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Is Religion Therapeutically Significant for Hypertension?

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Is Religion Therapeutically Significant for Hypertension? Sot. Sci. Med. Vol. 29, No. I, pp. 69-78, 1989 0277-9536/89$3.00 + 0.00 Printed in Great Britain. All rights reserved Copyright Q 1989Pergamon Press plc IS RELIGION THERAPEUTICALLY SIGNIFICANT FOR HYPERTENSION? JEFFREY S. LEV& and HAROLD Y. VANDERWOL* ‘Institute of Gerontology, University of Michigan, 300 North Ingalls, Ann Arbor, MI 48109-2007, U.S.A. and %stitute for the Medical Humanities, The University ofTexas Medical Branch, Galveston, TX 77550, U.S.A. Abstract-Epidemiologic studies of the effects of religion on blood pressure suggest that religious commitment is inversely associated with blood pressure and that several religious denominations or groups have relatively low rates of hypertension-related morbidity and mortality. In this review, we examine the implication that certain characteristics and functions of religion account for this association, and we posit 12 possible explanations for this finding. We propose that a salutary effect of religion on blood pressure can be explained by some combination of the following correlates or sequelae of religion: the promotion of health-related behavior; hereditary predispositions in particular groups; the healthful psychosocial effects of religious practice; and, the beneficial psychodynamics of belief systems, religious rites, and faith. Since past epidemiologic studies may have been methodologically limited or flawed, possible explanations for the findings of these studies also include epistemological confusion, measurement problems, and analytical errors. Finally, for the sake of completeness, two more speculative hypotheses are identified: superempirical and supernatural influences or pathways. Key words-blood pressure, hypertension, religion, methodology, epidemiology INTRODUCTION published data are scant, that existing findings are largely inconsistent, and that greater attention to Hypertension is a serious and widespread clinical and conceptual and theoretical issues would be premature public health problem. For many people with common, at the present time. This paper challenges each of nonsevere forms of high blood pressure, nondrug these conclusions and offers a new approach that will therapies are often the treatments of choice. Behav- enable researchers to investigate more precisely how ioral or psychosocial treatment modalities typically religious factors may be related to cardiovascular include stress-reduction, dietary change, and various disease and hypertension specifically, and health alterations in life style. Because research into the effi- status generally. cacy of these factors has implications for both treat- The scientific study of the effects of religion on ment and primary prevention, social epidemiologists morbidity and mortality was first reviewed by Levin have long shown interest in the effects of these kinds and Schiller [4], who were surprised to discover of socioenvironmental and intrapsychic determinants. roughly 250 studies dating back over 150 years which In many epidemiologic studies of cardiovascular incorporated at least one measure of religion, vari- disease, researchers have included one or more indi- ously defined. Over four dozen of these studies cators of religious involvement. This is perhaps in- included analyses of the effects of religion on cardio- formed by the assumption that religion or religiosity vascular disease, and many focussed specifically on may represent a reflection or avenue of psychosocial hypertension. This paper elaborates on the hyper- influence and, thus, in some unspecified manner, be tension section of the Levin and Schiller review as therapeutically significant. Indeed, many epidemiolo- augmented by several more recent studies, and repre- gists are aware that significant associations between sents the first comprehensive overview of empirical measures of religion and blood pressure exist in the research on religious factors in blood pressure. literature, and many clinicians are aware of anecdotal Many investigators may be surprised to discover evidence regarding patients whose high blood press- that the literature detailing the impact of religion on ure was helped or better managed because of some blood pressure comprises nearly 20 studies published regimen or some system of meditation sanctioned by over 30 years. Outcome variables in these studies a religious group. Occasionally, after noting a collec- include mean blood pressure, systolic (SBP) and tion of seemingly anomalous findings involving diastolic (DBP) blood pressure, hypertensive heart religion variables, a reviewer will tentatively postulate disease mortality, hypertension-related mortality, a therapeutic role for religion. Jenkins’ comprehen- and