Religion, aging, and health: exploring new frontiers in medical care.

Abstract: The purpose of this review article is to selectively examine research that was designed to evaluate the relation between religious involvement and health among older people. Four facets of religion are examined in detail: church-based social support, religious coping, forgiveness, and prayer. In addition, potential negative effects of religion on health are discussed. Negative interaction in the church as well as religious doubt are evaluated in this respect. Throughout, an effort is made to show how current research on religion and health may be used to provide more comprehensive care for our aging population.

Key Words: health, medical intervention, older adults, religion

**********

Researchers at the Centers for Disease Control (CDC) recently provided some sobering facts about the health of our aging population. (1) According to these scientists, approximately 80% of all persons 65 years of age and older have at least one chronic medical condition, and 50% have two or more. Given the high prevalence of chronic illness among older people, it is not surprising to find that they consume a disproportionately large amount of the nation's health care resources. As the CDC investigators report, the health care cost per capita for people 65 years of age and older is 3 to 5 times greater than the cost for individuals who are younger than 65 years of age. (1)

To hold down skyrocketing medical costs, it is imperative that we learn more about the factors that influence the health of our aging population. This is especially important because, as recent demographic trends reveal, the proportion of older people in the United States is growing rapidly. In fact, it is predicted that the number of older individuals will increase from 12.4% in the year 2000 to nearly 19.6% in 2030. (1)

There is growing recognition among health care providers that social and psychologic factors may exert a significant influence on the physical and mental health of older adults. For example, a substantial number of studies indicate that older people who experience stressful life events (eg, death of a loved one or significant financial problems) may be at risk for a wide range of physical and mental health problems. (2) Similarly, research suggests that older people who are embedded in tightly knit social networks tend to enjoy better health and live longer than older adults who do not maintain close ties with others. (3)

Although a range of potentially important psychosocial risk factors have appeared in the literature, the purpose of this paper is to critically review an area that has received a good deal of attention in recent empiric work--the relation between religion and health in late life. Proponents of this research maintain that older people who are religious tend to enjoy better physical and mental health than older individuals who are not involved in religion. (4) It is important to consider mental as well as physical health outcomes because research consistently shows that many presenting complaints in primary care settings arise from mental health problems rather than physical health problems. (5)

There are two reasons why research on religion, aging, and health is important. First, as discussed above, physical health problems are especially prevalent in late life. Second, research suggests that older people are more involved in religion than younger adults. If religion has a beneficial influence on health, then these salubrious effects should be especially evident in aging populations.

As research in the field continues to mature, researchers are becoming increasingly aware that religion is a complex, multidimensional phenomenon. (6) This means, for example, that religion encompasses a number of dimensions or factors including prayer, attending worship services, building social relationships with people at church, and using religious teachings and principles to cope more effectively with stressful life events. Consequently, the potential health-related benefits of religion may arise from either a wide range of factors or only a few specific facets of religious involvement. It would not be possible to examine all the dimensions of religion that might be linked with health in this brief review. Instead, a more reasonable strategy involves carefully examining a few key elements that look especially promising and that are particularly relevant for those working in clinical settings.

With this goal in mind, the discussion that follows is broken down into three main sections. First, four facets of religion are examined in some detail: church-based social support, religious coping, forgiveness, and prayer. The same approach will be taken to explore each domain: Each construct will be defined and an effort will be made to show why it may be associated with better physical and mental health. A brief discussion will be provided at this juncture that aims to show why each dimension of religion is especially relevant for older people. Finally, the potential for using each dimension of religion to develop interventions in clinical settings will be reviewed.

After examining these potential beneficial mechanisms, section two will focus on an issue that has not received sufficient attention in the literature--the negative side of religion. This small but growing body of research suggests that there may be costs as well as benefits associated with being involved in religion. (7,8) Therefore, to provide a more balanced view of research on the religion-health connection, it is important to consider the potential downside of religion as well.

Finally, section 3 will contain a brief overview of wider issues in research on religion and health. More specifically, a series of general issues are identified that should be kept in mind as work in the field is reviewed. Thorny practical problems and ethical issues in applying research on religion in clinical settings are also briefly highlighted at this point as well.

