Annotated bibliography on religion, spirituality and medicine.

Benson H, Dusek JA, Sherwood JB, et al. Study of the Therapeutic Effects of Intercessory Prayer (STEP) in cardiac bypass patients: a multicenter randomized trial of uncertainty and certainty of receiving intercessory prayer. Am Heart J 2006;151:934-942.

Intercessory prayer (IP) had no effect on complications after CABG, although those who knew they were being prayed for had slightly more complications.

This was a multicenter double-blinded randomized control trial with 1205 patients randomly assigned to Christian groups praying for them (601 were told that they would receive IP and 604 were not told) and 597 were assigned to a control group that was not prayed for. Average age of participants was 64. There was no difference in complication rate (primary endpoint) between those prayed for (52%) and those not prayed for (51%), although there was a trend for those prayed for to have more major events (secondary endpoint) (18% versus 13%, RR = 1.18, 95% CI 1.03-1.35). Those who were told they were being prayed for had slightly more significant complications (59% versus 52%, RR 1.14, 95% CI 1.02-1.28).

Comment

This study had no scientific grounds on which to explain an effect, and also had no theological grounds that would justify an effect. It tells us nothing about the relationship between religion and health, or about the efficacy of IP in terms of prayer to a Christian God. It does suggest that positive human intentions have no effect at a distance (extrasensory perception or psychokinesis), which a large Duke study also found recently (Lancet 2005; 366(9481): 211-217). Another reasonable conclusion is that the highly constrained and reductionistic scientific method is simply the wrong tool for studying the supernatural.

Yi MS, Luckhaupt SE, Mrus JM, et al. Religion, spirituality, and depressive symptoms in primary care house officers. Ambul Pediatr 2006;6:84-90.

One-quarter (25%) of primary care house officers experience significant depressive symptoms. Depressed house officers have significantly lower spiritual well being and poorer religious coping.

Data were collected on 227 house officers in internal medicine, family practice, and pediatrics at the University of Cincinnati Medical Center, measuring depressive symptoms, religious coping, and spiritual well being using established measures. Spiritual well being and religious coping were inversely related to depressive symptoms. Investigators concluded that attending to the spiritual needs of house officers may help them cope better with the rigorous duties involved in training.

Comment

This is a reasonably well-done study using a systematic sample and established measures. The findings seem valid and are consistent with other reports (J Am Board of Fam Practice 1995;8:367-375, J Am Board of Fam Practice 1999;12:206-213).

Reyes-Ortiz CA, Ayele H, Mulligan T, et al. Higher church attendance predicts lower fear of falling in older Mexican-Americans. Aging Ment Health 2006;10:13-18.

Frequent church attendance predicted significantly less fear of falling over time in older Mexican Americans.

A population-based sample of 1341 Mexican Americans over age 70 participated in the third wave of the Hispanic Established Populations for Epidemiologic Studies in the Elderly (EPESE). Religious attendance in 1998 to 1999 predicted less fear of falling in 2000 to 2001 (OR = 0.73, 95% CI 0.58-0.92, P = 0.008), independent of gender, objective lower body performance, history of falls, arthritis, hypertension, and urinary incontinence. The authors concluded that religious attendance may help older adults cope better with fear of falling.

Comment

This study presents important findings and is well researched. If religious attendance helps to reduce fear of falling, then this could be a major factor explaining why others have found that frequent church attenders are at lower risk for developing functional disability over time (J Gerontology 1997;52B:s306-s316).

Rew L. Wong YJ. A systematic review of associations among religiosity/spirituality and adolescent health attitudes and behaviors. J Adolesc Health 2006;38:433-442.

The authors found that religiosity and spirituality appear to be important correlates of attitudes toward health and health behaviors in adolescents.

A total of 43 studies in persons 10 to 20 years old were identified between 1998 and 2003. Religiosity/spirituality had positive effects on health attitudes and behaviors in 84% of studies reviewed. The majority of the studies were well designed, but often did not include a theoretical framework or provide clear definitions of religiosity/spirituality.

Comment

The diversity of measures of religiousness/spirituality and of health attitudes/outcomes in this review precluded a true meta-analysis. Otherwise, the review was systematic, comprehensive and generally well done. Given the importance of adolescent attitudes toward health and health behaviors in establishing lifelong patterns of healthy living, it is significant that almost 7 of 8 studies found positive effects for religion/spirituality. Even with such data, health professionals often do not address these factors in adolescent care.

Curlin FA, Chin MH, Sellergren SA, et al. The association of physicians' religious characteristics with their attitudes and self-reported behaviors regarding religion and spirituality in the clinical encounter. Med Care 2006;44:446-453.

This study of 1,144 physicians across the United States found low rates for physicians addressing religious/spiritual (R/S) issues and high resistance to doing so, related strongly to their own personal R/S beliefs and practices.