history of hypertension. Measures of religion sive overview of psychosocial precursors to heart include religious attendance, church membership, disease [l] and Kaplan’s excellent prolegomenon on religious affiliation, ethnic traditions within Judaism, the cardiovascular effects of religious beliefs [2] are monastic orders, clergy status, religious education, examples of such reviews. Epidemiologists are typi- and subjective religiosity. Implicit in these studies is cally urged to tread gingerly in such virgin terrain, the suggestion that religion may be therapeutically and to exhibit great caution in drawing any definitive significant for hypertension. This suggestion clearly conclusions [3]. These warnings sometimes imply that merits scrutiny, assessment, and synthesis. 69 70 JEFFREYS. LEVIN and HAROLD Y. VANDERFTXIL This paper consists of two parts. First, published found lower SBP and DBP in monthly churchgoers findings are critically reviewed. Second, 12 hypothe- than in less frequent attenders, although the trend fell ses are posited as alternative explanations for why just short of statistical significance [9]. The other measures of religion might be significantly associated study found a significant, inverse association between with blood pressure variables. These hypotheses can religious attendance and biologic effective blood press- serve to generate additional explanatory factors for ure, an algebraic combination of SBP and DBP [lo]. future research in this area, as well as for other In a study in Evans County, Georgia, subjects report- studies examining the effects of religion on morbidity, ing at least weekly religious attendance had lower mortality, and health. SBP, even after controlling for Quetelet score, or body mass [ 111. In a study in San Antonio, Levin and Markides [12] found just the opposite. Among older REVIEW OF EMPIRICAL FINDINGS Mexican Americans in a three-generations sample, religious attendance was not significantly associated Published studies in this area are best reviewed by with a history of hypertension. However, a single- segregating them on the basis of how they oper- item measure of subjective religiosity was significant, ationalize religion. Implicit in the use of continuous and in a positive direction. Because this study exam- measures of behavior (e.g. religious attendance) or ined older subjects, however, this latter finding may attitudes (e.g. subjective religiosity) is the assumption be spurious when generalized. On the one hand, the that religious experience and commitment represent least religious subjects in this population may have a cluster of investigatable effects-independent been excluded from the study because of mortality variables-that can be related to health outcomes due to hypertension. On the other hand, the onset of through multivariable analyses. Those studies exam- morbidity due to hypertension may have engendered ining the effects of religious commitment will be a turn toward greater religious concern. Either cir- considered first. Second, studies that utilize categori- cumstance could have produced this unexpected cal measures of religious ufiliution will be reviewed. finding [13]. In this second set of studies, differences in blood To summarize, all but one of the above studies pressure variables are examined either by contrasting suggest that certain religious indicators are associated a religious denomination or group with an all-others with lower blood pressure or lower rates of hyperten- category (e.g. Mormons vs non-Mormons; Buddhists sion. Five studies revealed protective effects for vs non-Buddhists) or by contrasting two different religion and a sixth showed a strong, but non- religious groups (e.g. Trappists vs Benedictines; significant protective trend, while the seventh study’s Mormons vs Seventh-Day Adventists). Segregating finding of a deleterious effect may have been spurious studies into these categories serves a useful heuristic due to its cross-sectional design. end, for it captures the very different types of analyses employed in the literature. Religious afiliation Additional studies have investigated rates of hyper- Religious commitment tension morbidity or mortality across religious de- Several studies have investigated the effects of nominations or groups. In most instances, these various behavioral and attitudinal indicators of studies contrast a delimited religion, denomination, religious commitment on blood pressure. Overall, or sect (e.g. Buddhists, Protestants, Mormons) with these studies indicate that subjects reporting higher a more inclusive ‘all others’ category of subjects. In levels of religious commitment seem to be at lower most of these investigations, the more homogeneous risk for morbidity and mortality. Findings are sum- religious group was found to be at significantly lower marized in Table
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