Church-based Social Support

Church-based support is defined as emotional, tangible, informational, and spiritual assistance that is exchanged among people who worship together. There is considerable evidence that social relationships tend to thrive in religious settings. (9) This is not surprising because virtually all religions in the world extol the virtues of loving one another and caring for those who are in need. In fact, this is one reason why some researchers maintain that social ties in the church are specially close-knit and may be more beneficial than social relationships that arise in secular settings. (10) In addition, as discussed above, a vast number of studies conducted in secular settings suggest that social support provided by family members and friends tends to bolster health and extend longevity. (11) If social relationships exert a beneficial effect on health, and if social ties are especially strong in the church, then it follows that the salubrious effects of religion on health may be traced, at least in part, to church-based, social support networks.

Although all people may benefit from church-based social ties, there are two reasons why they may be particularly important for older people. First, late life has often been characterized as a time of significant role loss. More specifically, older people retire from work, many encounter widowhood, and children reach maturity and leave the home. Each of these role transitions may be accompanied by the loss of social relationships. Church-based social ties may rise to fill this need. The second reason why church-based social ties may be important may be found in the basic nature of the aging process itself. As people get older, they experience an inevitable decline in both physical and cognitive functioning. (12) As a result, things they used to take care of on their own must now be tended to by significant others. It appears that church-based, social support systems are especially helpful in this regard. For example, church members often provide transportation to worship services, and they frequently take care of fellow members who are ill. (11)

Because people in church may help each other in a number of different ways, it is important to identify the specific types of helping behavior that may influence physical and mental health. For example, people at church may provide emotional support (eg, express interest and concern in the well-being of another), tangible assistance (eg, help with shopping), or they may provide spiritual support. Spiritual support involves the sharing of religious experiences and feelings as well as helping others adapt religious teachings and principles in daily life. (13) The distinction between different types of church-based social support is important because, as a recent nationwide survey by Krause (13) reveals, spiritual support but not emotional support from fellow church members is associated with better self-rated health. This finding is important because it suggests that the health-related benefits of religion may arise from dimensions of support that are unique to the church (eg, spiritual support) and not from types of assistance that may be found outside as well as inside the church (eg, emotional support).

The study by Krause (13) further contributes to the literature by showing one way in which the potential health-related effects of spiritual support may arise. More specifically, this study suggests that more spiritual support is associated with having a closer relationship with God; people who have a closer relationship with God are more optimistic, and people who are more optimistic tend to rate their health more favorably than those who are less optimistic. However, this study does not exhaust all the ways in which the support received at church may influence health. For example, a number of religious denominations have strict prohibitions against using alcohol and tobacco. Some researchers argue that informal encouragement from fellow church members represents one way in which these guidelines are adapted and reinforced. (10) Also, there is some evidence in the literature that social support provided in secular settings tends to bolster immune functioning. (14) If social ties in the church are especially close-knit as Ellison and Levin claim, (10) then perhaps they exert an even more beneficial effect on the immune system than social relationships in secular settings.

Research on church-based support is important because it lends itself well to clinical intervention. A good deal has been written about the use of social support research to guide formal support groups in secular settings. (15) Some support-based interventions appear to be quite effective. (16) However, far less research has been conducted on the development and assessment of support-based interventions in religious settings. This is unfortunate because formal groups already exist in the church that provide an important source of support to those who join them. For example, prayer groups and Bible study groups are thought to be a source of significant support. (17) A high priority for the future involves designing rigorous interventions to assess the efficacy of these potentially important sources of assistance.

Religious Coping

A considerable number of studies conducted in a wide range of disciplines indicates that stress may exert a noxious effect on physical as well as mental health. (18) As this literature evolved, it quickly became evident that most people who are confronted by stressful events do not experience physical or mental health problems. This led to the realization that many people are able to cope effectively with the stressors they encounter. This simple observation created a vast secular literature on coping responses. (19) Coping responses are the specific cognitive and behavior acts that people use in an effort to avoid or reduce the deleterious effects of stress.

