Confronting Loneliness with Devotion: A Short-Term Ethnography of Bible (E-)Reading in a Palliative Care Unit

This is an open access article distributed under the terms of the cc by 4.0 license. Confronting Loneliness with Devotion A Short-Term Ethnography of Bible (E-)Reading in a Palliative Care Unit Gaudenz Urs Metzger | ORCID: 0000-0003-2062-7030 Zurich University of the Arts, ZHdK, 8005 Zurich, Switzerland gaudenz.metz[email protected] Received: 05 April 2022 | Accepted: 12 September 2023 | Published online: 30 November 2023 Abstract Today, the practice of religion is strongly influenced by digitalisation, in not only everyday life but also liminal situations such as dying. Apps, social networks, and virtual church services offer believers opportunities for participation when their mobility is impaired due to ageing and severe illness. This short-term ethnography explores Bible (e-)reading and (religious) encounters in a palliative care unit of a Swiss hospital, drawing on in-depth interviews, participant observation, and documentary photography. Using the case of a devout Protestant, who was chosen as a case study from a sample of 12 terminally ill patients, I will investigate 1) the existential issues involved in the dying process, 2) how Bible (e-)reading alleviates these issues, and 3) the networks and encounters with which the practice is connected. The results show that anticipation of death in conjunction with personality and social issues bestow a complex emotional tone on the Christian’s end-of-life journey. Bible reading, performed both through mobile mediation and face-to-face with companions, is an avenue through which to gain strength and hope in this difficult situation. Another important finding is that the devotional practice involves an exchange of gifts, which transposes the practice into a moral economy of compassion and care. Keywords dying and death – loneliness – Bible reading – religious coping – networked religion – palliative care Published with license by Koninklijke Brill nv | doi: 10.1163/21659214-bja10085 © Gaudenz Urs Metzger, 2023 | ISSN: 2165-9214 (print) 2588-8099 (online) Journal of Religion, Media and Digital Culture 12 (2023) 340–361 341 Introduction Attitudes towards dying and death in highly individualised and secularised societies are diverse, yet for many people religion remains important to deal with the uncertainty and suffering brought on by terminal illness. Like almost all domains of contemporary life, religious practices and rituals, which provide meaning and hope to faithful dying persons, are altered by the social processes of digitalisation and mediatisation. Today, the daily practice of religion takes place in various types of media and forms of interaction in online and faceto-face environments, whose separating lines have become blurred due to the proliferation of mobile phones and permanent Internet accessibility. Websites, apps, and social media supplement and extend traditional spheres of religious practice and support. By engaging in digital technologies, Christians facing hardship connect with the (extra)mundane and create weak and strong ties of support with communities of faith and compassionate individuals, who accompany them through dark times virtually and in person. According to Lutheran theologian Deanna A. Thompson (2016), who herself has been seriously ill with cancer, the “wideness of church” and “the body of Christ incarnate in it” (p. 11) can be experienced in virtual reality. These religious networks and encounters—which from Thompson’s “emic” view mediate Christ’s body and messages virtually and enable healing and comfort through communicative and devotional practices and media—have not been treated in much detail in ethnographic studies. So far, research on dying and death in the digital age has focused on aspects such as blogging about terminal illness and emphasised how the digital and the rapidly changing technological world offer a number of positive allowances for the dying and thus counteract the sequestration of death (Drescher, 2012; Lagerkvist, 2019; Lagerkvist & Andersson, 2017; Metzger, 2023a; Walter, 2020; Walter et al., 2012). These studies demonstrate that digital mediations mould and co-constitute the experiences of suffering, dying, and bereavement and that the realms of illness and death “are equally constitutive parts of ‘being in and becoming with the digital world’” (Lagerkvist & Andersson, 2017, p. 559). The vital role of technologies in people’s lives and different modes of communication are an important key to understanding the social experience of dying and the (religious) practices to cope with it in mediatised and globalised Western culture. In contrast to the publicly visible and well-studied representations of dying and death on the Internet, much less is known about the ordinary media engagement of terminally ill Christians, whose voices are not present in late modern mass media culture. confronting loneliness with devotion Journal of Religion, Media and Digital Culture 12 (2023) 340–361 342 Drawing on 18 months of ethnographic research conducted among patients receiving palliative care in Switzerland, this study investigates how the devotional practice of Bible (e-)reading serves as a means for coping with existential issues in dying. The emphasis will not lie on the digital as such, but rather on the interplay between this practice and different media and communicative