Spirituality Through a Stethoscope: Health Measures
By Howell Sasser, PhD, Dr. Sasser is Director, Research Epidemiology, R. Stuart Dickson Institute for Health Studies, Carolinas HealthCare System, Charlotte, NC; he reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
Part 3 of a Series on Spirituality
Interest in the connection between spirituality and health began with anecdotal, and later more systematic, observations that religiously observant people appeared to be healthier and live longer. An earlier article in this series discussed some of the possible mechanisms or aspects of religious practice that might mediate this apparent relationship.1 Briefly, these can be summarized as the beneficial effect of religion/spirituality on health behaviors, social support, self-efficacy, and coping.
The cogency of these explanations, coupled with the limited strength of earlier studies' findings, might leave the skeptical observer with the impression that spirituality is, at best, a convenient heading for a group of factors that are by no means unique to it. However, recent studies have benefited from more rigorous methodology and more powerful statistical techniques. In some cases, these have suggested a benefit of spirituality even after controlling for social factors. This article addresses the main areas of inquiry and findings to date.
Mortality
Research on spirituality and mortality is long-standing, dating at least to Durkheim's 1897 study of suicide.2 (It should be noted that Durkheim was also among the first to suggest that the apparent effect of religion on various aspects of life was attributable to associated social factors, rather than to anything intrinsic to religious or spiritual practice. Skepticism has been part of research on spirituality and health since the beginning.) The earliest work, including Durkheim's, was based on denominational and confessional differences, comparing Protestants, Catholics, and Jews. This typology has come to seem simplistic, and more recent work has focused on explorations of the nature and intensity of religious practice.
Hummer and colleagues reported findings from the National Health Interview Survey.3 The study population of 21,204 was followed for nine years. Religiosity was defined based on frequency of attendance at public services (never, less than once per week, once per week, more than once per week)—potentially problematic given the likelihood that attendance would itself be a consequence of health, as much as a predictor of it. Cox proportional hazards models were used to control for potential confounders including demographic factors, health conditions and practices, and social support. After controlling for all other factors, those who never attended public worship had a 50% greater relative hazard of death as compared with those who attended more than once per week. When causes of death were sorted into broad categories, the apparent association attenuated, especially after controlling for other important variables.
Oman and colleagues reported in 2002 on findings from 31 years of follow-up in the Alameda County Study.4 An original sample of 6,928 participants was recruited in 1965, and resurveyed at nine-year intervals. Religiousness was again defined as attendance at public worship services (less than weekly, weekly, or more). Assessment of baseline factors showed that frequent attendance at religious services (once a week or more) was not associated with chronic medical conditions, perceived health, or depression, but was associated with impaired mobility, higher weight, and more close social contacts. After controlling for demographic factors, health conditions and practices, and social support, infrequent attendance was associated with a 21% increased relative hazard (risk) of death from all causes (relative hazard [RH] = 1.21, 95% confidence interval [CI] 1.06-1.37). When causes of death were analyzed separately, only in the cardiovascular category did attendance remain statistically significant (RH = 1.21, 95% CI 1.02-1.45), although there was a statistically nonsignificant doubling of the hazard of death from digestive causes with infrequent attendance.
Musick et al also reported similar findings, but offered an important insight into the variable effects of different components of religious devotion.5 They found that a measure of private religious devotion was positively associated both with mortality and with frequency of service attendance. After private devotion was controlled for, the association of more frequent attendance with lower risk of death was strengthened. This offers some evidence of benefit in reduced mortality specifically from public expressions of spirituality, even after controlling for health factors that might both limit a person's capacity to perform such actions and have an independent impact on mortality.
Finally, Lutgendorf and colleagues reported prospective findings on religious participation, circulating levels of interleukin-6 (IL-6), and mortality.6 IL-6 has been shown to play a role in stress and immune responses, so lower levels might be expected to be associated with lower mortality. In a sample of 557 people 65 years of age or older, 12-year morality and mean IL-6 levels declined with increasing frequency of religious attendance. These findings were sustained after adjustment for a large number of potential confounders. Complex modeling showed that IL-6 levels mediated the relationship between attendance and mortality, suggesting that religious practice might have an impact on mortality at least in part through an effect on immune responses.
Immune Function
A great deal has been written about the interaction of the affective state and the immune system. Given the range of emotions that religious devotion can evoke, it seems logical to consider spirituality as at least an indirect modifier of immunity. Koenig and colleagues studied the relationship of religious attendance and a number of markers of immune function (IL-6, alpha-2 globulin, fibrin d-dimers, polymorphonuclear leukocytes, lymphocytes) in a population of 1,718 adults age 65 and older.7 Although there was evidence of a weak association of higher frequency of religious attendance with more favorable levels of IL-6 and the other markers, adjustment for other health and demographic variables mitigated much of this effect.