Recently, there has been a growing interest in research on coping responses that have an explicitly religious orientation. (8) This is not surprising, since the sacred texts in many different faiths contain detailed guidance on how to handle adverse life experiences. Included among religious coping responses are things like turning to God for guidance and strength when dealing with a stressor or trying to see how the problem situation might be part of God's larger plan. (8) An impressive number of studies done in a wide range of social settings indicate that people who rely on positive religious coping responses are more likely to avoid the pernicious effects of stress than individuals who do not turn to religion in an effort to deal with the adversity that confronts them. (8)

Although religious coping has been shown to benefit people of all ages, it is important to reflect on why it may be especially helpful for older adults. Many of the stressors that confront older people are either chronic in nature (ie, they do not dissipate over time) or they are not easily amenable to change. For example, many elders live on fixed incomes, and as a result, financial problems tend to be persistent and ongoing. Similarly, death of a loved one is a frequent problem in late life, yet older people have little control over this event. Gotlieb (20) argues that religious coping responses may be especially efficacious under these conditions because they help people endure and accept things that cannot be changed. In addition, by accepting the permanence of some situations, individual efforts and actions may subsequently be devoted to those stressful situations that can be altered or avoided.

As with church-based support, the literature on religious coping lends itself well to intervention design. For example, Cole and Pargament (21) have devised a treatment program that is designed to help people use religious coping responses to assist in dealing with stressors associated with receiving a diagnosis of cancer. Unfortunately, most interventions involving religious coping have not been conducted with older people.

Forgiveness

There are several different ways to approach the study of forgiveness. For example, people may forgive others, they may forgive themselves, or they may feel that God has forgiven them for the things they have done wrong. So far, the majority of studies in the literature focus on forgiving others. Following Enright et al, (22) forgiving others is defined as, "... a willingness to abandon one's right to resentment, negative judgement, and indifferent behavior toward one who has unjustly injured us, while fostering the undeserved qualities of compassion, generosity, and even love toward him or her" (pages 46 to 47). Virtually every major religion in the world extols the virtues of forgiving others. (23) If so many different faiths in so many different cultural settings encourage forgiveness, then it must be performing an important function.

There is some evidence that forgiving others may have a beneficial effect on health. More specifically, a growing body of evidence suggests that forgiving others is associated with better physical (24) and (especially) better mental health. (25) However, much less is known about how these potentially salubrious effects may arise. Even so, three promising leads may be found in the literature. First, when people are not willing to forgive others, they often relive the hurtful act over and over again. There is some evidence that this type of rumination is associated with poor mental and physical health. (24) Second, forgiving others helps restore and renew social ties that were previously a source of significant support. This is important because, as discussed earlier, strong social ties are linked with better physical and mental health. Finally, at a more basic physiologic level, forgiving others promotes positive emotions, which have been shown to exert a beneficial effect on health. (26)

Although there has not been a lot of research on age differences in forgiveness, the work that has been done so far consistently shows that older people are more likely than younger individuals to say they forgive others. (27,28) Butler's compelling work on the life review process helps show why these age differences in forgiveness may arise. (29) He argues that as people enter late life, they often invest a significant amount of time reviewing the experiences they have had with an eye toward weaving their life stories into a more coherent whole. Themes of forgiveness figure prominently in this process. In particular, Butler maintains that one of the key developmental tasks in the life review process is the, "... expiation of guilt, the resolution of intra-psychic conflicts, and the resolution of family relationships" (page 236). (29) Like religious coping, forgiveness is well-suited for designing interventions to improve the health and well-being of older people. Entire volumes have been written on how to use forgiveness in secular clinical settings. (30) Moreover, some studies assess the effectiveness of forgiveness by using an experimental design. (24) But there is less research on designing interventions that explicitly use religiously motivated forgiveness, and very little work has been done specifically with older people.