Data for this study were collected using a mailed 12-page survey with a response rate of 63%. Questionnaires were sent to a stratified random sample of physicians aged 65 or younger from the American Medical Association Physician Masterfile. All specialties were included. No more than 10% of physicians regularly addressed spiritual issues, and 45% indicated it was usually or always inappropriate for a physician to inquire about a patient's R/S. Whether or not physicians addressed R/S issues in clinical practice depended heavily on their personal R/S beliefs and practices. Only 23% of physicians with both low religiosity and low spirituality "ever" inquired about R/S (ie, took a spiritual history), compared with 76% of physicians with high religiosity and high spirituality. Similar figures were obtained regarding "ever" having prayed with a patient (30% versus 76%, respectively). Major barriers to addressing spiritual issues were also assessed. Interestingly, physicians who noted insufficient time were significantly more likely to inquire about R/S (58% versus 44%). Those who reported concern about offending patients, who reported general discomfort with discussing R/S, and who felt they had insufficient knowledge and training were less likely to address R/S with patients (and were less R/S themselves).

Comment

This is one of the largest and best-designed studies of American physicians' attitudes and behaviors toward R/S in clinical practice. It gives a glimpse of how physicians view addressing R/S issues, how often they actually do so, and especially important, factors that influence these attitudes and behaviors. An overarching conclusion was that physicians who are not themselves R/S, who feel uncomfortable addressing these issues, and who indicate insufficient training, were less likely to feel that it was appropriate for physicians to address R/S issues or actually do so themselves. It highlights the need for training (1) to help physicians recognize how their own personal biases influence their attitudes and behaviors, and (2) to help dispel barriers related to lack of comfort and lack of knowledge that prevent them from regularly addressing R/S inpatient care.

Jaffe DH, Eisenbach Z, Neumark YD, et al. Does living in a religiously affiliated neighborhood lower mortality? Ann Epidemiol 2005;15:804-810.

Middle-aged and older adults living in neighborhoods with a higher density of religious affiliation in Israel were found to have a lower mortality rate over a 10-year follow up.

Investigators used data from the Israel Longitudinal Mortality Study that included 141,683 individuals aged 45 to 89 years living in 882 statistical areas. There were 29,709 deaths reported during the 9.5-year follow up. Multivariate statistical models (adjusting for age, origin, marital status, education, and area-socioeconomic status (SES) indicated that men living in religiously affiliated neighborhoods had a 25% lower mortality rate than those living in religiously unaffiliated areas (OR = 0.75; 95% CI, 0.67-0.84). Women living in religiously affiliated areas had a 14% lower mortality rate during follow up (OR = 0.86; 95% CI, 0.67-0.96). The effect in men was particularly striking because of a dose-effect response. Benefits were evident in both middle-aged and elderly age groups. Among women living in high-SES areas, density of religious affiliation was unrelated to mortality.

Comment

The major weakness of the study is that it did not control for dietary factors; however, even if diet were to explain the effect, adherence to diet would still be considered a religious factor that mediated the effect (rather than a confounder) and would not invalidate the finding. This is one more study that documents the effects of religious involvement on health at the community level (see J Health and Soc Behav 1990;31:185-202, AJPH 1996;86:341-346.). This finding suggests a link between the religiousness of a community and the amount of "social capital" in that community (where social capital is defined as degree of perceived social support, level of trust, frequency of volunteering to meet others' needs, donations to nonprofits, etc.).

Hill TD, Angel JL, Ellison CG, et al. Religious attendance and mortality: an 8-year follow-up of older Mexican Americans. J Gerontol B Psychol Sci Soc Sci 2005;60:S102-109.

This study found that weekly or more frequent attendance at religious services predicted a 32% reduction in mortality during an 8-year follow up of 3,050 Hispanics age 65 or older.

Data were obtained from the population-based Hispanic EPESE (Established Populations for Epidemiologic Studies in the Elderly) that studied Hispanics in Texas, California, New Mexico, Arizona, and Colorado between 1993 and 2001. After adjusting analyses for demographics, physical functioning, social support, mental health, health behaviors, and cardiovascular health (both control variables and explanatory variables), investigators found that weekly attenders had a hazard ratio (HR) for mortality of 0.68 during follow up (P < 0.001).

Comment

This is one of the few studies that have examined the religion-health relationship in Hispanics. The Hispanic EPESE is one of the best-designed and executed studies to date on elderly Hispanics in the southern and western United States. The church has for centuries been central to these largely Catholic populations of middle to low socioeconomic status. The finding is consistent with the results of a meta-analysis of over 20 studies that documented a 37% increase in longevity for frequent religious attendance across age and ethnic backgrounds (see Health Psychology 2000;19:211-222)

Wink P, Larsen B, Dillon M. Religion as moderator of the depression-health connection: Findings from a longitudinal study. Research on Aging 2005;27:197-220.

Reported that religiousness (religious attendance and importance of religious beliefs) measured 30 years previously during middle adulthood moderates the effects of physical health problems on depression in later life. Spirituality, which emphasized noninstitutional expressions (meditation, emphasis on sacred connectedness with God or nature, blending of diverse religious and mythical traditions), however, had no such buffering effect on depression.

