HEALTH AND RELIGION

HEALTH AND RELIGION . Since the mid-1980s, there has been increasing interest in the relationship between religion and health. Consider that a MEDLINE search of all scientific literature on religion or spirituality and health between 1980 and 1982 revealed forty-six articles; between 2000 and 2002, however, that number had increased to 393 articles. Similarly, a PSYCHLIT search of the psychological literature on religion or spirituality between 1980 and 1982 revealed 101 articles; between 2000 and 2002 the number had increased more than tenfold to 1,108 articles. Although much of the research on religion and health has been conducted in the United States, hundreds of studies have also been reported from other areas of the world, including Canada, Great Britain, Australia, continental Europe, Norway and Sweden, India, Israel and other parts of the Middle East, China, Korea, and Japan (see Koenig et al., 2001). Many of these studies found similar relationships between religion and health. Nevertheless, this research, in the United States and elsewhere, has with good reason come under criticism by some researchers, who also question how the findings should be applied clinically.

Historical Connection

Western concepts of health care have their origins in the values and activities of religious organizations. The first large hospital in the Western world was built by the Christian church in the late fourth century ce, and for the next one thousand years the church built and staffed hospitals throughout western Europe and England. The first nurses were members of religious orders—the Catholic Sisters of Charity and, later, the Protestant Deaconesses—and they provided most of the nursing care in Western hospitals till the early 1900s. Many physicians during this time were also clergy, a tradition that carried over into the United States during colonial times.

After the French Revolution at the end of the eighteenth century, however, medicine became more and more separated from religious influences. Despite this trend, many hospitals continued to be affiliated with and supported by religious institutions, both in the United States and western Europe. With the rise of science in the latter half of the nineteenth century, the separation between religion and medicine became complete. In the early twentieth century, Sigmund Freud wrote prolifically about the neurotic aspects of religion, influencing both the field of psychology and medicine. As a result, religion came to be seen within the scientific health-care profession as either irrelevant to health or inimical to it. This was before systematic, large-scale research studies began to objectively examine the relationships between health and religious belief and practice.

Religion versus Spirituality

In the late 1980s the term spirituality began to be used in preference to the word religion, since religion suggested doctrine, divisiveness, and institutional power, whereas spirituality was seen as more personal and inclusive. For the purposes of this entry, religion is defined as an organized system of beliefs, practices, and rituals designed to connect a person to the sacred or transcendent (god, ultimate truth, ultimate reality), and to promote one's relationship and responsibility to others within the context of a faith community. Spirituality, on the other hand, is understood as a personal quest to understand the answers to ultimate questions about life, about meaning, and about one's relationship to the sacred, which might or might not lead to religious doctrines, rituals, or a faith community. Because spirituality is such a broad concept, however, researchers have had difficulty measuring it as distinct from religion; thus, most studies have measured spirituality in terms of religious beliefs or practices, and most research that examines the relationship with health has examined religion, not spirituality. For that reason, the word religion will be used throughout this discussion.

Religion and Mental Health

A systematic review of research conducted prior to 2000 identified 724 quantitative studies of the relationship between religion and mental health. Of those, 478 (66%) found a statistically significant relationship between religious involvement and better mental health, greater social support, and less substance abuse. Nearly 80 percent of studies examining the association between religion and well-being reported one or more significant positive correlations between these variables. This was particularly true for optimism, meaning and purpose, and hope in the future. The majority of studies examining the relationship between religion and self-esteem also reported greater feelings of self-worth among the more religious.

Similar associations were also found in studies of mental disorder. Of ninety-three cross-sectional and prospective studies, sixty (65%) found lower rates of depression or depressive symptoms and faster speed of remission from depression among those who were more religious. In fact, at least three clinical trials demonstrated faster recovery from depression, anxiety, and grief associated with bereavement among religious persons receiving religious-based psychotherapies. These findings came not only from the United States, but also from the Netherlands and Malaysia, and involved not only Christians but also Muslims and Buddhists. Furthermore, more negative attitudes toward suicide and lower rates of suicide among the religious were found in fifty-seven of sixty-eight studies performed during the twentieth century, which is consistent with research showing lower rates of depression and greater well-being.