strategies used to create meaning and foster support in the face of death. This will be exemplified by the case of a Protestant, who I picked from the totality of research encounters in order to provide a glimpse into lived religion in dying. Research on this topic is still scarce. The temporal experience of dying is a social, psychological, and biological process (Glaser & Strauss, 1974) that may not be limited to a few days or hours before death but can instead begin when, for example, a terminal illness is diagnosed (Kellehear, 2017). This paper highlights the importance of investigating the digital engagement of Christians facing death in relation to a larger set of behaviours, practices, and fabrics of culture. The detailed study of lived religion and mutual sympathy between different people I will provide in this article should allow for understanding challenges in coping with existential issues, as well as illuminate how mediated religion and emotional support function on various levels of the end-of-life journey. I want to elaborate on three interrelated research questions into which the case provides valuable insights: 1) What are the emotions and existential issues involved in the Protestant’s end-of-life journey? 2) How does Bible (e-)reading alleviate these issues and affect emotional well-being? 3) With which (virtual) support networks and encounters is the religious practice connected in the hospital? Ethnographic studies have found that the practice of digitally and mobilemediated religion is usually part of a set of religious practices and interactions (Bellar, 2017; Fewkes, 2019). Offline and online religious practices are interconnected, with the latter being imprinted by the values, structures, and expectations of the offline world (Campbell, 2012a). In many cases, digital religion is an extension and supplement of traditional forms of religion, which today, according to Campbell (2012a), is performed in personalised and fluid networks between online and offline contexts. In this article, I will draw on Campbell’s (2012a, 2012b) concept of networked religion to capture the social networks, spaces, and encounters Bible (e-)reading is a part of during the time spent in the hospital. The social spaces in the investigated case are primarily “on ground” yet connected to mobile-mediated environments of religious practice metzger Journal of Religion, Media and Digital Culture 12 (2023) 340–361 343 and support. Campbell (2012a) highlights that “seeing religious community as a social network is not limited to studies of religion online” (p. 70). During the research, I myself became part of such networks several times, and the boundaries between scientific work and support for the dying were blurred. The participants of my study relied on me as a patient listener to whom they could release their emotions and feelings and thus ease their struggles. This openness of both the researcher and the informant, as we will see later in this article, is the prerequisite of ethnographic knowledge and research, which is not based on distanced observational stance but is an inevitably collaborative activity (Pink et al., 2016). Literature Review The case investigated in this article touches on issues of loneliness and emotional suffering, religious coping, and the effects of digitalisation on Bible reading habits and possibilities for assisting the dying. The first section of the review delineates the phenomenon of loneliness in relation to the fabric of Western society and historical developments such as medicalisation and highlights different dimensions of loneliness. The second section is concerned with Bible reading as a religious coping strategy to promote health and wellbeing and the rise of app culture, which altered Christians’ daily engagement with the Bible. Finally, the proliferation of digital technologies is discussed in relation to meaning-making and religious engagement at the end-of-life. Loneliness and Suffering in Dying Emotional suffering and existential issues in relation to dying, such as loneliness, social isolation, depression, fear and anxiety, sadness, or hopelessness are well known and have been widely documented (Albinsson & Strang, 2003; Boston et al., 2011; Hemberg & Bergdahl, 2020). From a historical perspective, loneliness has been linked with the Calvinist doctrine of predestination (Weber, 1905/2013). In addition, it has been associated with the weakening of religious bonds in modernity, in which the individual is confronted with and has to respond to existential uncertainties alone (Bauman, 2000; Giddens, 1991). The feeling of loneliness, in which an individual experiences isolation from human contact or socialisation, is multifaceted and can encompass interpersonal, social, cultural, cosmic, and psychological dimensions (Bodford, 2017). From a psychological point of view, loneliness can emerge due to a variety of reasons and at different life stages in different intensities. Commonly used loneliness scales conceptualise the phenomenon within dimensions confronting loneliness with devotion Journal of Religion, Media and Digital Culture 12 (2023) 340–361 344 such as deprivation, abandonment, missing companionship, and meaningful relationships (Bodford, 2017). Empirical studies found that both men and women experience loneliness in old age (Yang & Victor, 2011), with impending death a contributing factor to loneliness (Sand & Strang, 2006). Classical