A cohort of 184 subjects born in the 1920s in the San Francisco area was followed up through 1997 to 2000. Religiousness, spirituality, physical health, and depression were assessed when these individuals were in their 40s (middle age), 50s (late middle age), and 60s/70s (later life). The highest level of depression during the later life evaluation was among persons with greater physical illness. There was a significant concurrent (cross-sectional) interaction present for religiousness and physical health on depression when all were measured in later life [F(1,147) = 5.48, P = 0.039]), indicating a moderating effect of religion on the physical illness-depression relationship. More importantly, there was a significant prospective interaction between middle-age religiousness and late life physical health on late-life depression [F(1,134) = 4.01, P < 0.05)], suggesting that religiousness 30 years earlier during middle age reduced the effects of physical illness on depression in later life.

Comment

Greater religiousness both concurrently and prospectively moderated the effect of poor physical health on depression in later life. In contrast, no such effect was found for spirituality. This is an important study because there is so little longitudinal research that has measured religiousness and its effects on depression over time, especially over several decades. Even more intriguing is the fact that this study examined both religiousness and spirituality, and was able to compare their differential effects on the physical health-depression relationship. The findings suggest that the more amorphous, diffuse, harder to define concept of spirituality may be less effective in helping older adults adapt to the stress of physical illness, compared with the more traditional concept of religiousness.

la Cour P, Avlund K, Schultz-Larsen K. Religion and survival in a secular region. A twenty year follow-up of 734 Danish adults born in 1914. Soc Sci Med 2006;62:157-164.

Frequent religious attendance predicted a significant reduction in mortality among older adults studied in a northern European country known for its secular culture.

A total of 734 persons aged 70 years old living in Denmark were followed for 20 years, tracking vital status or the age of death. Religious membership (94% Danish Folk Church), importance of religious affiliation (39% important), religious attendance (65% rarely or often), and religious TV/radio (52% rarely or often) were measured at baseline, along with gender, education, medical and mental health, social relations, help given and received, and health behaviors. Religious involvement was associated with female gender, greater social connections, and better health behaviors. Relative hazards (RH) of dying were calculated for each aspect of religious involvement, controlling for both confounders and explanatory variables. Uncontrolled analyses found that those who attended religious services rarely or often had a RH of 0.73 (95% CI 0.64-0.87) compared with those who never attended (27% reduction in mortality). After controlling for both confounders (gender and education) and explanatory variables (health, social connections, and health behaviors), the RH decreased somewhat, but remained significant (RH 0.82, 95% CI 0.68-0.97). Importance of religious affiliation was also associated with reduced mortality (RH = 0.70, 95% CI 0.58-0.85) (30% reduction); controlling for confounders and explanatory variables reduced the effect to nonsignificance (HR 0.87). Viewing religious radio/TV had no effect on mortality. The effects of religious involvement on mortality were greater in women than in men, and in general, were somewhat smaller than found in more religious environments such as the United States.

Comment

This is the first study of the effects of religious involvement on physical health in secular Europe. The effect of religious attendance on reducing mortality, after controlling for confounders, was significant although was somewhat smaller than usually found in the United States. The concern with this study, though, is that they combined "rarely" attend with "often" attend and compared this category to "never" attend. More valid would have been to compare "often" attend to "rarely" and "never" attend; most studies in the United States have compared "weekly attendance or more" with "less than weekly attendance."

Kristeller JL, Rhodes M, Cripe LD, et al. Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med 2005;35:329-347

Oncologists and their patients were generally comfortable performing and receiving a spiritual history. Three weeks after the intervention, compared with controls, patients in the intervention group experienced a reduction in depressive symptoms, increases in functional well being, and an improved doctor-patient relationship.

The study involved 118 consecutive outpatients with cancer (average age 60) seen in the offices of four oncologists (2 Christian, 1 Hindu, and 1 Sikh). They alternately assigned patients (rather than randomly) to either the intervention group or a control group to minimize burden on any one oncologist. The FACT-G (quality of life), Brief Symptom Inventory-Depression, and Primary Care Assessment Survey Interpersonal and Communication Scales were administered before and three weeks after the intervention. Intervention patients received the OASIS spiritual history (SH), which took 6 minutes to administer, and increased the length of the visit by 1.7 minutes (from 13.1-14.8 min). In 85% of cases, oncologists felt comfortable with administering the SH, and in 76% of cases the patient indicated the SH was useful. At the 3 week follow up, compared with the control group, the intervention group had a greater reduction in depressive symptoms (P < 0.01), improved sense of interpersonal caring from the physician (P < 0.05), and increased functional well being (P < 0.001). The authors concluded that taking a SH had a positive impact on the perception of care and well being of patients.

Comment

This study is the first to assess the impact of taking a SH on the patient and the doctor-patient relationship. Multiple benefits of only a single discussion with their physician about spiritual issues were evident after only three weeks. The fact that two of the four oncologists were non-Christians and over 80% of the patients were Christian suggests that the religious background of the physician did not matter much in terms of the benefits received.