Prayer

One of the foremost studies on religion was conducted over a century ago by William James. (31) He maintained that prayer is, "... the very soul and essence of religion" (page 486). Describing prayer as, "... religion in action ...," James believed that prayer is the arena in which the "real" work of religion is done. Recent studies on the frequency of prayer are consistent with the observations of James because this research suggests that prayer may be the most common form of religious practice. More specifically, Gallup and Lindsay (32) report that more than 90% of Americans pray, and 74% indicate they pray at least once a day. Given the central role of prayer in religious life, it is not surprising to find that it has been the subject of considerable research. (33-35) This literature tends to show that more frequent prayer is associated with better physical and mental health. (33)

Assuming that research on the health-enhancing benefits of prayer is valid, it is important to reflect on why these salubrious effects may arise. A number of potentially important mechanisms have been identified in the literature. In his widely cited research, Benson (36) argues that engaging in ritual activities, such as those found in religious settings, tends to promote the relaxation response. This is a state in which blood pressure is lowered, and heart rate, breathing rate, and metabolic rate decrease. Benson maintains that the relaxation response has a beneficial effect on health and that it may be especially helpful for warding off hypertension. It appears that certain types of prayer are more likely to induce the relaxation response. For example, Paloma and Gallup (35) studied the effects of a number of different types of prayer on psychologic well-being. They found that meditative prayer (sitting quietly and thinking about God) is more efficacious than petitionary prayer (ie, asking God for something specific) or ritual prayer (eg, reciting prayers contained in the Bible).

This is only one of a potentially wide range of factors that may explain the connection between prayer and health. Two more novel factors have been identified in recent research by Krause. (37,38) In the first study, Krause (37) reports that the effects of chronic economic problems on health are reduced for older people who prayed for others. He maintains that praying for others enhances positive self-feelings because it helps older people take their minds off their own problems for a while and it makes them feel as though they are doing something worthwhile for someone in need. In the second study, Krause (38) finds that beliefs associated with prayer outcomes may have an important influence on positive self-feelings in late life. More specifically, this research reveals that feelings of self-worth are highest among older people who believe that God answers prayers at the best time and that God knows the best way to answer prayers. In contrast, self-esteem is lower among those elders who believe their prayers are answered right away and believe they usually get exactly what they ask for.

A vast literature consistently shows that older people are more likely to pray than younger individuals. For example, Barna (39) reports that across six separate nationwide surveys, older people are more likely than younger people to pray during the typical week. Once again, if prayer is beneficial for health, then this relationship may be most evident among those who pray the most--older people.

More interventions have focused on prayer than any other facet of religion. As a result, it is easier to see why prayer might be an especially important way of using religion in clinical settings. One of the most widely cited interventions using prayer was conducted by Byrd. (40) Using a double-blinded, randomized experimental design, he instructed religious people to pray for patients in a coronary care unit of a large hospital. Byrd found that the severity of illness for subjects who were in the experimental condition involving prayer was lower than that of subjects in the control group. Moreover, subjects in the experimental prayer group needed less ventilatory assistance, fewer antibiotics, and fewer diuretics than subjects in the experimental group. Byrd, therefore, claimed that intercessory prayer has a beneficial therapeutic effect. (40) Similar results have been observed in other experimental studies. (41,42)

Although the findings from these studies are provocative and controversial, a good deal of work remains to be done. For example, this research shows that prayer may enhance the health of those who are significantly ill, but it fails to provide a convincing explanation for why this may be so. In addition, certain statistical issues (eg, failure to adjust significance tests for the effects of repeated hypothesis testing) raise questions about the validity of these findings as well. Finally, most of the research on prayer has not focused explicitly on older people, and as a result, it is difficult to tell if this resource is especially beneficial for them. Still, the widespread practice of prayer in the general population coupled with the findings provided by the clinical interventions suggest that continued research on prayer and health is warranted.

The Potential Dark Side of Religion

The discussion provided up to this point may create the impression that religion is good for everyone and that all who become involved in it are likely to reap health-related benefits. Unfortunately, it is not that simple. Religious institutions are primarily human endeavors. Because human beings are flawed, so are the institutions they create. This means that as in any other area in life, there may be negative as well as positive aspects associated with religious involvement. Yet, when the literature on religion and health is reviewed, the potential downside of religion is rarely discussed. Although several different negative aspects of religion have been identified in the literature, two specific dimensions will be discussed below: negative interaction in the church and religious doubt.