sociological thinkers have connected the phenomenon to medicalisation (Elias, 2001; Giddens, 1991; Kellehear, 2007; Mellor & Schilling, 1993). Medicalisation, which can be defined as “the process by which previously nonmedical problems become defined and treated as medical problems, usually as diseases or disorders” (Conrad, 2013, p. 196), resulted in the removal of dying and death from domestic spaces to hospitals. Elias (2001) argues that many of old and dying people’s living environments are “deserts of loneliness” (p. 74). They are secluded in care homes and hospitals and thus lose emotional attachment to loved ones and the community. Empirical evidence supports this view, highlighting that due to increasingly restricted social interaction, patients lose protection against isolation and have a reduced ability to share thoughts with others, which, in turn, triggers a sense of meaninglessness and existential loneliness (Sand & Strang, 2006; Sjöberg et al., 2018). At the same time, it has been observed that the modern hospice movement and the postmodern revival of death counteract this problem and lead to a reintegration of dying and death into society (Walter, 1994). In the individual case, however, little is known about which religious, psychological, social, and structural factors contribute to loneliness and suffering in dying and how patients cope with these issues. Bible Reading as a Coping Strategy Religious and spiritual practices can facilitate coping with negative feelings and existential crises. Religious coping is defined as “religiously framed cognitive, emotional, or behavioural responses to stress, encompassing multiple methods and purposes as well as positive and negative dimensions” (Wortmann, 2013, p. 1647). In his comprehensive review of research on religion/spirituality and health, Koenig (2012) identified a total of 454 studies between 2000 and 2010 that describe how religion/spirituality helped people to cope with a wide range of illnesses. In this broad field of research, a few empirical studies have likewise focused on the benefits of Bible reading to deal with adversity, thus supporting the idea stressed by several scholars that devotion to the Bible is less a theological endeavour than a means to acquire practical knowledge for both daily and transitional phases in life (Daiber et al., 1993; Hutchings, 2017; Ryrie, 2013). Qualitative studies found that solitary Bible reading plays an important role in the self-health management of older adults and is a healthpromoting strategy during stressful life events (Arcury et al., 2000; Hamilton metzger Journal of Religion, Media and Digital Culture 12 (2023) 340–361 345 et al., 2013). In addition, a recent quantitative study based on a survey of US citizens assessed the positive effect of reading the Bible on dealing with life stressors (Krause & Pergament, 2018). Previous research also established that Bible study is not only an individual endeavour but also a dialogical event and space, “highlighting the social significance that imbues the relationships produced among readers and their texts” (Bielo, 2009, p. 157). While some ethnographic research has been carried out on Bible reading (Bielo, 2009), no studies have been found that investigate the devotional practice in relation to dying. E-Reading and the Proliferation of Digital Technologies In recent decades, a cultural change has taken place that has deeply influenced the way people engage with the Bible and other sacred texts throughout their lives. Digitalisation and the Internet have dislodged both religious and secular reading practices from their natural place in the constellation of modalities and media (Mangen & van der Weel, 2016). The Pew Research Center (2022) has reported that 3 in 10 Americans now read e-books. According to the American Bible Society (2019), around 55% of the people who read the Bible regularly use the Internet, and 44% use an app to access the Bible. A growing body of literature has begun to examine the effects of digitalisation on religious reading practices and understanding of the Bible (Dyer, 2019; Ford, 2019; Hutchings, 2015, 2017). Recent studies have provided typologies for religious apps (Campbell et al., 2014; Wagner, 2013) and showed how these apps train users into habits of regular Bible engagement (Dyer, 2019; Hutchings, 2015). Ethnographic studies have examined the use of religious apps in varied cultural contexts from an anthropological perspective and demonstrated how religious uses of apps and digital media often interact in complex ways with activities and communities on the ground (Bellar, 2017; Fewkes, 2019). Bellar (2017), who studied Christians’ choice and use of religious mobile applications, emphasises that daily Bible engagement through apps and the expected outcome of encouragement are indicative of offline practices “blurring into the online or mobile context” (p. 121). While the effects of digitalisation on reading the Bible (Dyer, 2019; Hutchings, 2015) and the use of apps in different religious traditions (Fewkes, 2019) are well researched, there is a lack of studies that examine the benefits of Bible e-reading at the end of life. Scholars have highlighted that many religious older people have limited ability to leave their homes for religious purposes because they are ill or live in isolation (Okun & Nimrod, 2021). When illness and physical impairment limit a person’s access to the