Flannelly KJ, Galek K, Handzo GF. To what extent are the spiritual needs of hospital patients being met? Int J Psychiatry Med 2005;35:319-323.

Investigators estimate, based on prior systematic research, that about 20% [+ or -] 10% of hospitalized patients in the United States see a chaplain, depending on setting and hospital type.

Researchers calculated this figure based on a series of studies by their research group that surveyed former patients, hospital staff, and examined hospital records for documented chaplain referrals. They also reported, based on a national survey, that there were approximately 0.8 to 1.0 full-time equivalent (FTE) chaplains on hospital staffs per 100 patients in the 80 to 95% of US hospitals with a daily census of 100 patients or more. Researchers concluded that a figure of 20% (for percentage of patients visited by a chaplain) was reasonable in terms of the number of patients that a single chaplain would likely be able to visit in the time allotted.

Comment

This is the first estimate published of the average number of hospitalized patients in the US seen by a chaplain (ie, 1 or more visit). Research suggests that 76% of medical-surgical patients and 88% of psychiatric patients report experiencing 3 or more religious needs during acute hospitalization (see J Nerv Ment Dis 1997;185:320-326). If only 1 in 5 patients see a chaplain, then there is likely to be a considerable unmet need. This unmet need has been underscored by a survey of 1,732,562 patients representing 33% of all hospitals in the United States and 44% of all hospitals with more than 100 beds, where patient satisfaction with the emotional and spiritual aspects of care had one of the lowest ratings among all clinical care indicators and was one of highest areas in need of quality improvement (see Jt Comm J Qual Saf 2003;29:659-670).

Hamilton JL, Levine JP. Neo-Pagan patients' preferences regarding physician discussion of spirituality. Fam Med 2006;38:83-84.

Surveying members of Neo-Pagan religions (Wicca, Druidry, Asatru), investigators anticipated that members of these religions would be concerned with public disclosure and therefore less willing than members of other religions to have doctors take a spiritual history with them. The exact opposite was found. Over 80% indicated that they thought it was important to have their physician ask about religious beliefs, and almost the same percentage indicated that if their doctor did so, then this would strengthen their trust in the doctor, given the impact their beliefs might have on their medical decisions.

A total of 673 surveys were sent to those who attend Neo-Pagan religious services (through their clergy) or who visit Neo-Pagan-themed websites. Sixty-eight percent of respondents completed surveys (n = 458) (age not provided). The largest group of respondents was Wiccan (also called witchcraft) (n = 188). Subjects came from 42 US states and five Canadian provinces. Results indicated that 73% indicated that their religious/spiritual beliefs would influence their medical decisions; 84% agreed that it would be important to have their physician ask about religious beliefs; and 81% reported that it would strengthen trust in their doctor if a spiritual history were taken.

Comment

It is clear from this survey that for patients in whom religion is important, even (and perhaps especially) if their religious beliefs are unconventional, that the vast majority would be receptive to their physician taking a spiritual history and communicating about the role their beliefs play in coping with illness and medical decisions.

Canada AL, Parker PA, de Moor JS, et al. Active coping mediates the association between religion/spirituality and quality of life in ovarian cancer. Gynecol Oncol 2006;101:102-107.

Study of women with ovarian cancer found that religion/spirituality (R/S) was associated with greater overall quality of life, greater emotional and functional well being, and fewer ovarian cancer-specific concerns. Effects of R/S were mediated through more active coping behaviors.

Women with ovarian cancer who had just completed a course of adjuvant chemotherapy in Texas were surveyed (n = 129, mean age 59). Subjects completed the COPE (standard coping measure), the FACT-O (quality of life assessment for ovarian cancer patients), and the Systems of Belief Inventory-15R (a measure of R/S). Eighty-five percent of women had stage III or IV ovarian cancer. Results indicated that R/S was correlated with active coping (COPE) (r = 0.23, P = 0.022), quality of life (r = 0.25, P = 0.012), emotional well being (r = 0.24, P = 0.014), and functional well being (r = 0.28, P = 0.004) (FACT-O), as well as fewer ovarian cancer-specific concerns (r = 0.27, P = 0.006). Effects of R/S on quality of life were mediated by active coping practices.

Comment

This is a cross-sectional study that cannot determine direction of causation (ie, does poor quality of life adversely affect R/S beliefs or do R/S beliefs positively affect quality of life?). However, this study from the MD Anderson Cancer Center adds further evidence to the growing body of cross-sectional, longitudinal, and clinical trial research (see J Clin Oncology 2006;24:635-642) research suggesting that R/S beliefs and practices play an important role in patients' coping with life-threatening illness and in enhancing quality of life.

Alderete E, Juarbe TC, Kaplan CP, et al. Depressive symptoms among women with an abnormal mammogram. Psychooncology 2006;15:66-78.

Women with an abnormal mammogram were surveyed, assessing depressive symptoms and predictors of depression severity. Only three factors were independently associated with lower depression severity in multiple regression models: Asian ethnicity, higher income, and weekly attendance at religious services.