Two studies by researchers at the University of Miami examined markers of immune function in men infected with the human immunodeficiency virus (HIV). A 1999 paper by Woods et al reported on 106 mildly symptomatic HIV-positive men.8 Factor analysis was used to develop two aggregated religion variables—religious behavior and religious coping. These variables, along with other psychosocial factors, were used to predict T-helper-inducer cell (CD4+) counts, a key marker of immune competence. After controlling for self-efficacy and active coping, religious behavior was a significant predictor of CD4+ count. This suggests a role for religious devotion independent of its value as a coping resource.
A second study by Ironson et al compared long-term acquired immune deficiency syndrome (AIDS) survivors with HIV-positive, but not yet AIDS-diagnosed, comparitors.9 Elements of a complex measure of spirituality and religious behavior were used to examine factors that might predispose to long-term survival. Not only did the long-term survivors score higher on most measures of religiosity, but both religious behavior and long-term survival also were found to be related to levels of urinary cortisol, a neurohormone with immunomodulatory properties. That cortisol is primarily associated with stress suggests that both affective responses and related hormonal processes may be in the causal pathway between religious behavior and immune function.
Immune function also has come to play an important role in modern cancer treatment. Sephton and colleagues reported results of a small study of religious expression and immune status in women with metastatic breast cancer.10 Religiousness was defined in two dimensions—importance of spiritual expression and attendance at public religious services (both on four-point scales). Women reporting higher levels of spiritual expression also had higher average levels of circulating white blood cells and higher total lymphocyte counts. Those reporting higher levels of attendance also had higher levels of immune function, but the differences were not statistically significant. Although numerous potential confounders were controlled for in the analysis, the cross-sectional nature of the study urges caution in interpreting its results.
Hypertension
The role that spirituality or religious behavior might play in hypertension, either directly or through the mediation of some other mechanism, is among the most studied potential convergences of religion and health. In a 1997 article, Timio and colleagues presented 30-year follow-up data comparing 144 cloistered nuns with 138 lay women.11 By the time of the report, the lay women's mean blood pressure had risen in a pattern anticipated with age, while the nuns' had not. The nuns also had rates of fatal and non-fatal cardiovascular events half as great as those of the lay women. The authors attributed these findings to differences in levels of psychosocial stress.
Koenig and colleagues interviewed a group of 3,936 people age 65 and older at three intervals of three years.12 The likelihood of having a diastolic blood pressure (DBP) reading of 90 mmHg or higher among those who attended public worship once per week or more, or prayed or studied the Bible once per day or more, was 40% lower than among those who did these activities less often. Interestingly, among those who had been told by a physician that they had hypertension, people who reported greater religious activity were also more likely to be adherent to their medication(s). The authors acknowledged that this might mitigate, but could not completely explain, the apparent association of religious activity and blood pressure.
Steffen and colleagues collected 24-hour ambulatory blood pressure readings from a sample of 155 people, 78 African-American and 77 Caucasian.13 The religious dimension in this case was defined as religious coping, as determined by a psychological instrument measuring coping of all kinds. After controlling for demographic and health variables, it was found that higher levels of religious coping were not associated with lower blood pressure in Caucasian participants, but were in African-American participants. The authors noted extensive prior research that shows religion to be a key coping resource among African-Americans, suggesting that it is perhaps coping more than coping style that is the mediating factor.
A small study (n = 112) conducted by Hixson et al in white women college graduates also considered religious coping, but added the further dimension of "intrinsic religiosity," defined as the view that religious faith is a supreme value in its own right.14 In a path analysis, both factors showed some effect, with higher levels of religious activity associated with lower DBP. The association with systolic blood pressure (SBP) was less clear, and no statistically significant effect could be demonstrated either for DBP or SBP.
Heart Disease
A series of papers in the mid-1980s by Friedlander and colleagues is a good example of the issues and possibilities in faith-related health research.15,16 The first article in the series showed that there were differences in heart disease risk factors between groups of observant and non-observant Jewish men and women living in Israel. Participants in the study rated their own degree of religious devotion (Orthodox = most observant; Traditional = moderately observant; Secular = non-observant). The study size was small, including only 746 people, of whom 271 rated themselves as Orthodox. Those who considered themselves to be Orthodox had lower rates of smoking and lower levels of several measures of plasma lipids. They also consumed less total fat and saturated fat. These findings are important because they outline a potential confounding relationship that any claim for a direct relationship between religious devotion and heart disease rates must overcome.
The second article in the series attempted to do this. Using somewhat larger samples (539 people who had had a myocardial infarction [MI] and 686 people who had not) in a case-control design, they assessed a variety of potentially disposing or protective factors. In models controlling for demographic variables, exercise, body mass index, lipids, and hypertension, men who had had an MI were more than three times more likely to self-identify as Secular than those who had not (odds ratio [OR] = 3.63, 95% CI 2.20-6.01). For women, there was a six-fold difference (OR = 6.62, 95% CI 1.62-27.0). Although the retrospective nature of the study leaves room for criticism of its findings, the inclusion of many known heart disease factors previously shown also to be associated with degree of religiousness suggests that there was an independent effect of religious devotion. The authors speculated that social cohesion and strong social support among the Orthodox might play a part.