world, digital technologies seem an asset for practicing religion, creating meaning, and finding support. confronting loneliness with devotion Journal of Religion, Media and Digital Culture 12 (2023) 340–361 346 Previous studies have postulated that social media and apps make and reinforce connections with the mundane and extramundane, provide social support, and allow for seeking information, sharing experiences, and coping with and communicating about existential issues (Drescher, 2012; Lagerkvist, 2019; Rains, 2018; Thompson, 2016). However, it remains unclear how the proliferation of digital technologies such as devotional apps influences and moulds the daily lives and religious practices of terminally ill Christians. Methods and Data (Digital) Ethnography As noted above, this article is based on a single case study. I selected the case from a sample of 12 terminally ill patients who I met between 2020 and 2022 in Switzerland. I chose an open and process-oriented ethnographic approach that acknowledges “the ways which media are inseparable from the other activities, technologies, materialities and feelings through which they are used, experienced and operate” (Pink et al., 2016) to explore patients’ end-of-life journeys. Over a period of 18 months, I made several short field visits. Because of the participants’ poor health and need for privacy and retreat, it proved difficult to engage with them over a longer period of time. Moreover, research was further complicated by the covid-19 crisis. In times of lockdowns, field access provided by two urban hospitals with palliative care units and a hospice in a rural area in Switzerland was hindered, and I was forced to communicate with participants via video conferencing, email, or WhatsApp.The overall study is comprised of several “short-term ethnographies” in which the ethnographer clearly indicates their intentions and engages participants in their project (Pink & Morgan, 2013). Pink and Morgan (2013) argue that short-term ethnographies are by no means “quick and dirty” or less valuable than long-term engagement but should “go beyond observation” (p. 353) to create encounters that benefit from the production of forms of intensity and empathy. The knowledge that stems from these encounters and their interpretation, however, is limited and represents a specific embodiment and “partial perspective” (Haraway, 1988, p. 583)—in this case, that of a 43-year-old non-religious male researcher, who has never been seriously ill himself and had hardly ever had any contact with death until the beginning of this research. Depending on the situation and needs of the 12 participants, different qualitative methods, such as informal conversations, in-depth interviews, participant observation, photo-elicitation (Lapenta, 2011), and Internetethnography, were applied. The approach was designed to adapt to their metzger Journal of Religion, Media and Digital Culture 12 (2023) 340–361 347 difficult living conditions and provide options for collaborative research. By letting the participants decide how they wanted to interact and communicate with me, collaboration and self-determination should be strengthened and vulnerability thus mitigated.1 Given the insightful nature of certain cases, I opted for reporting three of the conducted short-term ethnographies in independent sub-studies (Metzger 2023b, 2023c). The rationale for this single case study is the so-called revelatory case (Yin, 2015, S. 184). According to Yin, “this situation exists when a researcher has an opportunity to observe and analyze a phenomenon previously inaccessible to social science inquiry” (ibid.). As noted above, no ethnographic studies have been found that investigate the devotional practice of Bible (e-)reading in relation to dying. Consequently, I decided to explore the case of the Protestant in detail in order to provide a glimpse into the practice of religion at the end of life in digital culture. Participant Remo, a 73-year-old with whom I had three encounters over the course of a week, suffered from pancreatic cancer in the late stage.2 He was admitted to a palliative care station in autumn 2020 due to a severe health crisis he had faced at home. He died on 17 November 2020, a couple of weeks after our first meeting. The cancer had been diagnosed two years earlier, in 2018. Remo lived with his wife in a major city in Switzerland. They met after the death of his first wife, with whom he had one son. Remo was an engaged Protestant throughout his life. He participated in Christian youth camps in the 1960s and was inspired by the zest for life of his group leaders. After graduating from high school, he joined a religious fraternity, in which he was trained as a deacon. He worked for nearly 30 years for a local congregation, assisting and supporting individuals, organising social activities for older people, and visiting the sick and dying in their homes. Data Collection This article draws on different types of data: 1) two in-depth interviews (25 October and 27 October 2020) with a maximum length of two hours, which 1 The author is committed to an ethical and sensitive research approach in accordance with the principles of professional responsibility of the American Anthropological Association (http://ethics.americananthro.org/category/statement/). The project was reviewed by the Ethics Committee of the Canton of Zurich (Declaration of Competence basec-No. Req2019-00221, Cantonal Ethics Committee Zurich, Switzerland). Written informed consent was obtained from the participant. 