Greater social support (nineteen of twenty studies), less loneliness, and less substance abuse (drugs, alcohol, smoking; 121 out of 145 studies) have also been documented among the more religious. Greater marital stability, lower delinquency, and more pro-social activities (volunteering, for example) are other common findings. At least 75 percent of research on substance abuse has been in adolescents and college students, whose drug and alcohol use behaviors are likely to affect health over a lifetime. New research conducted since that systematic review has largely confirmed these findings.

This does not mean, however, that religious beliefs and practices are never associated with worse mental health, particularly in individual cases. Religious beliefs and practices can foster rigid thinking and excessive guilt, and may drive some persons away from seeking health-care services that they need. In general, however, data from cross-sectional, prospective, and clinical trial research are increasingly dispelling past notions that religion typically fosters mental or emotional instability.

Religion and Physical Health

The relationships between religion and better mental health, greater social support and marital stability, and lower rates of substance abuse and delinquency, are likely to have physical health consequences. This would be expected, given the well-established connections between psychosocial factors and neurological, endocrine, and immune functioning. Although studies of religion and physical health are less common than those of mental health, a similar pattern of results emerges.

Several studies have examined associations between religion and immune functioning, blood pressure, heart disease, cancer, overall mortality, and disability level. Five studies that examined the relationship between religion and immune functioning all reported associations. Two of these studies were conducted on persons with HIV/AIDS, two in older adults with immune senescence with aging, and one in women with metastatic breast cancer. Whether immune function is measured in terms of interleukin-6 levels, CD-4 and total lymphocyte counts, or natural killer-cell numbers, the findings favor the more religious. Lower serum cortisol levels have also been linked to greater religiousness, which may help to explain the immune findings.

Of twenty-three studies examining the relationship between religiousness and blood pressure, fourteen found lower rates of hypertension or lower blood pressure among those who were more actively religious. The association appears to be particularly strong for diastolic blood pressure, compared to systolic blood pressure, and therefore may be of special importance given the influence of diastolic hypertension on myocardial infarction (heart attack) and stroke. Consequently, it is not surprising that eleven of sixteen studies examining the associations between religious activity and heart disease found lower rates of myocardial infarction, death from coronary artery disease, and longer survival after open-heart surgery among the more religious. At least one study has found lower rates of stroke among more frequent church attendees.

Of six studies examining cancer, four found lower mortality in the more religious, a finding consistent with the influence of neuroendocrine and immune function on the development and course of cancer. Whether in persons with cancer or other health conditions, survival in general appears to be longer among persons who are more religiously active. Of fifty-two studies examining that relationship, thirty-nine reported significantly longer survival among those who attended religious services more often, prayed more frequently, or demonstrated more commitment to religious beliefs. The effects are particularly strong for religious attendance, even when the effects of social support and the ability to physically attend church are statistically controlled for. In one of the largest studies, involving 21,000 randomly selected persons of all ages across the United States, Robert Hummer and colleagues (1999) found that persons who attended religious services more than weekly survived an average of seven years longer than persons who did not attend services; for African Americans, the difference in survival was fourteen years.

Some criticize these studies by pointing out that people who are sicker are physically less able to attend church services. While being physically disabled can adversely impact religious attendance during the short term, Ellen Idler and colleagues (1997) at Yale found that the effects of attendance on preventing the development of disability over the long run are substantially stronger. Religiousness may impact the perception of disability, so that at any given level of objective physical illness, those who are more religious may be less likely to perceive themselves as disabled, compared to those who are less religious. Perception of disability may be influenced by the optimism, hope, and meaning that people derive from religious beliefs.