There is also some evidence of a benefit of religious devotion on cardiac mortality. A study by Oxman and colleagues examined mortality after cardiac surgery.17 In a group of 232 patients age 55 and older, there were 21 deaths within six months of surgery. These were defined as cases, with the remainder of the sample as controls. Religiousness, defined as deriving some or a great deal of strength and comfort from religion (versus little or none), was entered into regression models with various demographic, clinical, and psychological factors. After adjusting for all other variables, the risk of death among those not finding substantial strength and comfort in religion was more than three times as great as among those who did report such a feeling. Interestingly, when a variable testing the interaction between religious activity and social participation was entered into the model, it did not show predictive value. This suggests that the benefit of religious activity for the participants in this study was not tied to the social or organizational aspects of religion.
Negative Effects
After examining claims for the positive impact of religious faith on health, it is important to note that the effect of religion can be negative also. The Koenig blood pressure study noted that those who reported watching religious television programs or listening to religious radio programs had higher average blood pressure than those who did not. This association may have masked differences in health status that restricted some people to these forms of religious participation, but it is worth considering that religious activity is rarely content-neutral, and some religious styles may evoke more stress than they relieve. A study by Fitchett and colleagues also makes the point that religious faith may be challenged by illness, precipitating psychic stress that does nothing to promote coping with physical illness.18 This religious struggle may be brief or lengthy, mild or profound, but presumably it introduces a complexity that might be absent in a nonreligious person.
Conclusion
There are numerous explanations for why those expressing religious devotion might have better health outcomes in some (but not all) situations. Religion has strong social components, as well as aspects that are more inward and not overtly cognitive. Early research had difficulty measuring religiousness in any dimension other than the purely external, a fact that led to criticism of findings of benefit from religious activity. More recent studies have been more nuanced, and appear to show some residual benefit of religious faith after controlling for the material and interpersonal aspects. This is important, not just for those whose health may preclude active participation in public worship, but also for the large number of people who find value in a private spirituality that is not associated with any organized religion. It also brings into focus the fact that the nature of the effect of religious practice on health remains largely undefined, and perhaps indefinable, given the subtle variation in the content and construction of faith from person to person.
Recommendation
As noted before in this series, religious faith, though arguably beneficial to health, is not a pill that can be prescribed. The positive (and negative) effects of faith can accrue to the religiously active patient without (and perhaps despite) any physician intervention. This does not mean that the physician cannot act to help his or her patient explore more fully the social and emotional resources that may be available through the patient's religious activity. The physician should also be aware of the constructions that a patient may place on his or her illness on the basis of his or her place on the religious spectrum. This can help to allay fears, set reasonable expectations, and foster deeper physician-patient communication.
References
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2. Durkheim E. Suicide: A Study in Sociology. Glencoe, IL: Free Press; 1951.
3. Hummer RA, et al. Religious involvement and U.S. adult mortality. Demography 1999;36:273-285.
4. Oman D, et al. Religious attendance and cause of death over 31 years. Int J Psychiatry Med 2002;32:69-89.
5. Musick MA, et al. Attendance at religious services and mortality in a national sample. J Health Soc Behav 2004;45:198-213.
6. Lutgendorf SK, et al. Religious participation, interleukin-6, and mortality in older adults. Health Psychol 2004;23:465-475.
7. Koenig HG, et al. Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults. Int J Psychiatry Med 1997;27:233-250.
8. Woods TE, et al. Religiosity is associated with affective and immune status in symptomatic HIV-infected gay men. J Psychosom Res 1999;46:165-176.
9. Ironson G, et al. The Ironson-Woods Spirituality/Religiosity Index is associated with long survival, health behaviors, less distress, and low cortisol in people with HIV/AIDS. Ann Behav Med 2002;24:34-38.
10. Sephton SE, et al. Spiritual expression and immune status in women with metastatic breast cancer: An exploratory study. Breast J 2001;7:345-353.
11. Timio M, et al. Blood pressure trend and cardiovascular events in nuns in a secluded order: A 30-year follow-up study. Blood Press 1997;6:81-87.
12. Koenig HG, et al. The relationship between religious activities and blood pressure in older adults. Int J Psychiatry Med 1998;28:189-213.
13. Steffen PR, et al. Religious coping, ethnicity, and ambulatory blood pressure. Psychosom Med 2001;63:523-530.
14. Hixson KA, et al. The relation between religiosity, selected health behaviors, and blood pressure among adult females. Prev Med 1998;27:545-552.
15. Friedlander Y, et al. Coronary heart disease risk factors among religious groupings in a Jewish population sample in Jerusalem. Am J Clin Nutr 1985;42:511-521.
16. Friedlander Y, et al. Religious Orthodoxy and myocardial infarction in Jerusalem—a case control study. Int J Cardiol 1986;10:33-41.
17. Oxman TE, et al. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995;57:5-15.
18. Fitchett G, et al. Religious struggle: Prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients. Int J Psychiatry Med 2004;34:179-196.
Sasser H. Spirituality through a stethoscope: Health measures. Part 3 of a series on spirituality. Altern Med Alert 2007;10(1):1-5.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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