Negative Interaction in the Church

Negative interaction refers to unpleasant social encounters in church that are characterized by criticism, rejection, competition, the violation of privacy, and the lack of reciprocity. Ineffective helping and excessive helping are also subsumed under the broad rubric of this construct as well. Studies conducted in secular settings suggest that the effects of negative interaction exert a noxious effect on health and well-being. (43) Moreover, there is some evidence that the effects of unpleasant social encounters may be more pernicious than the positive things that people do. (44)

Although negative interaction arising in secular settings may have a deleterious effect on health and well-being, it may have an even greater impact within the church. Basic tenets of most religions emphasize the importance of loving other people and taking care of those who are in need. If a person enters a religious setting with these expectations in mind but instead encounters negative interaction, then the sharp contrast between what was expected and what was encountered may be a significant source of distress. A study by Krause et al (45) provides some support for this view. This research reveals that negative interaction in the church is associated with an increase in depressive symptoms. Moreover, the deleterious effects of negative interaction are more evident among members of the clergy and elders (ie, lay leaders in the church) than among rank-and-file church members. This suggests that the more deeply involved people are in the church, the more likely they will be troubled by the negative interaction they encounter there.

Although studies on age differences in the effects of negative interaction in the church have yet to appear in the literature, there are three reasons why unpleasant social encounters in the church may be especially troubling to older people. First, as noted earlier, older people are more involved in religion than younger people. If religion is more important to them, then they are more likely to endorse the basic tenets of the faith regarding relationships with others. To the extent that this is true, unpleasant social encounters in the church may be especially difficult for older people. Second, as the opportunity to develop and maintain social ties declines with advancing age, the relationships that are retained are likely to become increasingly important. If these relationships are a source of strife, then the relative lack of alternative sources of social support may be especially stressful for older people. Finally, there is some evidence in the literature that as people grow older, they are more likely to seek out relationships that have an explicitly emotional focus. (46) To the extent this is true, older people may be more vulnerable to unpleasant interaction in the church because these negative social encounters stand out in sharp contrast to the emotional assistance they value highly.

The literature on negative interaction in the church provides a valuable lesson for those who wish to develop interventions. This issue can be illustrated by turning to a study done in a secular setting by Heller et al. (47) These investigators attempted to create new beneficial social ties among older low income women. Unfortunately, the intervention was a failure. They subsequently found that what the older women in their study really wanted (and needed) was the alleviation of problems in current social relationships. Simply put, this work suggests that researchers should be careful about trying to bolster positive ties in the church if negative social relationships are the problem in the first place.

Religious Doubt

Religious doubt is defined as, "... a feeling of uncertainty toward, and a questioning of, religious teachings and beliefs" (page 28). (48) Religious doubt occupies an unusual place in the literature because there is considerable disagreement about whether it is good or whether it is bad. One the one hand, some theologians and researchers maintain that doubt is essential for developing a deeper religious faith. (49,50) But in contrast, other theologians and researchers argue that having doubts about one's faith is a significant source of psychologic distress. (7,51) Although there is contradictory evidence in the literature, most empiric studies suggest that religious doubt has detrimental effects on health and well-being. One study by Krause and Wulff (7) provides some interesting insight into the finer nuances of this relationship. More specifically, their study suggests that religious doubt is associated with more symptoms of depression and less satisfaction with health. However, the noxious effects of religious doubt are especially evident among people who occupy a formal role in the church (eg, member of a church governing board).

There are a number of reasons why religious doubt may have an adverse effect on health and well-being. For example, when people have doubts about their faith, they may either withdraw from or come into conflict with religious others who still adhere closely to the basic tenets of the faith. Either way, doubt may lead to a loss of social support, which, as noted earlier, is an important health-enhancing resource.

It is especially important to point out that the effects of religious doubt on health and well-being may be stronger for older than for younger people. For example, some researchers, such as Erikson, (52) maintain that religion becomes especially important as people enter late life and begin to face the prospect of their own death more fully. Erikson argues that they are especially inclined to turn to religion at this time for solace. However, if doubts arise about religion at this point in the life cycle, anxiety about death may become especially acute. Although this argument may appear to be reasonable, one of the few studies on age differences in the relation between religious doubt and well-being suggests that it is more of a problem for younger than older people. (53) Clearly, more research is needed on this important issue.

It is probably too early to think about devising interventions to help people deal with the potentially noxious effects of religious doubt because too many unanswered questions remain. For example, most people have doubts about their faith from time to time, but their concerns typically dissipate quickly. This suggests that only doubts that linger for some time may have undesirable effects on health. Similarly, we need to know more about the wider social context in which doubt may arise. For example, doubts about religion may have less of an effect if members of the same congregation share doubts about the same issue.