Depressive symptoms were evaluated using the Composite International Diagnostic in 910 women ages 40 to 80 years who recently received an abnormal screening mammogram from four clinical sites in the San Francisco Bay Area. Mammograms were classified as abnormal but probably benign, suspicious or highly suspicious, or indeterminate using standard criteria. Multivariate logistic regression indicated that that Asian ethnicity, annual incomes greater than $100,000 and weekly attendance at religious services were associated with fewer depressive symptoms.

Comment

The study examined factors affecting women's emotional reaction to the major stressor of having an abnormal mammogram. In this relatively secular area of the country, it is interesting that among a host of psychosocial and health factors, attendance at religious services was an independent and significant predictor of fewer depressive symptoms among women, again emphasizing the role of religion as a coping behavior.

Tully J, Viner RM, Coen PG, et al. Risk and protective factors for meningococcal disease in adolescents: matched cohort study. BMJ 2006;332:445-450.

Religious observance (attendance) was associated with a greater than 90% reduction in the likelihood of teenagers having meningococcal disease, an effect that was equal to or greater than the effect of meningococcal vaccination.

This prospective case-control study of 144 pairs of 15 to 19 year olds (one with meningococcal disease and one matched for age and sex) examined biologic and social risk factors for meningococcal disease among late adolescents. Subjects with meningococcal disease were recruited at hospital admission in regions of England representing 65% of the country's population. In 79% of cases, meningococcal disease was confirmed in microbiologic cultures. Factors that increased the risk of disease were a history of preceding illness, intimate kissing with several partners, and being a university student. Factors that reduced the likelihood of disease were religious observance (OR = 0.09, 95% CI 0.02-0.60) and receiving meningococcal vaccination (OR = 0.12, 95% CI 0.04-0.40). Religious observance was defined as "attending one or more religious ceremonies" in the fortnight period before illness (or interview for controls); results were also confirmed for habitual religious attendance in the previous year. Multiple exposures and a host of psychosocial variables were controlled for in the analyses.

Comment

Investigators explained results as consistent with other studies indicating lower risk among more religious persons (see Pediatr Infect Dis J 1997;16:979-983) and to "other lifestyle factors that promote health and protect against infection." Note that both active and passive smoking were controlled for in the analysis, and this had no effect on the results. Investigators also acknowledged that, "Religious observance has been associated with lower risk for all cause mortality, substance abuse, and sexual risk taking in adolescents and has beneficial immune effects." It is likely that more religiously observant adolescents were at lower risk for a number of biologic, psychosocial, and lifestyle factors. Of course, this was a case-control study, and its weakness is that there may have been some other unmeasured factor correlated both with meningococcal disease and with religious observance that could explain this effect.

Ostbye T, Krause KM, Norton MC, et al. Ten dimensions of health and their relationships with overall self-reported health and survival in a predominately religiously active elderly population: the cache county memory study. J Am Geriatr Soc 2006;54:199-209.

This study examined the health and survival of nearly the entire resident population over age 65 of Cache County, Utah (total n = 3,413). Cache County is 91% Mormon, and over 80% meditate, nearly 80% attend worship/scripture study groups, close to 70% read scripture/holy writings, and over one-third of those aged 65 to 84 volunteer in religious organizations. Those who were more religiously involved had better self-rated health, and also had a lower relative risk of dying during the 7-year follow up that was 12 to 53% less than persons not as religiously involved.

The Cache County Memory Study consists of 3 waves of surveys and clinical assessments in 1995 to 96 (Wave I), 1998 to 99 (Wave II), and 2002 to 03 (Wave III). Logistic regression models were used to determine cross-sectional correlates of the likelihood of reporting excellent/good health in Wave II. Those who volunteered in a religious organization (OR 1.78, 95% CI 1.45-2.18) or attended worship/scripture study groups (OR 1.52, 95% CI 1.25-1.85) were significantly more likely to report excellent/good health. Adjusting analyses for 14 confounders and explanatory variables (not separately examined) fully accounted for these associations. Wave II data were also examined prospectively as predictors of mortality through January 2005. Cox proportional hazards regression models were used to determine predictors. Religious involvement predicted a relative rate (RR) of mortality of 0.47 (95% CI 0.38-0.57) (RR for volunteering in a religious organization) to 0.79 (95% CI 0.64-0.97) (RR for direct experience of God). After adjusting for 14 other confounders and explanatory variables in multivariate models, this accounted for all effects except for volunteering in a religious organization, which continued to predict lower mortality (RR = 0.78, 95% CI 0.61-0.99).

