’: Does one without the other protect against adolescent… Discussion 25% Weekly smoking Religious attendance The aim of this study was to assess the relationship of non-attending religious attendance, spirituality and their interaction with 20% attending health-risk behaviour among adolescents in a highly sec- 15% ular environment. The results showed that mere religious attendance and spirituality were associated with only one 10% or two kinds of health-risk behaviour, but their multi- 11.0% 9.9% 10.9% 5% plicative interaction was associated with four of the five n=434 n=16 n=30 4.1% behaviours examined. Attending respondents and spiritual n=7 0% no yes respondents were less likely to be regular smokers, and Spirituality spiritual adolescents were less likely to overuse alcohol. The associations were not significant for cannabis, drug use and early sexual intercourse. We also found that religious 25% Weekly drinking Recent cannabis use attendance and spirituality were not associated with health- risk behaviour in case of mutual adjustment. Moreover, 20% with the exception of smoking, the religious attendance and 15% spirituality were not mediators for each other for the association with health-risk behaviour. 10% 15.9% The association of religious attendance and spirituality 13.5% 12.4% n=44 12.6% 10.8% n=13 n=500 n=20 5% with less risk behaviour as we found in our study is con- 7.6% 8.1% n=11 n=163 n=13 2.7% sistent with previous findings of other authors (Kub and n=2 0% Solari-Twadell 2013; Rew and Wong 2006). Religious no yes no yes Spirituality attendance and spirituality may influence risk behaviour via several pathways. First, religious systems generally Lifetime drug use Sexual intercourse emphasize one’s responsibility to care for health and dis- 25% courage behaviours that could harm the body (Koenig 2012). Second, parents of religious respondents show a 20% stronger parental monitoring of adolescents’ behaviour 15% (Mahoney 2010), which may to a certain degree prevent 25.5% 22.2% n=26 the occurrence of unwanted behaviours. Third, religious n=445 10% * 18.8% 17.4% n=18 15.1% organizations offer different leisure-time activities, which n=16 11.8% n=11 n=12 5% 7.9% may also serve as a prevention of some risk behaviours n=156 2.7% (Adamczyk and Felson 2012). It requires further analysis ** n=2 * 0% no yes no yes which would include also the additional variables to dis- Spirituality criminate between these explanations. However, we also found that the interaction of a low Fig. 2 Prevalence of adolescent weekly smoking, weekly drinking, level of spirituality and religious attendance was associated recent cannabis use, lifetime drugs use and early sexual intercourse in with an increased level of health-damaging behaviours, groups with different combinations of spirituality and religious attendance; *p \ 0.05; **p \ 0.001 (Czech Republic, 2014) which differs from the findings of Pitel et al. (2012). This study dealt with a similar issue in Slovak adolescents, but found the religious/non-spiritual group not to be so distinct Religious attendance was not a significant mediator for from the other groups as we found. An explanation could the association of spirituality with health-risk behaviour be the different cultural contexts of Slovakia and the Czech (p [ 0.10 for all types of health-risk behaviour). On the Republic—religiosity is distinctly more prevalent in Slo- other hand, spirituality was a significant mediator for the vakia (85.3% Christian) than in the Czech Republic (23.3% association of religious attendance with smoking only Christian) (Pew Research Center 2014). A second expla- (p = 0.03); it was not a significant mediator for religious nation may be the different way of assessing spirituality, attendance with other types of health-risk behaviour i.e., using a question on the importance of faith by Pitel (p [ 0.10 for all types of health-risk behaviour except for et al. (2012) versus using the spirituality questionnaire as smoking). we did, with the latter probably being a stronger measure. Prevalence of health-risk behaviour K. Malinakova et al. Our finding of a higher prevalence of some risk beha- adolescents’ behaviour and attitudes. Therefore, a useful viours among adolescents who attend but are not spiritual strategy to prevent adolescent health-risk behaviour might raises important questions about this specific group, which be to create an environment where spiritual values are has rarely been studied. Some adolescents may attend shared and respected by the whole group, for example, in church services without an adequate internal conviction. scout and other organizations, or different activities in We could argue that their religious practice is more the youth centres. result of external pressure, usually from the family. Thus, Our results also show that the available evidence on the experienced discrepancy could result in a desire to rebel religiosity and spirituality should be interpreted with cau- in some way, for example, by health-damaging behaviour. tion. It is important to keep in mind the multidimension- In addition, this discrepancy may lead to substantial exis- ality of both constructs and the consequent ambiguity in tential distress, causing individuals to regulate their emo- definitions and methods of measurement. A group of ‘‘re- tions in maladaptive ways, for example, through alcohol or ligious respondents’’ may include participants with differ- drug use (Aldwin et al. 2014). At the same time, higher ent levels of spirituality, which could lead to spirituality was associated with less likely weekly smoking misinterpretation of results. Future research on this topic and drinking, but not with the other risk behaviours. and on the causal pathway is therefore recommended. Therefore, the popular being ‘‘spiritual, but not religious’’ might have only a limited impact on someone’s behaviour, Conclusion as some other authors also concluded (Jang and Franzen 2013). Our findings suggest that religious attendance or spiritu- ality separately have only limited impact on adolescent Strengths and limitations health-risk behaviour. Spirituality may only protect against health-risk behaviour if combined with religious atten- This study has several important strengths, the most dance, and if not the reverse holds true for attendance important being its large and representative sample and its without being spiritual. Thus, this study shows the impor- high response rate. It is also the first study that uses the tance of the internalization of adolescent religious values shortened version of the SWBS in the Czech environment. with and its impact on health-risk behaviour, inviting for However, the high proportion of non-attending respondents more attention for research on this theme. (92.8%) and the correspondingly low number of attending Acknowledgements This study was supported by the Grant Agency respondents represent a limitation of our study, as it of the Czech Republic project Spirituality and Health among Ado- decreased the power of the study in particular regarding lescents and Adults in the Czech Republic (Grant No. 15-19968S) and moderation. Another limitation might be information bias, by the Czech Ministry of Education, Youth and Sports (MEYS) as our data were based on self-reports of adolescents, (Grant Nos. LG14042 and LG 14043). which can be influenced by social desirability. A third limitation is the cross-sectional design of the study which Compliance with ethical standards does not allow us to make conclusions on causality. Conflict of interest The authors declare that they have no conflict of interest. Implications Ethical statement The Czech HBSC study was conducted under Our findings suggest that taking care of the spiritual and auspices of Ministry of Education, Youth and Sports of the Czech Republic and the World Health Organization Country Office in the religious needs of adolescents may affect their risk beha- Czech Republic. The study design was approved by the Ethics viours. Such care could include, for example, family and Committee of the Faculty of Physical Culture, Palacky University in school education as well as pastoral care focussing on Olomouc (No. 17/2013) and conducted in accordance with the ethical promoting the process of finding one’s own identity and the requirements formulated by the Convention on Human Rights and Biomedicine (40/2000 Coll.). healthy spirituality of the adolescent. We found that, in particular, religious attendance without strong spirituality Open Access This article is distributed under the terms of the Creative may not be protective or can even increase the likelihood Commons Attribution 4.0 International License (http://creative commons.org/licenses/by/4.0/), which permits unrestricted use, dis- of health-risk behaviour. This could lead to educating tribution, and reproduction in any medium, provided you give parents on the deleterious effects of forcing adolescents to appropriate credit to the original author(s) and the source, provide a attend church without internal spiritual drive. Alterna- link to the Creative Commons license, and indicate if changes were tively, our results support the idea that the more effective made. interventions would be the ones that lead to internalization of the spiritual values. 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Published: May 29, 2018

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