Conclusion

Viewed broadly, a good deal of research has been conducted on religion and health, and the findings appear to be very promising. (4) But it is important to keep three general observations in mind when reviewing this literature. First, the correlation between any facet of religion and health is not perfect. This means that religion may benefit some but not all individuals. However, this does not mean that religion is, therefore, unrelated to health. After all, not everyone who smokes subsequently develops lung cancer. Instead, researchers must identify the circumstances under which certain individuals may enjoy the potential health-related benefits of religion. Second, everyone dies, and as Neuland (54) points out in his compelling book, most become ill before they do. Consequently, it is not surprising to find that even the most religiously devoted individuals may suffer from debilitating illness. It is important not to lose sight of these basic facts when discussing findings on religion and health. Third, some (but not all) deeply religious people strongly believe that religion should not be pursued for the purpose of improving one's health. Instead, some consider it to be a perversion of their faith to do so. Instead, these individuals believe religion should only be used for personal spiritual development, to worship God, and to serve God as well as one's fellow man. Cast within more sociologic terms, this means that the potential health-related benefits of religion represent an unintended consequence, or latent function, of leading a religious life.

One has yet to conclusively prove that religion affects health, but, because the connection has not been proven, it does not follow that it is necessarily false. Instead, a more prudent conclusion is that enough information has been generated to suggest that the relation between religion and health is worthy of further consideration. This is especially true with respect to research on religion and mental health problems.

The work that lies ahead will not be easy. A number of issues must be addressed if we are to move the field forward. To begin with, researchers need to devise better measures of religion. So far, a good deal of work has focused primarily on the frequency of church attendance and health, but as the discussion provided above has revealed, there is far more to religion than this. In addition, researchers need to develop better models of religion and health that provide a well-articulated rationale for why these constructs may be related. Finally, if research on religion and health is to be carried over into clinical settings, then we need more well-designed experimental studies that clearly demonstrate the clinical efficacy of being involved in religion.

Three important considerations should be kept in mind as researchers strive to bring research on religion into clinical settings. First, it is important to think about whether physicians are the best individuals to provide religion-based care. This seems unlikely because it does not appear that physicians have the time to master the finer nuances of the religion-health connection when they already have other significant demands on their time. Instead, a more reasonable approach should involve finding ways to more closely integrate ministers and chaplains into the health care team. Second, we need to develop protocols that will help health care providers know when patients want to discuss or implement religious factors in their treatment. This is an especially sensitive issue because some people may become offended if they are asked whether they would like to discuss religious issues when they come in for health care. Finally, the United States Constitution clearly calls for the separation of church and state. This raises vitally important questions about whether it is appropriate to implement religiously oriented interventions in medical facilities that receive state or federal funding. Insights provided by medical ethicists are needed to resolve this thorny issue.

These comments are in no way meant to dissuade further research on religion and health. To the contrary, as noted above, the work that has been done so far is very promising. But there are more fundamental reasons for pursuing research on religion and health in late life. Many older people define their lives based upon religion, and many interpret the things that happen in their lives through it. As a result, it is important for clinicians to approach patients with a better understanding of the world as the patient sees it. This perspective is consistent with the basic tenets of the biopsychosocial model that is discussed frequently in the family medicine literature. (55)

Some time ago, the noted psychiatrist Carl Jung said, "Everything to do with religion, everything it is and asserts, touches the human soul so closely that psychology least of all can afford to overlook it" (page 337). (56) Given the mounting evidence that points to a religion-health connection, it would appear that those in the medical professional cannot afford to overlook it either.

To array a man's will against his sickness is the supreme art of
medicine.
--Henry Ward Beecher

Accepted December 19, 2003.

References

1. Morbidity and Mortality Weekly Review. MMWR 2003;52:101-106.

2. Krause N. Early parental loss, recent life events, and changes in health among older adults. J Aging Health 1998;10:395-421.

3. Krause N. Received support, anticipated support, social class and mortality. Res Aging 1997;19:387-422.

4. Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. New York, Oxford University Press, 2001.