Comment

First, it is important to realize that members of this highly religious Mormon county are known to have the highest life expectancy at age 65 of any other county in the entire United States, and that the life expectancy of men after age 65 in this country exceeds national norms by almost 10 years. Second, even within this population, where the influence of religion has probably reached its ceiling in term of health benefits, analyses indicated that those who volunteered in religious organizations or who attend worship/scripture study groups were more likely to report excellent/good self-rated health, and those who volunteered in a religious organization, read scripture/holy writings, attended worship/scripture study group, or had direct experiences of God, were more likely to survive. Thus, this study documents better health among those who are more religious even in a population that is already very religious, and provides further indirect evidence of the effects of religious involvement on community health. From a critical perspective, it also illustrates the problem of confusing "control" variables (age, gender, race, education, socioeconomic status) with "explanatory variables" (mood, social support, and a host of baseline health variables that religious involvement likely affected during the lifetimes of these individuals), when studying the effects of religion on health.

Schoeneberger ML, Leukefeld CG, Hiller ML, et al. Substance abuse among rural and very rural drug users at treatment entry. Am J Drug Alcohol Abuse 2006;32:87-110.

This study found that the majority of rural substance abusers in a religious area of the United States had no religious affiliation.

Interviews were conducted with 1,579 substance abusers (all ages) in rural and very rural areas of Kentucky. A majority of respondents were involved in outpatient treatment programs (57%), had a prior history of substance abuse treatment (55%), and had been referred by the criminal justice system (64%). Fifty-one percent reported no religious preference.

Comment

Of note here is that in a midwestern state near the Bible Belt, over 50% of drug users had no religious preference. This is in marked contrast to only 7% of persons indicating no religious preference who live in rural areas of the United States in general, let alone rural areas of Kentucky (Religion in American. Princeton Religion Research Center, 1996 Report, The Gallup Poll). Either religious involvement helps to prevent substance abuse in rural areas, or substance abuse results in an alienation from religious organizations, or both.

Benjamins MR. Does religion influence patient satisfaction? Am J Health Behav 2006;30:85-91

Patients who indicate religion is very important to them are more satisfied with the health care they receive.

Investigators used data from the Health and Retirement Study (HRS), a nationally representative sample of 14,557 persons ages 51 to 106 in the United States, to examine the relationship between importance of religion and satisfaction with their health care encounters. Confounders and explanatory variables controlled for in this analysis included age, gender, race, marital status, education, net worth (financial status), self-rated health, activity limitations, chronic conditions, and depressive symptoms. Bivariate analysis indicated that persons indicating that religion was very important to them were significantly more likely to report satisfaction with health care (P [less than or equal to] 0.001). Multivariate logistic regression analyses controlling for the confounders and explanatory variables described above indicated a persistent and significant association between religious importance and satisfaction with health care (P [less than or equal to] 0.01).

Comment

Previous research cited above indicates that many patients are dissatisfied with the way their emotional and spiritual needs are not being met in medical settings. As medicine becomes more rigorously scientific and technologically oriented, there is concern that the patient as a whole person is being left behind. Those for whom religion is very important, however, may have an easier time of negotiating the healthcare system. Although the cross-sectional nature of this survey precludes determination of direction of causation, one possible explanation is that religious persons may be more self-sufficient in terms of meeting their own emotional needs, compared with patients for whom religion is less important, and may experience greater satisfaction from whatever level of health care they receive. Patients who are coping poorly with their illness are less likely to be satisfied with health care in general. Of course, patients who are not satisfied with their health care may also withdraw from religious involvement because it may seem that their prayers are not being answered.

Hill TD, Burdette AM, Angel JL, et al. Religious attendance and cognitive functioning among older Mexican Americans. J Gerontol B Psychol Sci Soc Sci 2006;61:P3-9.

Researchers found that religious attendance slows the rate of cognitive decline over time in older Mexican Americans.

Investigators used data from four waves of the Hispanic EPESE that involves 3,050 individuals over age 65 of Mexican origin, with the baseline survey conducted in 1993 to 94 and follow-up data obtained in 1995 to 96, 1998 to 99, and 2000 to 01. The MMSE was used as a measure of cognitive functioning. Linear growth curve modeling was used to predict cognitive function over time. On average, cognition declined by 1.71 points every 2 years or 5.13 points during the course of the 6-year study. Religious attendance in 1993 to 94 was used to predict cognitive functioning trajectories over the course of the study. Control variables included functional disability, sensory impairments, health behaviors, psychological distress, chronic diseases, and sociodemographic factors (age, gender, education, English proficiency, and social engagement). Effects of religious attendance had a dose response effect on cognitive functioning trajectories. Compared with those who never attended religious services, those who attended more than weekly declined more slowly in cognitive functioning by 0.75 MMSE points per 2-year period, or 2.25 points over the study period. For weekly and more than weekly attendance, effects were significant at P < 0.01.

Comment

This well-designed study using the latest in linear growth curve modeling is one of three studies that have documented an effect of religious involvement over time in slowing cognitive decline in older adults and those with Alzheimer disease (see J Gerontology 2003; 58B:S21-S29, and presentation by Kaufman & Freedman, Baycrest Centre for Geriatric Care, Toronto, 57th Annual Meeting of the American Academy of Neurology, Miami Beach, FL, April 13, 2005). These findings could be explained by the hypothesis that religious attendance is a unique form of social engagement that may influence cognitive functioning.