2 The name of the interviewee is a pseudonym. Details such as names of places and third parties that could lead to identification of the participant were removed from the article. confronting loneliness with devotion Journal of Religion, Media and Digital Culture 12 (2023) 340–361 348 were recorded on a digital audio recorder and subsequently transcribed (quotations in this article were translated from Swiss German to English and therefore do not reflect all original nuances and subtleties); 2) Informal conversations and field notes of participant observation; 3) photographs of Remo’s living environment in the hospital; and 4) two obituaries of Remo, found on the Internet after his death. Data Analysis I used an open coding approach to analyse my data. For exploratory case studies whose aim is to explore new and unknown fields, working from the “ground up” is an obvious and beneficial strategy (Streb, 2010), which has been, for example, demonstrated in grounded theory research (Glaser & Strauss, 1967). To identify the main themes and shed empirical light on my research questions, I assigned codes to the data, each code representing a concept of potential interest. The insights I gained refined my analytical path and allowed me to illuminate key aims of this study: 1) the emotions and existential issues involved in dying, 2) the purpose and outcome of Bible (e-)reading, and 3) the social (religious) networks and encounters with which the practice is connected. Findings To get to the palliative care unit of the hospital, located on a hill above the city in which Remo was treated, one had to walk through several long and partly unused wings. The ward was situated in a hidden corner of the hospital, and it almost seemed to me as if someone wanted to banish the dying to behind the scenes, as described by sociologist Norbert Elias in his seminal book The Loneliness of the Dying (2001). When I entered Remo’s room to have our first conversation, he was chatting with his wife. She promptly said goodbye to him and nodded to me as she left. The small man invited me to take a seat opposite him. His smartphone and a heavy Bible were lying on the coffee table. Behind the table, on the windowsill, stood a beautiful bouquet of sunflowers, which one of his many visitors must have brought along. He was wearing a big and cosy anthracite-coloured track suit, which concealed his emaciated body—a clear indication of the long-lasting cancer and the therapies he had undergone. He was partially bald, wearing rimless glasses, and his gentle look suggested a good-natured person. During our conversation, his smartphone rang several times. He seemed to be socially well connected. Shortly before we wrapped up our first conversion, the next visitor was already knocking on the door. metzger Journal of Religion, Media and Digital Culture 12 (2023) 340–361 355 to share thoughts with a loved one and a community of peers results in a sense of abandonment and triggers loneliness, which is reinforced by—but cannot be reduced to—the modern institution of the hospital. The Protestant’s feeling of inner loneliness was not, as with the Calvinists in earlier times, owed to the uncertainty of eternal salvation, “which was the most important thing in life for the man of the Reformation age” (Weber, 1905/2013, p. 61), but emerged due to interpersonal challenges and barriers of communication as well as structural factors such as the sequestration of death. Furthermore, the results suggest that Remo’s worldly attachments contributed to his suffering at the end of life and struggles to accept death. In the realm of his experience, death signifies, inter alia, a painful separation from the things he adhered to and loved—for example social relationships—as his deep sadness and attempts to review his fading life in the hospital through conversations with psychologists, pastors, and me revealed. Finding closure proved difficult for the Protestant, as he dedicated himself and his work to this world and not the afterlife. On the whole, it emerged that Remo’s sensitive personality bestowed a complex emotional tone on his journey of dying and that neither religious practice nor family and community networks could always keep him from falling into sadness and despair. The case highlights that despite holistic care and digital technologies, which counteract the sequestration of death (Drescher, 2012; Lagerkvist & Andersson, 2017; Walter, 2020), problems such as loneliness and isolation remain pertinent in dying. With respect to the second research question, the results of this study demonstrate that the religious (e-)reading practices performed at the palliative care unit mitigated emotional suffering and feelings of loneliness. The overall outcome of the practice was encouragement and hope. These results reflect those of other qualitative studies, which found that reading the Bible promotes mental health during stressful life events (Hamilton et al., 2013). Furthermore, the findings support the notion of Bible reading as a lifesupport strategy, based on the practical and applicable knowledge stored in the text. The patterns of Bible engagement reported in this study show how “the reader seeks to apply the text, to find a point of personal relevance within it” (Hutchings, 2017, p. 279). An important finding is that the socially