5. Schurman RA, Kramer PD, Mitchell JB. The hidden mental health network. Arch Gen Psychiatry 1985;42:89-94.

6. Fetzer Institute/National Institute on Aging Working Group. Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research. Kalamazoo, MI, Fetzer Institute, 1999.

7. Krause N, Wulff KM. Religious doubt and health: Exploring the potential dark side of religion. Soc Religion 2004;65:35-56.

8. Pargament KI. The Psychology of Religion and Coping. New York, Guilford, 1997.

9. Krause N. Exploring race differences in a comprehensive battery of church-based social support measures. Rev Religious Res 2002;44:126-149.

10. Ellison CG, Levin JS. The religion-health connection. Health Educ Behav 1998;25:700-720.

11. Krause N. Social support, in Binstock RH, George LK (eds): Handbook of Aging and the Social Sciences. 5th edition. San Diego, Academic Press, 2001, pp 272-294.

12. Baltes PB. The many faces of aging: toward a psychology of old age. Psychol Med 1991;21:837-854.

13. Krause N. Church-based social support and health in old age: exploring variations by race. J Gerontol Soc Sci 2002;57B:S332-S347.

14. Kiecolt-Glaser JK, Malarkey WB, Cacioppo JT, et al. Stressful personal relationships: immune endocrine functioning, in Glasser R, Kiecolt-Glaser JK (eds): Handbook of Human Stress and Immunity. San Diego, Academic Press, 1994, pp 321-340.

15. Gottlieb BH. Selecting and planning support interventions, in Cohen S, Underwood LG, Gottlieb BH (eds): Social Support Measurement and Intervention. New York, Oxford University Press, 2000, pp 195-220.

16. Hogan BE, Linden W, Najarian B. Social support interventions: do they work? Clin Psychol Rev 2002;22:381-440.

17. Wuthnow R. Sharing the Journey: Support Groups and America's Quest for Community. New York, Free Press, 1994.

18. McEwen B. The End of Stress as We Know It. Washington, DC, Joseph Henry Press, 2002.

19. Aldwin CM. Stress, Coping, and Development: An Integrative Perspective. New York, Guilford, 1994.

20. Gottlieb BH. Conceptual and measurement issues in the study of coping with chronic stress, in Gottlieb BH (ed): Coping with Chronic Stress. New York, Plenum, 1997, pp 3-40.

21. Cole R, Pargament K. Re-creating your life: a spiritual/psychotherapeutic intervention for people diagnosed with cancer. Psycho-oncology 1999;8:395-407.

22. Enright RD, North J. Introducing forgiveness, in Enright RD, North J (eds): Exploring Forgiveness. Madison, WI, University of Wisconsin Press, 1998, pp 3-8, 46-47.

23. Rye MS, Pargament KI, Ali A, et al. Religious perspectives on forgiveness, in McCullough ME, Pargament KI, Thoresen CE (eds): Forgiveness: Theory Research, and Practice. New York, Guilford, 2001, pp 17-40.

24. Berry JW, Worthington EL. Forgiveness, relationship quality, stress while imagining relationship events, and physical and mental health. J Counseling Psychol 2001;48:447-455.

25. Krause N, Ellison CG. Forgiveness by God, forgiveness of others, and psychological well-being in late life. J Sci Study Religion 2003;42:377-391.

26. Ryff CD, Singer B. The contours of positive human health. Psychol Inquiry 1998;9:1-28.

27. Girard M, Mullet E. Forgiveness in adolescents, young, middle-aged, and older adults. J Adult Dev 1997;4:209-222.

28. Mullet EA. Houdbine A, Laumonier S, et al. Forgiveness: factor structure in a sample of young, middle-aged, and elderly adults. Eur Psychol 1998;3:289-297.

29. Butler RN, Lewis MI. Aging and Mental Health. St Louis, MO, CV Mosby, 1982.

30. Hargrave TD, Anderson WT. Finishing Well: Aging and Reparation in the Intergenerational Family. New York, Brunner/Mazel, 1992.