Hill TD, Burdette AM, Ellison CG, et al. Religious attendance and the health behaviors of Texas adults. Prev Med 2006;42:309-312.

In a random sample of Texas adults, investigators found that weekly attendance at religious services was associated with a wide range of healthy behaviors.

Using a statewide probability sample of 1504 Texans who participated in the 2004 Survey of Texas adults, investigators used a series of logistic regression models to assess the effects of religious attendance on 12 health behaviors after controlling for several background correlates of religious involvement and health behaviors, including age, gender, race, marital status, number of children, socioeconomic status, impaired health, and others. Health behaviors associated with weekly attendance include: regular physical examinations (OR 1.65, 95% CI 1.21-2.23), dental examinations (OR 1.56, 95% CI 1.16-2.10), vitamin use (OR 1.68, 95% CI 1.25-2.25), infrequent bar attendance (OR 2.16, 95% CI 1.45-3.22), regular seatbelt use (OR 2.20, 95% CI 1.26-3.85), regular walking (OR 1.73, 95% CI 1.29-2.32), strenuous exercise (OR 1.84, 95% CI 1.34-2.52), sound-sleep quality (OR 1.49, 95% CI 1.03-2.15 for > weekly attendance), never smoking cigarettes (OR 2.03, 95% CI 1.52-2.71), and moderate drinking (OR 2.82, 95% CI1.65-4.81).

Comment

Religious involvement is associated with a number of health behaviors and healthy lifestyles that could help to explain the effects that religion has on health (this is also true for adolescents, see Health Education and Behavior 1998; 25: 721-741). Bear in mind that health behaviors do not confound the relationship between religion and health, but instead help to explain how religious involvement influences health and longevity (ie, it is an explanatory variable).

WHOQOL SRPB Group. A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life. Soc Sci Med 2006;62:1486-1497.

The study involved 18 countries from South America, the Middle East, Africa, Europe, and Asia. Spirituality, religion and personal beliefs (SRPB) were highly correlated with all five World Health Organization Quality of Life (WHOQOL) domains.

Cross-sectional relationships were examined between SRPB and WHOQOL domains in two areas of Brazil, Argentina, Uruguay, Egypt, Israel, Kenya, Italy, Lithuania, Spain, Turkey, England, China, two areas of India, Tokyo, Malaysia, and Thailand (n = 5087). The five WHOQOL domains included physical health, psychological health, independence, social support, and environment. Eight SRPB subscales, each assessed with four questions, included spiritual connection, meaning of life, awe, wholeness & integration, spiritual strength, inner peace/serenity/harmony, hope & optimism, and faith. The total SRPB was significantly correlated with WHOQOL physical health (r = 0.16), psychological health (r = 0.46), independence (r = 0.17), social support (r = 0.37), and environment (r = 0.35).

Comment

This study is unique in providing systematic data on persons from a variety of countries and religions on which such data were not previously available. The instrument to measure spirituality, religion and personal beliefs (ie, the SRPB) however, was highly confounded with items that were really indicators of mental health itself (meaning of life, inner peace, serenity, hope, optimism), and did not assess spirituality/religion as a unique concept separate from psychological well being. Therefore, any correlations with the WHOQOL domains (especially psychological health) are suspect for tautological or circular associations.

Regnerus MD, Burdette A. Religious change and adolescent family dynamics. Sociological Quarterly 2006;47:175-194.

Increase in the personal importance of religion in adolescents across time is correlated with better family relationships.

Investigators employed data from two waves (1994 and 1996) of the National Longitudinal Study of Adolescent Health, a national sample of adolescents in Grades 7 through 12. In Wave I, 20,745 in-home interviews were completed and these were repeated in 14,738 adolescents in Wave II. At each wave, investigators measured personal importance of religion and family relationships, comparing changes in each across these two points in time (2 yr). Results indicated that growth in personal religious salience (ie, importance of religion in life) was uniquely related to better family relations, even after controlling for behavioral changes including substance abuse patterns.

Comment

The National Longitudinal Study of Adolescent Health is perhaps the best source of reliable data about adolescent health in the US today. This massive survey involved high schools in over 80 communities nationwide. Based on a 2-year longitudinal study, these investigators found that an increase in the importance of religion was associated with better family relationships, independent of other more established predictors of family relationship quality. For health professionals who deal with adolescents, it is important to know that positive religious experiences may help to optimize family relationships and promote beneficial consequences on adolescent and future adult health.

Krupski TL, Kwan L, Fink A, et al. Spirituality influences health related quality of life in men with prostate cancer. Psychooncology 2006;15:121-131.

Men with early stage prostate cancer who have higher spirituality have better health-related quality of life and psychosocial health than other men scoring lower on spirituality.

A total of 222 men, whose names were drawn from a state-funded program that provided free prostate cancer treatment to the poor, were surveyed. Validated instruments of spirituality, disease-specific quality of life, and mental health symptoms were used. High spirituality was associated with significantly better physical health, mental health, sexual function, and less urinary problems, independent of other predictors.