Concerns of Critics

Although critics of the religion-health relationship are few, they are particularly vocal and articulate in their arguments. Richard Sloan and colleagues have stressed that the research linking religion with physical health is weak and inconsistent. They voice ethical concerns about the implications of that research for the practice of medicine. "Should Physicians Prescribe Religious Activities?" (2000) is the title of one such article in which the authors claim that the research is not strong enough to warrant prescribing religion to helpless patients. Instead, they say that health professionals should stay out of the religious lives of patients, emphasizing that health professionals other than chaplains are not trained to address religious or spiritual issues, and bringing up such issues could make patients feel guilty or feel responsible for causing their own illnesses. In some countries, such as Australia, critics claim that religion is not as important to patients as in the United States. These are important points that require careful consideration.

Advocates in favor of health professionals addressing spiritual issues in patient care counter these claims by saying that while physicians or nurses should never prescribe religion to those who are not religious, there is much they can and should do. In particular, they could take a spiritual history to learn if the patient is religious and how that might affect his or her medical care. If the patient is religious, the doctor or nurse could orchestrate the meeting of the patient's spiritual needs, utilizing the patient's religious resources to facilitate healing. Advocates would agree that most of the research, while consistently showing that the religious tend to be healthier, has not shown that becoming religious for health reasons alone (rather than for religious motivations) is likely to result in better health. Clinical trials demonstrating such an effect do not exist. Therefore, there is little evidence to justify physicians encouraging religious conversion as a route to better health. Even if such evidence did emerge in future research, the ethical implications of health-care professionals promoting religion among those who are not already religious would be legion.

Conclusion

There is growing evidence of a relationship between religion and better mental health, social functioning, and health-promoting behaviors. Because of the increasingly well-established connections between the emotions, physiology, and body functions, there is every reason to expect an association between religion and physical health. Although research on religion and physical health is growing, and several clinical trials to establish the causal nature of this relationship are underway, the evidence remains largely preliminary at this point and there is much further work to do. The preliminary evidence based on epidemiological findings thus far, however, fits a pattern that investigators have seen for other psychological and sociodemographic factors that have later been proven to influence physical health. Certainly these findings deserve further attention by researchers and they deserved to be studied in more sophisticated ways to demonstrate if and in what circumstances religion may influence health for better or for worse. Cautious and sensible application to clinical practice of what is already known would also seem warranted.

Bibliography

Hummer, Robert A., Richard G. Rogers, Charles B. Nam, and Christopher G. Ellison. "Religious Involvement and U.S. Adult Mortality." Demography 36 (1999): 273–285.

Idler, Ellen L. "Religion, Health, and Nonphysical Senses of Self." Social Forces 74 (1995): 683–704.

Idler, Ellen L., and Stanislav Kasl. "Religion among Disabled and Nondisabled Elderly Persons, II: Attendance at Religious Services as a Predictor of the Course of Disability." Journal of Gerontology: Social Sciences 52B (1997): S306–S316.

Koenig, Harold G. "An 83-Year-Old Woman with Chronic Illness and Strong Religious Beliefs." Journal of the American Medical Association 288 (2002): 487–493.

Koenig, Harold G. Spirituality in Patient Care. Radnor, Pa., 2002.

Koenig, Harold G., and Harvey Jay Cohen. The Link between Religion and Health: Psychoneuroimmunology and the Faith Factor. New York, 2002.

Koenig, Harold G., Michael E. McCullough, and David B. Larson. Handbook of Religion and Health. New York, 2001.

Mueller, Paul S., David J. Plevak, and Teresa A. Rummans. "Religious Involvement, Spirituality, and Medicine: Subject Review and Implications for Clinical Practice." Mayo Clinic Proceedings 76 (2001):1225–1235.

Peach, Hedley G. "Religion, Spirituality, and Health: How Should Australia's Medical Profession Respond." Medical Journal of Australia 178 (2003): 86–88.

Sloan, Richard P., Emilia Bagiella, Larry VandeCreek, Margot Hover, Carlo Casalone, Trudi Jinpu Hirsch, Yusuf Hasan, Ralph Kreger, and Peter Poulos. "Should Physicians Prescribe Religious Activities?" New England Journal of Medicine 342 (2000):1913–1916.

Harold G. Koenig (2005)