31. James W. William James: Selected Writings. New York, Book-of-the-Month Club, 1902/1997.

32. Gallup G, Lindsay DM. Surveying the Religious Landscape. Harrisburg, PA. Morehouse Publishing, 1999.

33. Levin JS. How prayer heals: a theoretical model. Altern Ther 1996;2:66-73.

34. McCullough ME, Larson DB. Prayer, in Miller WR (ed): Integrating Spirituality into Treatment: Resources for Practitioners. Washington DC, American Psychological Association, 1999, pp 85-110.

35. Paloma MM, Gallup G. Varieties of Prayer: A Survey Report. Philadelphia, Trinity Press International, 1991.

36. Benson H. Timeless Healing: The Power and Biology of Belief. New York, Scribner, 1996.

37. Krause N. Praying for others, financial strain, and physical health status in late life. J Sci Study Religion 2003;42:377-391.

38. Krause N. Assessing the relationships among prayer expectancies, race, and self-esteem in late life. Unpublished manuscript.

39. Barba G. The State of the Church, 2002. Ventura, CA, Issachar Resources, 2002.

40. Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J 1988;81:826-829.

41. Dossey L. Healing Words: The Power of Prayer and the Practice of Medicine. San Francisco, Harper Collins, 1993.

42. Harris WS, Gowda M, Kold JW, et al. A randomized controlled trial of the effects of remote intercessory prayer on outcomes in patients admitted to the coronary care unit. Arch Intern Med 1999;159:2273-2278.

43. Rook KS. The negative side of social interaction: Impact on psychological well-being. J Person Soc Psychol 1984;46:1097-1108.

44. Ingersoll-Dayton BN, Morgan DL, Antonucci TC. The effects of positive and negative exchanges on aging adults. J Gerontol: Soc Sciences 1997;52:S190-S200.

45. Krause N, Ellison CG, Wulff KM. Church-based emotional support, negative interaction, and psychological well-being: findings from a national sample of Presbyterians. J Sci Study Religion 1998;37:725-741.

46. Carstensen LL. Social and emotional patterns in adulthood: support for Socioemotional Selectivity Theory. Psychol Aging 1992;7:331-338.

47. Heller K, Thompson MG, Trueba PE, et al. Peer support telephone dyads for elderly women: was this the wrong intervention? Am J Commun Psychol 1991;19:53-74.

48. Hunsberger B, McKenzie B, Pratt M, et al. Religious doubt: a social psychological analysis, in Lynn ML, Moberg DO (eds): Research in the Social Scientific Study of Religion. Greenwich, CT, JAI Press, 1993, vol 5, pp 27-51.

49. Tillich P. The Dynamics of Faith. New York, Harper and Brothers, 1957.

50. Allport GW. The Individual and His Religion. New York, Macmillan, 1950.

51. Barth K. Evangelical Theory. New York, Hold, Reinhold, and Winston, 1963.

52. Hoare CH. Erikson on Development in Adulthood. New York, Oxford University Press, 2002.

53. Krause N, Ingersoll-Dayton B, Ellison CG, et al. Aging, religious doubt, and psychological well-being. Gerontologist 1999;39:525-533.

54. Neuland SB. How We Die: Reflections on Life's Final Chapter. New York, Alfred A. Knopf, 1993.

55. Spann S. Family medicine: a rational model for primary care throughout the world. Fam Commun Health 1994;17:45-51.

56. Jung CG. CG Jung: Psychological Reflections. New Jersey, Princeton University Press, 1970.

RELATED ARTICLE: Key Points

* A growing number of studies suggest that involvement in religion may exert a beneficial effect on the physical and mental health of older people.

* There appear to be negative as well as positive influences of religion on health.

* Much remains to be learned about the specific facets of religion that may have a salubrious effect on health and the mechanisms that link these various facets of religion and health.

* Research on social relationships in the church, religious coping, forgiveness, and prayer appear to be especially promising.

* Lingering issues regarding the role of the physician in providing religious-based treatments, and ethical problems involving the provision of religious-oriented treatment in government-funded facilities remain unresolved.

Neal Krause, PHD

From the Department of Health Behavior and Health Education, School of Public Health, The University of Michigan, Ann Arbor, MI.

Support for this research was provided by a grant from the National Institute on Aging (RO1-AG-04749).

Reprint requests to Dr. Neal Krause, Department of Health Behavior and Health Education, School of Public Health, The University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029. Email: [e-mail]