supported reading practice in co-presence with others enabled social bonding and thus alleviated loneliness. Sand and Strang (2006) highlight that injured bodily integrity and physical suffering trigger existential loneliness and emphasise that the sensitive bodily co-presence of caregivers and dying persons “can give reassurance and reduce aloneness” (p. 1386). The findings of this study suggest, in an analogous manner, that apart from the reported theological assumptions, which influenced Remo’s perceived quality of the social reading practice, the confronting loneliness with devotion Journal of Religion, Media and Digital Culture 12 (2023) 340–361 356 sheer presence of a caring body and voice when reading aloud Bible verses reduced loneliness when he was treated at the hospital. The third question of this research was with which social (religious) networks, spaces, and encounters the practice of Bible reading is connected with and support the dying person during the time spent in the palliative care unit. The findings shed empirical light on the network metaphor and the idea that “people in contemporary society live in religious social networks that are emergent, varying in depth, fluid, and highly personalized” (Campbell, 2012a, p. 71). Remo had strong ties with his community, which shared his Christian values and provided support, as the examples of the visitor or the befriended pastor with whom he was in contact via WhatsApp underline. While some of the networks were established networks and existed online and offline, transcending the walls of the hospital, the encounter with me was ephemeral and grounded solely in face-to-face interaction. Furthermore, the findings of this study highlight the importance of both virtual and on-ground networks and ties that can be utilised for support in a difficult time and “make transformational differences in the lives of those who suffer” (Thompson, 2016, p. 16). The current study found that digital and physical spaces of support and religious practice are closely interrelated. If we look at the social Bible study carried out in the hospital, we can conclude that Bible e-reading constitutes a supplement to this practice, which can be convenient when illness and physical impairment affect access to communities and people. The smartphone was an asset for Remo to practice religion anywhere, anytime. It was always at hand in the hospital and could be taken along, for example, when waiting for an operation. By and large, the findings support the idea that the use of religious apps is indicative of offline practices blurring into the mobile context (Bellar, 2017) and that mobile-mediated and online religious practice can be seen as an extension of offline religiosity (Campbell, 2012a). As the analysis revealed, the latter in the studied case also included gift exchange, transforming the practice of Bible reading into a moral economy of compassion and care in which I myself happened to engage. Mauss (2002) argues that the passing of gifts “forges a bilateral, irrevocable bond” (p. 77) between those giving and receiving—an observation that this study can confirm. The written Bible verse and the devotional book that the friend brought to the hospital as a gift added a social dimension to the religious practice with a powerful effect in the given situation. For Remo, this dimension was a key feature of being a Christian that apps and smartphone support but cannot fully cover. The findings I have presented here, of course, are limited, which is true for all case studies. There is clearly a need for ethnographic work in the area of dying and death, which uses a variety of methods in order to further our metzger Journal of Religion, Media and Digital Culture 12 (2023) 340–361 357 understanding of the relationships between online and offline worlds in which people living with terminal illness make meaning, practice religion, and experience support. The portrait of dying I outlined in this article is a fragmentary account of living with terminal illness in contemporary Western culture and must be viewed in relation to the particular moment when Remo and I met. How his feelings and thoughts about life and death moved or changed in the remaining weeks of his life, I do not know. Acknowledgements I am grateful to Remo and the other people at the end of life who shared their experiences and life stories with a stranger. Funding Details This study was funded by the Swiss National Science Foundation snsf under grant number 188869 as part of the project “Settings of dying—an interdisciplinary perspective 2020–23” (https://sterbesettings.ch/en). Editing and proofreading of this article was kindly supported by the Zurich University of the Arts zhdk. References Albinsson, L., and Strang, P. (2003). Existential Concerns of Families of LateStage Dementia Patients: Questions of Freedom, Choices, Isolation, Death, and Meaning. Journal of Palliative Medicine 6 (2), pp. 225–235. http://doi.org /10.1089/109662103764978470. American Bible Society (2019). State of the Bible 2019. https://americanbible.org/uploads /content/state-of-the-bible-2019_report_041619_final.pdf. Arcury, T. A., Quandt, S. A., McDonald, J., and Bell, R. A. (2000). Faith and Health Self-Management of Rural Older Adults. Journal of Cross-Cultural Gerontology 15 (1), pp.65–74. Bauman, Z. (2000). Liquid Modernity. Malden, MA: Polity Press. 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