Comment

This is one of the few studies that have examined the role of spirituality in the lives of men with prostate cancer. The men in this study, however, were largely indigent, so the findings may only apply to men with low socioeconomic status and certain ethnic backgrounds. Furthermore, the title is a bit misleading in that it determines causality, which of course cross-sectional studies cannot do. However, given the long survivorship of men with prostate cancer, quality of life is a major factor influencing the health and well-being of these men over many years. Knowledge about factors that potentially influence quality of life, then, are important for primary care physicians who take care of these men's medical problems.

Murray-Swank AB, Lucksted A, Medoff DR, et al. Religiosity, psychosocial adjustment, and subjective burden of persons who care for those with mental illness. Psychiatr Serv 2006; 57:361-365

This study found that many family caregivers of persons with serious mental illness turn to spirituality for support, and that this may be an important factor in caregiver adjustment.

A convenience sample of 83 caregivers participating in the Family to Family Education program (Baltimore, MD) were surveyed regarding their religious involvement and the adjustment to caring for a relative with severe mental illness (44% with schizophrenia, 50% with major affective disorder). Religiosity was assessed by religious attendance, importance of religion, and God as a source of strength (the latter two items were combined into a personal religiosity scale). Spiritual support was assessed by religious or spiritual support received in the past three months, including praying, watching or listening to religious media, reading the Bible or seeking support from their faith community. Depression (CESD), self-esteem and mastery (Family Impact Survey) were assessed with established measures. Caregiver burden (worry and displeasure) were assessed with the Family Experience Interview Schedule, and caregiver self-care by a six-item scale developed by investigators. Results indicated that 37% of caregivers had received religious or spiritual support within the past 3 months. Personal religiosity was positively correlated with level of mastery (r = 0.26) and with self-care (r = 0.33), and was negatively correlated with depression (r = -0.25) (all P < 0.05). After controlling for age, gender, education, and race, personal religiosity was inversely related to depression (B = -0.33), positively correlated with self-esteem (B = 0.33), mastery (B = 0.29), self-care (B = 0.42) (all P < 0.05), but not caregiver burden.

Comment

Caregivers of relatives with severe mental illness experience tremendous stress that affects both their psychological and physical health. This study, while cross-sectional and not population-based, helps to establish that at least one-third of caregivers report that they receive support from religion/spirituality, and measures of personal religiosity (but not religious attendance) are correlated with better mental health and adjustment. This finding is consistent with prospective studies of stressed caregivers (see Age Ageing. 1990;19:185-190) and supports the need for collaboration between mental health and religious communities in meeting the needs of caregivers and those they care for.

Huguelet P, Mohr S, Borras L, et al. Spirituality and religious practices among outpatients with schizophrenia and their clinicians. Psychiatr Serv 2006;57:366-372

In a study of patients with schizophrenia in Switzerland, investigators reported that while a minority of patients experience religious delusions (16%), over half participated in religious activities every day, and 59% indicated that spirituality was very important or essential (40%) in their daily living.

A convenience sample of 100 outpatients with schizophrenia (mean age 39) was assessed on clinical characteristics and religious involvement (cross-sectional). Interviews were conducted in a semi-structured format and audio taped. Patients' clinicians (n = 34) were also surveyed on their religious beliefs and practices, as well as on what they knew about their patients' religious involvement. Results indicated that while a majority of patients reported that spirituality was important in their daily lives, only 39% had spoken about this with their clinicians. In contrast, only 6% of clinicians participated in religious activities every day (versus 52% of patients) and only 4% believed that spirituality was essential for daily living (versus 40% for patients). Despite the fact that 93% of clinicians reported feeling comfortable speaking about spirituality with patients, in half of the cases, clinicians' perceptions of their patients' religious involvement were not accurate, and over half of the clinicians (54%) indicated they lacked skills in addressing this area.

Comment

Interestingly, in a study coming from secular Europe, investigators found that spirituality was very important or essential for daily living in almost 60% of patients, and in only a small percent-age were religious beliefs related to psychotic symptoms. (In trying to understand the reason for this high degree of religious involvement by these patients, investigators recently reported that over 70% of patients with schizophrenia indicated that religion provided hope, purpose and meaning in life [see Mohr S, Brandt P, Borras L, et al. Toward an integration of religiousness and spirituality into the psychosocial dimension of schizophrenia. Am J Psychiatry, in press]).

Furthermore, there appeared to be a large gap between the religious/spirituality involvement of patients and their clinicians, the majority of whom never addressed these issues with their patients and felt ill prepared to do so.

I think a hero is an ordinary individual who finds strength to persevere
and endure in spite of overwhelming obstacles.
--Christopher Reeve

Harold G. Koenig, MD

From the Departmenst of Psychiatry & Behavioral Sciences and Medicine, Duke University Medical Center, GRECC VA Medical Center, Durham, NC.

Reprint reqests to Dr. Harold G. Koenig, Box 3400, Duke University Medical Center, Durham, NC 27710. Email: [e-mail]